Anatomic anterior cruciate ligament reconstruction with a flexible reamer system and 70° arthroscope

Abstract

Anterior cruciate ligament (ACL) reconstruction techniques continue to evolve as surgeons seek to improve surgical process and outcome measures. On the basis of published data showing improved biomechanics, many surgeons now attempt to better re-create native ACL anatomy in reconstruction. Use of flexible reamer technology and a 70° arthroscope allows for excellent visualization of the native ACL anatomy, as well as precise and independent drilling of the tibial and femoral reconstruction tunnels, while offering several surgical and technical advantages compared with other drilling techniques. This technical note with accompanying video describes our use of the Smith & Nephew Clancy anatomic cruciate guide/flexible drill system (Smith & Nephew, London, England) with a 70° arthroscope.

Figures

Fig 1

While one is visualizing through the AL portal, a Clancy curved drill guide is introduced through the AM portal, ensuring that its tip rests in the middle of the ACL femoral footprint. The entry point for the guidewire should be located inferior to the lateral intercondylar ridge and directly onto the bifurcate ridge (when performing an anatomic single-bundle technique) and approximately 7 mm superior to the inferior chondral junction.

Fig 2

A flexible passing pin is inserted through the curved drill guide and advanced through the femoral condyle until it exits the distal thigh. Sounding of the lateral femoral outer cortex is performed, much as it is in fracture drilling, to obtain the intraosseous length.

Fig 3

The Clancy flexible reamer is inserted through the AM portal over the passing pin. Directly visualizing passage of the reamer across the medial femoral condyle will help avoid iatrogenic injury to the medial femoral condyle.

Fig 4

The prepared ACL graft is loaded onto the EndoButton and passed retrograde through the tibial tunnel back into the knee and then into the femoral tunnel. A probe or looped grasper should be used to help lever the pulling sutures and help navigate the graft through the intercondylar notch and into the femoral tunnel aperture.