Name: Flexible Reamer System for BTB ACL Reconstruction
Uploaded: 2017-08-09T00:00:00Z
Channel: Arthrex

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VID1-01129-EN | A | Flexible Reamer System for BTB ACL Reconstruction

Asheesh Bedi

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Flexible Reamer System for BTB ACL Reconstruction

Today, we're going to have the opportunity to review the Arthrex Flexible Reamer and pin system. We'll talk a little bit about flexible Reamers certainly reflects my bias, but I think they offer some advantages for ACL surgery and reconstruction. The kit as it comes, as you can see here, comes with a flexible reamer and a flexible pin, all in the same kit as a disposable system. Flexible reamers in general, while I open this, offer a number of different advantages. I think for the surgeon. One is they allow you to perform AnaToemic reaming from a medial portal without hyperflexion. They help to guide and transition around the geometry of the condyles and the notch to still have an anatomic starting point, but without the need for hyperflexion and sometimes the limited visualization from the fat pad. These flexible reamers in particular, I think, offer several advantages that I would like to show to you. The first and foremost is is starting with the very simple concept that they are disposable. And as you can imagine, and all of all of you who have used reamers having a sharp reamer, but particularly one that's reliable for each case, is particularly important. It only takes one broken reamer in the Or, and the experience of a broken reamer, particularly locked in the knee. To understand the importance of that and having a sharp reamer as well as a sharp pin, allow you to also avoid the morbidity of metal debris in the knee. As you can see, their design is unique. They're actually a segmental design in nature, so these are like links or segments. It offers tremendous flexibility as you can see here. And they offer a lot of versatility despite whichever portal or trajectory you use to approximate the starting point. These are also quite strong. And they've been specifically designed to have measurement points all the way to a depth of 52mm. The pin also is similarly marked. It's very flexible. I'll try to show you that here. As you can see, it has marking points, so you can use it to assess the overall depth and length of your tunnel, but also has tremendous flexibility and play with a good match for the reamers. So for me, all of these advantages are particularly important because I do prefer a medial portal reaming technique, but it's critically important that I have a trajectory that minimizes acute turns and so-called quote unquote, killer curves in the graph. And it's important, as we know, with low profile reamers and straight reamers, sometimes we get a very oblique femoral tunnel, which can introduce its own challenge in the mechanical properties of the graph, creating a killer curve. Their flexible reamers can allow us to have an anatomic starting point, but still have a favorable trajectory to keep the graph relatively collinear with the tibial tunnel. So as you can see here, this is the curved drill guide that's been designed to use with the flexible reamer and pin system. A few specific advantages that I see. One that I just discussed a little bit was the importance of the trajectory of your tunnel. You can see there is this reference guide point here. By pushing a button here you can change the angulation to five different set points. And this rotates the tip of your guide. As I mentioned earlier, it's not just about an anatomic starting point, but it's about the trajectory of your tunnel and having that trajectory allow for something that's collinear. To minimize a killer curve in the graft is important. So this gives you a reference point when you're holding it in the knee to get a sense of how much obliquity you're creating with that tunnel. Something like this being more flat and almost all epiphyseal in trajectory, and something here at 45 degrees and beyond being more typical. So you can reference this often with the handle of your guide, so you can get a sense of where that tunnel is headed. I'll just draw your attention to the tip here a little. It has this sharp point that's nice for engaging the lateral wall when you're placing your ACL. I often have a reference pilot hole or all mark in the wall marking the center of my footprint. This allows me to engage the wall to line the flexible pin with that pilot hole. So I have no concern that that drill guide is walking or migrating as I advance that pin into the into the condyle. All right. So here we are. Transition to the knee joint here I think you can see we've cleared out our ACL. You can see some of the membrane there between the PCL and the and the rest of the notch here. We've just done a minimal amount of cleaning here off of the notch wall. I've tried to preserve these anterior and inferior fibers of the ACL footprint on the femoral side. And I think that's important because it helps to remind you of those landmarks. Again. At this point, we can sort of introduce like a microfracture all here or something that helps us to kind of measure the dimensions of this footprint. You can see there we're out the back wall as you translate it anteriorly. Fibers go all the way to here. We recognize