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Is there a difference between the flexible and rigid reamer in femoral tunnel length in ACL reconstruction in anteromedial portal.

Introduction

Anterior cruciate ligament (ACL) is one of the important ligaments on knee. The ACL is the primary restraint to anterior translation of the tibia relative to the femur. It also acts as secondary restraint to tibial rotation and varus/valgus rotation. [1] An ACL injury is a twisting or tearing of the ACL in the knee, which may be partial or complete. [1] ACL injuries occur in about 68.6 per 100,000 persons per year, significantly higher in males between 19 and 25 years old. [2]. ACL injuries occur when bones of the leg twist in opposite directions under full body weight. Symptoms of ACL injury include a popping sound at the time of injury, knee swelling, and pain.

ACL reconstruction surgery is a surgical procedure that involves graft replacement of the torn ligament. The rate of ACL reconstruction increased significantly over time in all age groups. [2] ACL surgery is routinely done in orthopedic surgery. However, there is a need for these surgeons to perform reconstructive techniques with minimal or no technical error to decrease the incidence of graft failure. [3] In a study published in March 2016, most of the ACL reconstruction surgeries in North America were performed by subspecialty trained surgeons, 98% of which in sports medicine. The most preferred approach was an arthroscopic-assisted single-incision, the tibial tunnel placement shifted anteriorly and femoral tunnel placement shifted posterosuperiorly, use of transfixation pins and other devices decreased, and using hamstring autograft, and drilling the femoral tunnel through an accessory portal increased. [4]

Femoral tunnel length was shown to be correlated with the height and area of the lateral wall of the femoral intercondylar notch in anatomical single-bundle ACL reconstruction. [5] In a single bundle hamstring graft, a transportal approach for creating a femoral tunnel has recently become more popular than the trans-tibial technique. [6] However, a study has suggested that the 4 different approaches namely endoscopic transtibial teachnique, anteromedial portal technique, outside-in-technique, and outside-in retrograde drilling technique in femoral drilling had no significant differences in the advantages and disadvantages, and risks and benefits. [7] Femoral tunnel length is important because commonly used suspensory graft fixation devices are sensitive to the length of the femoral tunnel if the amount of graft in the tunnel is to be maximized. When it comes to reamers, an article published in July 2015 showed that the use of flexible reamers were more advantageous in the sense that it allows an additional way of uncoupling the tibial and femoral tunnels to clearly visualize and establish an anatomic starting point within the femoral footprint of the native ACL. Furthermore, the authors suggested that using flexible reamers prevent the complications associated with knee hyperflexion, short femoral tunnels and peroneal nerve injury in straight and rigid reamers. [8] In another study, the use of flexible reamers was shown to have longer femoral interosseous tunnel length compared to a rigid or a straight guide pin. [9] In the same study, they suggested that the femoral interosseous length more than 40 mm can be achieved using a flexible reamer, and not with a rigid straight pin. [9] Flexible guide pin system has gained popularity because of its theoretical advantages of longer femoral tunnel length, further distance from the common peroneal nerve and other structures, and lesser chance of injuring the cartilage of the medial femoral condyle. Because of this, we conducted this study to compare the femoral tunnel length using a flexible versus a rigid reamer in ACL anteromedial portal reconstruction surgery.

Materials and Methods

We conducted a retrospective medical record cohort analysis of all ACL reconstruction surgeries in the Arthroplasty and Sports Arthroscope Unit of the Orthopedics Department, Security Forces Hospital, Riyadh, Saudi Arabia between February and December 2014. The exclusion criteria was the following

(1) case with reversion ACL, (2) multiligmentus injury, (3) associated malalingment, (4) any associated orthopedic syndromes, (5) more than one surgeon, (6) any case converted from trans-tibial to medial portal or opposite, and (7) any case done by non-specialized surgeon. In all of these procedures, the femoral tunnel length were measured with digital calipers from 20 to 48 and reported in mm. Surgeries was performed by 3 surgeons in same hospital and the first surgeon was trained for rigid reamer and the second surgeon for flexible and the third was trained for both techniques.

Data obtained were recorded in a Microsoft Excel spreadsheet (Microsoft, Redmond, WA), and were analyzed using the Mann-Whitney test on the Statistical Program for Social Sciences (SPSS) version 20.0 (SPSS, IBM Inc., Chicago, Illinois, USA). The differences in tunnel lengths and distances from the guide pins to the common peroneal nerve and the femoral LCL origin using a flexible or a rigid reamer were compared. Variability in the surgeons who performed was also compared using the two types of reamers. Significance was set at p value less than 0.05.

