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Flexible reamers create comparable anterior cruciate ligament reconstruction femoral tunnels without the hyperflexion required with rigid reamers: 3D-CT analysis of tunnel morphology in a randomised clinical trial

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The hyperflexion required for femoral tunnel drilling in anterior cruciate ligament reconstruction can be challenging in patients with increased body habitus or musculature. Whilst allowing femoral tunnel creation without hyperflexion, additional benefits of flexible reamers have been proposed in terms of tunnel dimensions. The purpose of this study was to examine whether these theoretical benefits are seen in a clinical study.

Methods

Fifty adult patients (with isolated anterior cruciate ligament rupture) were randomised to reconstruction with either flexible or rigid femoral reamers. Femoral tunnel drilling was performed at 100° flexion (flexible system) or maximal hyperflexion (rigid system). Otherwise, the procedure was standardised. Femoral tunnel measurements were performed by a consultant musculoskeletal radiologist who was blinded to the method of femoral drilling. Tunnel position, length and angles (axial and coronal) were measured alongside aperture shape and exit point using three-dimensional computed tomography 3–6 months post-operatively.

Results

With no difference in tunnel position, tunnel length was found to increase with the use of the flexible system (37.8 ± 3.7 vs 35.0 ± 4.4 mm; p = 0.024). In addition, the exit point and fixation device were more anterior on the lateral femur using the flexible reamers (p = 0.016). No difference was seen in either tunnel angles or aperture shape. One case of incomplete posterior blow-out was seen in each of the study groups.

Conclusions

This comparative study shows that flexible reamers can reproduce a desired femoral tunnel position with only small improvements of no clinical relevance. As this can be achieved without hyperflexing the knee, these systems can be used for all patients (even when hyperflexion is a challenge).

Level of evidence

I.

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Fig. 1

taken from Fitzgerald et al. [5] under contract CC BY-NC-ND 3.0); b intraoperative radiograph image demonstrating the flexible nitinol wire passing through the curved guide and then following a straight course through the femur

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Abbreviations

ACL:

Anterior cruciate ligament

ACLR:

Anterior cruciate ligament reconstruction

CT:

Computer tomography

3D-CT:

Three-dimensional computed tomography

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Acknowledgements

The authors wish to thank the institutional research and development team for their support in both the design and undertaking of this study.

Author information

Authors and Affiliations

  1. Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, Devon, UK

    Jonathan D. Kosy, Katie Walmsley, Peter J. Schranz & Vipul I. Mandalia

  2. Royal Devon and Exeter Hospital, Exeter, UK

    Rahul Anaspure

Authors
  1. Jonathan D. Kosy
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  2. Katie Walmsley
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  3. Rahul Anaspure
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  4. Peter J. Schranz
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  5. Vipul I. Mandalia
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Contributions

JK performed the initial literature search, prepared the review board application and performed the analysis of the data. JK also wrote the first draft and performed subsequent editing of the manuscript. KW ran the prospective study including coordination of recruitment, imaging and follow-up. RA performed all of the radiographic manipulations, measurements and interpretations. PS and VM conceived the study and performed all of the surgery. All authors were involved in the editing of the manuscript (including approval of the final submission).

Corresponding author

Correspondence to Jonathan D. Kosy.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Institutional review board approval was received prior to commencing the project (Study number: 16/SW/0080).

Informed consent

All patients provided informed consent prior to recruitment including agreement for additional post-operative imaging to access tunnel characteristics.

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Kosy, J.D., Walmsley, K., Anaspure, R. et al. Flexible reamers create comparable anterior cruciate ligament reconstruction femoral tunnels without the hyperflexion required with rigid reamers: 3D-CT analysis of tunnel morphology in a randomised clinical trial. Knee Surg Sports Traumatol Arthrosc 28, 1971–1978 (2020). https://doi.org/10.1007/s00167-019-05709-7

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  • DOI: https://doi.org/10.1007/s00167-019-05709-7

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