Optimization of Anteromedial Portal Femoral Tunnel Drilling With Flexible and Straight Reamers in Anterior Cruciate Ligament Reconstruction: A Cadaveric 3-Dimensional Computed Tomography Analysis

Forsythe, Brian; Collins, Michael J.; Arns, Thomas A.; Zuke, William A.; Khair, M. Michael; Verma, Nikhil N.; Cole, Brian J.; Bach, Bernard R.; Inoue, Nozomu

doi:10.1016/j.arthro.2016.11.004

Cited by 15 publications

(20 citation statements)

References 18 publications

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“… 16 , 20 , 21 , 34 Kim et al 16 found that the AM and PL femoral tunnel apertures were larger (more elliptical) in the AM-RR group compared with the AM-FR group. Kosy et al, 20 Larson et al, 21 and Forsythe et al 9 all found no difference in tunnel aperture dimensions ( Table 4 ).…”

Section: Resultsmentioning

confidence: 88%

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Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review

Moran

Ignozzi

Werner

2021

Orthopaedic Journal of Sports Medicine

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Background: Recent studies have suggested that femoral tunnel drilling during anterior cruciate ligament (ACL) reconstruction (ACLR) with the use of a flexible reaming system through a standard anteromedial portal (AM-FR) may result in a different tunnel geometry compared with a rigid reamer through an accessory anteromedial portal with hyperflexion (AM-RR). Purpose: To summarize radiologic, anatomic, and clinical outcomes from available studies that directly compared the use of AM-FR versus AM-RR for independent femoral tunnel creation during ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed using the MEDLINE (PubMed) and Web of Science databases to identify all studies that directly compared radiologic, anatomic, and clinical outcomes between the use of AM-FR and AM-RR. The literature search, data recording, and methodological quality assessment was performed by 2 independent reviewers. The outcomes analyzed included resultant ACL graft positioning and graft bending angle; femoral tunnel positioning, aperture morphology, length, and widening; posterior wall breakage; and distance from various posterolateral knee structures. Results: A total of 13 studies met the eligibility criteria for inclusion. There was no difference in femoral tunnel aperture location between techniques. There were conflicting findings among studies regarding which technique resulted in a more acute graft bending angle. One study reported greater femoral tunnel widening upon follow-up with the use of AM-FR. AM-FR produced longer and more anteverted femoral tunnels than did AM-RR. The difference in tunnel length was significant and more prominent in lesser degrees of knee flexion. With AM-FR, femoral tunnels were farther from the lateral collateral ligament and peroneal nerve, and 1 of 5 studies had fewer reports of posterior wall breakage. There has been no literature comparing the clinical or functional outcomes of these techniques. Conclusion: Although no clinical studies exist comparing AM-FR and AM-RR for femoral tunnel creation during ACLR, both systems allow for reproducible positioning of an anatomic femoral tunnel aperture. The use of AM-FR results in longer and more anteverted femoral tunnels than using AM-RR, with exit points on the lateral femur that are different but safe. Surgeons should be aware of the technical differences with each method; however, further study is needed to identify any clinically important difference that results.

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Section: Resultsmentioning

confidence: 88%

“…Eight included studies 9 , 15 , 16 , 20 , 21 , 23 , 33 , 35 quantified femoral tunnel positioning by utilizing radiologic parameters. No studies reported any significant difference in the intra-articular femoral tunnel aperture location.…”

Section: Resultsmentioning

confidence: 99%

Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review

Moran

Ignozzi

Werner

2021

Orthopaedic Journal of Sports Medicine

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“…In adults, flexible instrumentation has been shown to create more anatomic and longer femoral tunnels that are further away from the posterior cortex compared to rigid drilling systems [23,24]. Additionally, these results can all be obtained at lower knee flexion angles with curved instruments, making this stage of the procedure less technically demanding with less risk of complications [9,10]. Rigid reamers have been shown to create horizontal tunnels with higher tunnel acuity, which may influence contact pressure between the graft and the tunnel aperture [25].…”

Section: Discussionmentioning

confidence: 99%

“…The curved guide was advanced through the AM portal and positioned on the marked location. The primary advantage of these instruments is that they allow for recreation of the ACL footprint while optimizing tunnel length and avoiding the need for hyperflexion of the knee [9,10]. The previous techniques describe placing the curved endoscopic femoral guide in the middle of the femoral footprint at 45°below the horizontal access, resulting in a superolateral trajectory.…”

Section: Treatment and Surgical Techniquementioning

confidence: 99%

All Inside Intraepiphyseal ACL Reconstruction Using Flexible Curved Instrumentation and Intraoperative Fluoroscopy in a Skeletally Immature Patient

Puzzitiello

Agarwalla

Garcia

et al. 2021

Case Reports in Orthopedics

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Case. A 13-year-old skeletally immature female presenting with an anterior cruciate ligament (ACL) rupture after a noncontact injury was treated with an intraepiphyseal ACL reconstruction. Flexible instrumentation was utilized to drill a femoral tunnel with an anatomic starting point, with a trajectory that curved inferolaterally away from the physis. At three years postoperatively, she had returned to her preinjury functioning and did not display any lower limb length growth abnormalities. Conclusions. The novel application of curved guides and flexible instruments, with intraoperative fluoroscopy, facilitated growth plate avoidance and a successful outcome of ACL reconstruction in a skeletally immature patient.

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“…One more effective method for safe drilling of the femoral graft socket makes use of flexible drills. 6 With their use, hyperflexion of the knee is avoided, and thus, the probability of damage to the MFCC and PCL fibers is decreased and visualization is not as poor as in a hyperflexed knee. Flexible drills, although avoiding the need for hyperflexion, have no mechanism to check overdrilling of the lateral femoral cortex.…”

Section: Discussionmentioning

confidence: 99%

Anterior Cruciate Ligament Femoral Socket Preparation Using a Cannulated, Calibrated Drill With Adjustable Stop and Slotted Cannula

Patwardhan¹,

Kandhari

2021

Arthroscopy Techniques

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Anteromedial portaleguided femoral tunnel preparation during anterior cruciate ligament reconstruction can be difficult owing to poor visualization. This may cause iatrogenic damage to the medial femoral condyle cartilage and the posterior cruciate ligament fibers or overdrilling through the lateral femoral cortex, creating difficulties in the use of femoral suspensory devices during anterior cruciate ligament reconstruction. We describe an accurate and safe technique for femoral graft socket preparation using a cannulated, calibrated drill with an adjustable stop and slotted cannula. This easy and reproducible technique uses simple additional instruments and effectively addresses concerns related to femoral graft socket preparation, without requiring additional surgical time.

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Optimization of Anteromedial Portal Femoral Tunnel Drilling With Flexible and Straight Reamers in Anterior Cruciate Ligament Reconstruction: A Cadaveric 3-Dimensional Computed Tomography Analysis

Cited by 15 publications

References 18 publications

Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review

Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review

All Inside Intraepiphyseal ACL Reconstruction Using Flexible Curved Instrumentation and Intraoperative Fluoroscopy in a Skeletally Immature Patient

Anterior Cruciate Ligament Femoral Socket Preparation Using a Cannulated, Calibrated Drill With Adjustable Stop and Slotted Cannula

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