Result

A total of 309 ACL reconstruction were done, 151 (48.9%) using a flexible reamer and 158 (51.1%) with a rigid reamer. The overall mean tunnel length was 38.6 [+ or -] 5.2 mm (range of 20-48 mm and median of 38.0 mm). Figure 1 shows the scatterplot of the tunnel lengths around the median.

The mean tunnel length in cases that used the flexible reamer was 39.0 [+ or -] 4.9 mm, and the mean tunnel length in cases that used the rigid reamer was 38.1 [+ or -] 5.4 mm. The mean difference in the tunnel length between flexible and rigid reamer was 0.88 mm. There was no statistical difference between the mean tunnel lengths between flexible and rigid reamers (p=0.139, 95% CI of -0.287 to 2.046). Figure 2 shows the mean and standard deviation (SD) of tunnel length between flexible and rigid reamer.

The mean (SD) tunnel length by one surgeon who performed all ACL reconstruction with flexible reamer was 37.9 [+ or -] 5.7 mm (95% CI of 36.8-39.0 mm). The mean (SD) tunnel length by another surgeon who performed all ACL reconstruction with a rigid reamer was 38.6 [+ or -] 4.8 mm (95% CI of 37.3-39.9mm). The mean (SD) tunnel length performed by a surgeon who used both flexible and rigid reamer was 39.0 [+ or -] 5.0 mm (95% CI of 38.2-39.8mm). There were no significant differences in the tunnel length performed by 3 different surgeons (p = 0.256, 95% CI of -2.78 to 2.83) (Figure 3).

Discussion

This study investigated on the differences in ACL femoral tunnel length after drilling with a straight or rigid reamer compared to a flexible reamer guide. The mean tunnel length created using the flexible reamer was relatively longer than rigid reamer; however the difference of 0.88 mm between the two types of reamers was not statistically significant (p = 0.139). The mean interosseous distance with the flexible reamer was 39.0 mm (range, 20-48 mm), and the mean tunnel length in cases that used the rigid reamer was 38.1 mm, range from 20 to 48 mm. For the flexible reamer, there were 75 (49.7%) who had tunnel length of less than 40 mm. On the other hand, there were 90 (56.9%) with tunnel length below 40 mm. In contrast to the study that was conducted by Silver et al. [9] in 2010, they found significant difference in the tunnel length between straight and flexible reamer. This difference in the findings is probably due to the drilling technique that was employed by the surgeons, as pointed out by Silver et al. [9] Furthermore, the average distance of the tunnels that were created by the flexible reamer was only 0.9 mm longer than the rigid reamer, which is significantly shorter as compared to the average difference of 6 mm in the study. [9] In that effect, the question on whether this tunnel length would allow the fixation device to be secured to the lateral femoral cortex. Since, a specific distance should be well accounted for engaging the suspensory devices.

Another issue is that most surgeons prefer to have 20 mm or more of length to give a better chance for healing and success of the reconstruction. Our study showed that all of the femoral lengths in both rigid and flexible reamers were 20 mm and above in length. In our case, drilling the femoral tunnel in the anteromedial porter leads to longer tunnels. However, our study showed that the use of flexible reamers and guide pins resulted in almost similar femoral tunnel lengths compared to use of the more rigid and straight guide pins.

The significant advantages of using a flexible reamer is the avoidance of the medial femoral condyle articular cartilage, and can curve around the medial condyle as pointed out by previous studies. [10, 11] These proposed advantages of the flexible reamer over the straight or rigid reamer may be obviated by the non-significant differences in the tunnel lengths between the two types of reamers. Another point that obviates the insignificant differences in our study is the fact that there were also no significant differences in the tunnel lengths that were created between the 3 different surgeons that performed the procedure.

Conclusion

The femoral tunnel length achieved with the use of a flexible or a straight reamer is not statically different.

DOI: 10.5455/ijmsph.2017.04082016594

References

[1.] Kiapour AM, Murray MM. Basic science of anterior cruciate ligament injury and repair. Bone Joint Res 2014;3(2):20-31.

[2.] Sanders TL, Maradit Kremers H, Bryan AJ, Larson DR, Dahm DL, Levy BA et al. Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. Am J Sports Med 2016 pii: 0363546516629944 [Epub ahead of print].

[3.] Carson EW, Anisko EM, Restrepo C, Panariello RA, O'Brien SJ, Warren RF. Revision anterior cruciate ligament reconstruction: etiology of failures and clinical results. J Knee Surg 2004;17:127-32.

