Avoidance of Reamer Breakage During ACL Reconstruction With Flexible Reamer System

Judd Fitzgerald; Paul Saluan; Dustin L. Richter; Nathan Huff; Robert C. Schenck

摘要

Authors’ Response: We greatly appreciate the viewpoints of Dr Jaiman concerning the timing/use of the 4.5-mm reamer when utilizing a flexible reamer for establishing a femoral tunnel. Using a flexible reamer system is very advantageous in creating a low femoral tunnel especially in the current context of concomitant anterolateral ligament (ALL) reconstruction or posterolateral corner reconstruction, as can often be needed with revision anterior cruciate ligament (ACL) surgery. Furthermore, avoiding knee hyperflexion facilitates placement of the femoral guide pin, as visualization and graft passage is almost never compromised as is often seen with straight pins/reamers placed using the necessary hyperflexion to avoid a short femoral tunnel. Furthermore, with modern flexible reamers and experience, the ACL tunnel length is maximized, with most condylar distances 35 to 40 mm with use of standard offset guides. As the reader suggests, utilizing the appropriate graft size reamer first is quite acceptable as it does seat the femoral tunnel/socket when the pin is placed ideally. We often utilize this first step. However, in those situations when the nitinol pin is too posterior or low on the lateral wall, using the 4.5-mm reamer first across the intercondylar distance allows adjustability of the femoral tunnel anteriorly or superiorly without having to replace the flexible pin. In our experience, redirecting a slightly low or posterior nitinol wire can be difficult as the nitinol pin often drops into the same track. Furthermore, there are advantages to knowing the condylar width (especially if too short or in the case of a less experienced surgeon) before seating the femoral tunnel. If the surgeon does elect to ream first with the 4.5-mm reamer, the femoral tunnel can still be seated in an accurate position, despite the mobility. One advantage of reaming with the 4.5-mm first, in our experience, is that it allows the flexible final-sized reamer to seat itself within the condyle in the scenario where the pin is too posterior. We agree that placement of the final socket centered on the bifurcate ridge is most critical, and we often ream with the final-sized reamer first then follow with the 4.5-mm reamer. We discussed in the article reaming with the 4.5-mm reamer first as it is a very nice technical trick to adjust the final socket without having to replace the nitinol pin when the initial attempt/placement could be adjusted slightly anteriorly or superiorly, which is often the case. When using a bone-tendon-bone autograft, this technique modification helps avoid posterior wall blow out from a posteriorly placed nitinol wire. Although using the final-sized reamer first works extremely well when the pin is placed accurately, we find that reaming with the 4.5-mm reamer first prevents the larger, final-sized reamer from kinking on the nitinol wire and is often easier to ream. With our change to the Stryker flexible system we have not had reamer or wire breakage regardless of the order of reaming. As to the use of the tibial guide, the proper selection of tibial angle we agree can be variable and is best adjusted to replicating the ACL tibial footprint. We find the 55° setting very useful when performing hamstrings autografts but have utilized other angles of approach, when appropriate, as suggested by the readers’ comment. Judd Fitzgerald, MD Albuquerque, New Mexico, USA Cleveland, Ohio, USA Paul Saluan, MD Dustin L. Richter, MD Nathan Huff, BS Robert C. Schenck, MD Albuquerque, New Mexico, USA.

机译：作者的回应：我们非常感谢Jaiman博士在使用柔性铰刀建立股骨隧道时关于4.5毫米铰刀的选择/使用的观点。使用柔性铰刀系统在创建低股骨隧道中非常有利，特别是在当前的前外侧韧带（ALL）重建或后外侧角重建的当前背景下，这通常是修订前交叉韧带（ACL）手术所需要的。此外，避免膝关节过度屈曲有助于股骨导针的放置，因为可视化和移植物通道几乎从未受到损害，就像使用必要的过度屈曲放置直销/扩孔钻以避免短股骨隧道所看到的那样。此外，凭借现代灵活的铰刀和丰富的经验，ACL隧道的长度得以最大化，使用标准偏置导向器可使most突的最大距离达到35至40 mm。正如读者所建议的，首先使用适当的移植物大小的铰刀是完全可以接受的，因为当理想地放置销钉时，它确实可以固定股骨隧道/插槽。我们经常利用这一第一步。但是，在镍钛合金销钉在侧壁上太靠后或太低的情况下，首先在across间距离上使用4.5毫米铰刀可以向前或向上调节股骨隧道的可调节性，而不必更换柔性销钉。根据我们的经验，由于镍钛合金针经常会落入同一条轨道，因此很难将镍钛合金线稍低或向后重定向。此外，在安置股骨隧道之前了解know突宽度（特别是如果太短或在缺乏经验的外科医生的情况下）具有优势。如果外科医生确实选择先使用4.5毫米铰刀进行扩孔，则尽管活动性强，但仍然可以将股骨隧道正确放置。根据我们的经验，先用4.5毫米铰孔的一个优点是，在销子太靠后的情况下，它可以使最终尺寸的铰刀灵活地置入within内。我们同意最关键的是将最终的套筒放置在分叉脊上，并且我们经常先用最终尺寸的铰刀扩孔，然后再使用4.5毫米铰刀。我们在文章中首先讨论了使用4.5毫米铰刀铰孔的方法，因为在最初的尝试/位置可以稍稍向前或向上调整时，调整最终的插座而无需更换镍钛合金销是一个非常好的技术技巧，通常案子。当使用骨骼肌腱-骨自体移植术时，此技术改进有助于避免后壁镍钛合金丝从后壁吹出。尽管在精确放置销钉时首先使用最终尺寸的铰刀效果非常好，但我们发现首先使用4.5毫米铰刀进行铰孔可以防止较大的最终尺寸的铰刀在镍钛合金丝上扭结，并且通常更容易铰孔。更改为Stryker柔性系统后，无论铰孔顺序如何，我们都没有铰刀或断线。至于胫骨引导器的使用，我们同意的正确的胫骨角度选择可能是可变的，最好调整以复制ACL胫骨足迹。我们发现55°设置在进行绳肌自体移植时非常有用，但如读者评论所建议的那样，在适当的情况下还采用了其他接近角度。 Judd Fitzgerald，医学博士，美国新墨西哥州的克利夫兰，美国俄亥俄州Paul Saluan，医学博士，Dustin L. Richter，医学博士，Nathan Huff，理学士Robert C. Schenck，医学博士，新墨西哥州，美国。

Avoidance of Reamer Breakage During ACL Reconstruction With Flexible Reamer System

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