here as posterolateral bundle as we come up here a bit more anteromedial bundle. So we'll measure right here from the back of the knee and work our way forward. This being about a millimeter there about 2 to 3mm for here about bisecting the footprint. And somewhere in here is probably where we're going to want to center our tunnel for a BTB graft. We might want to be a little bit on the higher end of this entire footprint tissue, knowing that as we put our interference screw in and when we rotate our graft, the working edge of that tunnel and those fibers will center in the footprint. So drilling here may actually interiorize us and anti-rise us too much. So we'll probably want to keep our footprint centered somewhere in there. I find it helpful to have this pilot hole here. I think it gives us a spot for us to rest our wire, and that gives us a marking spot for us to reference here. So we have no concern when we bring in our in our flexible guide that we've been in the right location, it's not unreasonable to switch your camera into your medial portal or use a 70 degree scope, whichever is your preference. But I think you can see here the advantages this gives us an on force look at that footprint. I think there's our footprint issue here. If anything we're slightly posterior or biased to the Am bundle, but just on the front edge of that should be in good shape for our graft. Now we can bring in our flexible guide here. And as we talked about earlier, that drill guide can advance nicely through our medial portal. We'll walk it right in. And here's the advantage I think you can see here. Remember I talked about this sharp tip in this particular place. I can place that tip right into that pilot hole. And the advantage there is that we'll walk that pin a little bit anterior like we desired. And I can see that trajectory here that it's going to give me. You can see on the outside that's aiming towards the metaphysis there, which should be favorable for us. So I can push the button here and we can rotate this guide down here. So that keeps that trajectory point for us and gives us that favorable trajectory for drilling. At this point, your assistant will simply advance through the guide. You can see that will nicely engage right up to the wall here. It slides nicely through the drill guide. We can advance right up to the wall. And again at exit checkpoint. As you can see on this cadaver specimen is you can see that your pin trajectory very nicely mirrors and matches the trajectory of your guide. And for me generally I want to see this pin come out relatively lateral. And about the exit point of the vastus lateralis. If you see the pin come out to proximal or central on the thigh or to distal and inferior, you know that your pin trajectory may be either all epiphyseal or two central and walking up the metaphysis. Now the drill guide can simply slide off of the flexible pin. This is a good step for you to check your trajectory. You can see here. On the inside we have good clearance here from the medial femoral condyle. So as our reamer advances we're not concerned about iatrogenic reaming. We're clearing our anterior horn of our medial meniscus and have a favorable trajectory into our footprint. So as you can see here, now we can advance our flexible reamer into the knee. I've placed this sled that just allows it to it to slide nicely without dragging in the fat pad. I think it's a nice tool that you can use both to protect the meniscus and, and also to slide the reamer right up to the condylar wall. I would just draw your attention to the fact that this view you're getting of a medial portal reamer is with the knee just hanging free in 90 degrees of flexion. And you can see we can advance that right up to the wall. There's your cutting tine. It protects your PCL as you advance. And you can even do a virtual rotation there to see that it's going to capture right up until that anterior margin of the footprint here. So this is an advantage for me because it does not require the hyperflexion of conventional straight reamer drilling. And here it's simply going to follow the pin. And this is a sharp reamer. So it doesn't require any force. The reamer will just do the work. So we'll go ahead there now so you can see how easily that advances. These reamers are nicely marked at multiple spots here. That's about 12 in about 16in. Good. And that's about 24. We usually advance 24 or 25. Typical for a BTB bone plug. There's our 28 mark. And at that point we can simply come back. And again the nice advantage here is as we get close here, we'll just take out the cutting time here and we'll slide that cutting time right towards this safe edge of our tunnel and slide it away from the condyle and out the knee. So here again, you can view directly that your medial femoral condyle has been entirely protected during that ream. Now's a good time to either slide your suction in or your shavrin in both and clear debris from the knee. So hopefully you can get a look at that tunnel that's been drilled here. I think you can see the pin is nicely centered. We can see margin of footprint tissue surrounding our entire reamed tunnel, which is really bisecting our Am and PL bundle. Now we can simply advance our guide pin through. We've placed a fiber wire to shuttle through our graft for the later step. And you can see the eyelet has