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.

Abstract

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. 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 3-6months post-operatively. 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 ± 4.4mm; 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. 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 forall patients (even when hyperflexion is a challenge). I.