[4.] Budny J, Fox J, Rauh M, Fineberg M. Emerging trends in anterior cruciate ligament reconstruction. J Knee Surg 2016;March 28 (Epub ahead of print).

[5.] Iriuchisima T, Ryu K, Suruga M, Aizawa S, Fu FH. The correlation of femoral tunnel length with the height and area of the lateral wall of the femoral intercondylar notch in anatomical single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2016 Feb 14 (Epub ahead of print).

[6.] Vaishya R, Agarwal AK, Ingole S, Vijay V. Current trends in anterior cruciate ligament reconstruction: a review. Cureus 2015;7:e378. Doi:10.7759/cureus.378.

[7.] Robin BN, Jani SS, Marvil SC, Reid JB, Schillhammer CK, Lubowitz JH. Advantages and disadvantages of transtibial, anteromedial portal, and outside in-femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction: a systematic review. Arthoscopy 2015;31:1412-7.

[8.] Fitzgerald J, Saluan P, Richter DL, Huff N, Schenck RC. Anterior cruciate ligament reconstruction using a flexible reamer system: Technique and pitfalls. Orthop J Sports Med. 2015; 3(7):2325967115592875. doi: 10.1177/2325967115592875. eCollection 2015.

[9.] Silver AG, Kaar SG, Grisell MK, Reagan JM, Farrow LD. Comparison between rigid and flexible systems for drilling the femoral tunnel through an anteromedial portal in anterior cruciate ligament reconstruction. Arthroscopy 2010;26:790-5.

[10.] Nakamura M, Deie M, Shibuya H, et al. Potential risks offemoral tunnel drilling through the far anteromedial portal: acadaveric study. Arthroscopy 2009;25:481-7.

[11.] Hall MP, Ryzewicz M, Walsh PJ, Sherman OH. Risk ofiatrogenic injury to the peroneal nerve during posterolateral femoral tunnel placement in double-bundle anterior cruciateligament reconstruction. Am J Sports Med 2009;37:109-13.

[12.] Lubowitz JH. No-tunnel anterior cruciate ligament reconstruction: the transtibial all-inside technique. Arthroscopy 2006; 22: pp. 900.e1-900.e11.

[13.] Ferretti M, Ekdahl M, Shen W, Fu FH. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy 2007; 23: 1218-25.

[14.] Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett WE. Reconstruction technique affects femoral tunnel placement in ACL reconstruction. Clin Orthop Relat Res 2008; 466:1467-74.

[15.] Heming JF, Rand J, Steiner ME. Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 2007; 35: pp. 1708-15.

[16.] Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 2008; 24: 113-5.

[17.] Lubowitz JH. Anteromedial portal technique for the anterior cruciate ligament femoral socket: Pitfalls and solutions. Arthroscopy 2009; 25: 95-101.

[18.] Nakamura M, Deie M, Shibuya H et al. Potential risks of femoral tunnel drilling through the far anteromedial portal: a cadaveric study. Arthroscopy 2009.

[19.] Basdekis G, Abisafi C, Christel P. Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy 2008; 24: 459-64.

[20.] Lee MC, Seong SC, Lee S, et al. Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 2007; 23:771-8.

[21.] Golish SR, Baumfeld JA, Schoderbek RJ, Miller MD. The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: a cadaveric study. Arthroscopy 2007; 23: 1187-92.

Saeed Koaban, Salman Alharbi

Arthroplasty and Sport Arthroscope, Orthopedics Department, Security Forces Hospital, Riyadh, Saudi Arabia.

Correspondence to: Saeed Koban, E-mail: mmhh696@gmail.com

Received August 4, 2016. Accepted August 24, 2016

Caption: Figure 1: Scatterplot of femoral tunnel lengths around the median.
Figure 2: A comparison of the mean tunnel
length between flexible and rigid reamers in
309 ACL reconstruction surgeries.

mean tunnel length

flexible   39.0 [+ or -] 4.9
rigid      38.1 [+ or -] 5.4

Note: Table made from bar graph.

Figure 3: Mean tunnel lengths between
three surgeons who performed the ACL
reconstruction surgeries. Surgeon 1
cases done by rigid reamer, and surgeon
2 cases done by flexible, and surgeon
3 cases done by both techniques.

Tunnel length in between surgeons

surgeon 1   37.9
surgeon 2   38.6
surgeon 3   39.0

Note: Table made in bar graph.
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Author:Koaban, Saeed; Alharbi, Salman
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Date:Jan 1, 2017
Words:2321
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