that loaded here, and we'll simply advance that through and keep the loop out. Our medial portal now is again a good time for you to come and inspect that tunnel. I'll sometimes view it right from the medial portal, right in the center of our footprint, in an appropriate position on the wall. Oftentimes there's bone debris. It's very easy to simply take your cannula and allow that all to decompress. You can see your exit point. So this to me is one of the advantages of the flexible reamer, a nice long tunnel with a good trajectory towards the metaphysis well centered in the anatomic footprint of your femoral side of the ACL. So as you can see now, we'll go ahead and prepare the tibial tunnel in our standard fashion. Here are our reference points anterior of the lateral meniscus centering within the footprint. So here we're going to go ahead and prepare that side. So next we'll simply come in from our tibial tunnel. Here you can bring in your grasper or a probe whichever is easier or more convenient. And simply grab your stitches that are coming from your femoral tunnel and advance them back down into your tibial tunnel. Now you're basically set for shuttling here. You can see here there's your tibial tunnel well centered in the footprint has good obliquity. I would point out if you notice here, this trajectory shows that we haven't created this killer curve on the femoral side. When we advance our bone plug. Next we're going to go ahead and shuttle in our patellar tendon graft. Here you can see our shuttle stitches are going to pull through our lead stitch in our graft. And now we'll simply advance that bone plug through our tibial tunnel. There's our plug as it advances into the notch. I do recommend sometimes having a probe here that we can use to change or manipulate the trajectory of our graph. Sometimes you can use the the drill hole in the plug right to your advantage, and then you can see that here we can start to slowly pull that and rotate our plug to be in a favorable trajectory. I typically recommend that the plug be oriented in this particular trajectory. So we maximize the safety of our interference screw on the bony side of the graft. So there I think you can appreciate where our graft is. It's relatively inferior. Our bone plug here in this safe zone anterior-superior in the tunnel. And here you can see the coronal obliquity and alignment of our new ACL graft. This one being a large ten millimeter graft in this relatively small knee fully reproducing the anatomy of that of that ligament. So now you're able to see here at the tendon bone interface where the plug has just been pulled in, it's docked nicely at the socket. We've kept our bone plug in a safe orientation. One way that you can actually introduce this wire to match the collinearity of your plug is to simply slide your guide in. Here. You can bring that right above the plug in this fashion, and your guide pin can advance right through your guide and help to slide to maintain that trajectory just adjacent to your bone plug so you can see the pin gets docked there. That allows us to slide the graph back. And this again confirms that we're on the safe side of our bone plug and docked linearly to our socket at this step. Now we would introduce our tap for our bio composite screws. These taps are nice because they actually have the ability to have some flexibility at the shaft to mimic the curvature and trajectory of our reamer. Here you'll see the tap coming through here. The tap comes back there after we've made our channel there. You can see we've tapped our channel there. The wire maintains itself in place. That helps us now to advance our screw. Here you can see that these screws get a good purchase at that bone bone interface here. We can advance that up under direct visualization. And again if you notice because we've done this carefully, even without a graph Protector, we have great confidence that our graft is not being lacerated as we advance our screw by carefully placing that wire at the appropriate interface, you can see that can get advanced right up flush to our wall. Here you can see our final fixation on the femoral side here. Our graft, as I as I mentioned earlier, does get rotated antero inferiorly and as you can imagine, that now keeps the tissue centered in the footprint. The screw just above the footprint. You can see here that obliquity and alignment, bringing that all the way anterior to our inner meniscal ligament in line with our anterior horn of our lateral meniscus. Here you can see that from our medial portal. Here you can see how we've maintained that colinear trajectory with our bone plug. And this nice obliquity and alignment of our fibers right into the native footprint tissue. After we've now completed fixation on our femoral side, the graft is cycled to eliminate any creep or elongation. And we turn our attention to the tibial side where we'll fix that colinear. Typically, we choose to fix that. In terminal extension, we check for isometry that the bone plug is not pistoning in and out of the socket with flexion and extension. Here we feel a minimal amount of that, and this then becomes fixed with a collinear interference screw using the same technique on the tibial side and terminal extension.

Flexible Reamer System for BTB ACL Reconstruction

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