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Aesculap® POSITION ACLThe anterior cruciate ligament reconstruction system Operating technique
Aesculap Orthopaedics
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Table of contents
POSITION ACLAnterior cruciate ligament reconstruction system 4
Operating technique1 | Transplant selection 6
2 | Transplant harvesting 8
3 | Drill channels 10
4 | Transplant preparation 15
5 | Transplant insertion and fixation 24
6 | Double Bundle Technique 27
7 | Postoperative Care 31
Implants 40
Basic instrument setFemoral aiming devices 43
Tibial aiming devices 44
Instruments 45
Basic Instrument SetSuture Board 46
Drills 47
InstrumentsDilators 48
Instruments 50
StorageAdditional instruments 51
Recommended Containers 52
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POSITION is a system for minimally invasive arthro-scopic anterior cruciate ligament reconstruction. The surgical procedure allows for free selection of thetransplant. With the POSITION Basic Instrument Set, positioningof drill channels and fixation of the transplant areperformed without a femoral incision. The POSITION Suture Board facilitates and supportsthe transplant preparation.
The freedom of selection of the transplant togetherwith the special POSITION titanium implants – theSuture Plate (femoral) and Suture Disk (tibial) – repre-sent an important advance compared to fixation de-vices such as intra- or extra-articular screws or staples.With correct assemply, transplant, fixation at a dis-tance from the joint obtains the same results as fixa-tion close to the joint. Fixation at a distance from thejoint also significantly facilitates any later revision.
The POSITION Implantation Set also makes the opera-tion easier. It contains all necessary implants and suture materials for this operating technique. Thesetare perfectly matched to one another – and are sim-ply presented in a single sterile pack – for outstanding results with much less effort.
POSITION ACL – anterior cruciate ligament reconstruction system
FO010R
FR507M
FO029
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POSITION Suture Plate
Femoral transplant fixation
� Less invasive – no lateral incision � Easy revisions – no intra-articular implants � Free selection of transplants with high rupture
resistance
POSITION Suture Disk
Tibial transplant fixation
� Better transplant integration attributable to the central position of the tendon in the drill channel.
� Less bleeding due to distal covering of the drill channel.
� Implant removal unnecessary, because of the flushfit of the Suture Disk on the bone surface andknots recessed in the implant. Defined repro-ducible tightening of the transplant with thePOSITION Twister.
� An important feature in the double bundle (DB) technique since each bundle must have a differenttransplant tension.
POSITION Implantation Set
� Simple sterile setup � All necessary components from one source � Matching suture materials and implants � Suture materials specific for single- and double-
bundle technique
Suture Plate Suture Plate mit Endless Loop
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Operating technique
1 | Transplant selection
� Variable transplant width� Easy preparation� Stable primary fixation� Preservation of active internal rotation� Slow, clinically proven ligamentation� Good long-term results (published)� Weakening of the antagonist
� Smaller skin incision in non-mobile area� No impairment of extensors� No problems associated with kneeling� Good blood supply to the strands� Elasticity similar to healthy cruciate ligament
Semitendinosus tendon
� Impairment of active internal rotation� Bleeding from transplant donor site� No published long-term results on
ligamentation and remodelling processes� Longer preparation time� Weakening of the agonist
Patellar tendon
� Problems from donor site defects� Impairment of the extensors� Approximately 15 % persistent quadriceps function loss� Anterior knee pain� Problems with kneeling activities� Slow ligamentation with transplant maturation� Very stiff transplant� Increased risk of cyclops syndrome and arthrofibrosis� Risk of patella fracture � Skin incision in mobile areas, tendency for keloid
formation � Drill channels are completely filled out with bone
material, but not with the tendon; synovial fluid canenter the drill channels and cause cystic expansion
� Double bundle technique not possible
Advantages Disadvantages
Advantages Disadvantages
Two innovations have improved the results of ACL re-construction surgery: the introduction of arthroscopicoperating techniques and targeted, early-functionalpostoperative therapy with immediate full extension. For a long time patellar tendon surgery was consideredthe ”gold standard” in ACL surgery. Femoral fixationwith the Suture Plate enables the use of the semi-tendinosus tendon with a quadruple technique. Thismeans that the gracilis tendon can be preserved forthe most part. The semitendinosus tendon alone is
suitable for performing the double bundle technique,involving the gracilis tendon only if necessary. Thequadriceps tendon is now being increasingly used forrevision transplants.
To assist in the selection of the appropriate transplant,the advantages and disadvantages of the differenttendon types are listed below.
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� Very thick long transplant� Variable transplant widths and lengths� Active internal rotation preserved� Weakening of the antagonist� Proven revision transplant� Scar distortion can be compensated with
the quadriceps muscle� Implantation technique similar to that
of the semitendinosus tendon
Quadriceps tendon
� Second ventral skin incision necessary� No published long-term results on ligamentation
and remodelling processes� Double bundle technique not possible
Advantages Disadvantages
The patellar tendon and semitendinosus tendon makegood transplants for the anterior cruciate ligament.However, the semitendinosus tendon is preferred inthe following cases:
� Patients involved in frequent kneeling activities� Patella infera� Morbus Osgood Schlatter disease� Tibial intramedullary nailing � Injury to the patella or patellar tendon
Regarding alternative operating techniques withoutlateral incision, the femoral block technique and central femoral fixation with an interference screware very common. For safety reasons, a distance of 1 mm to 2 mm to the posterior bone wall must bekept to prevent a bone break-through (“blow out”)caused by the fixation. Therefore, there is a tendencyto apply the drill channels too far towards ventralwhen implanting the interference screw.
Other possible complications:
� Damage to the transplant� Screw or bone defect following a revision
Revision often necessitates a two-stage intervention.Initially, the hole left by the interference screw isfilled out with a corticospongiosa bone chip. The actual stabilization is carried out in the second step.
The operating technique using the POSITION ACL Reconstruction System, as described below, takes intoaccount the above advantages and disadvantages:free choice of transplant, drilling technique withoutlateral incision and extra-articular implants for trans-plant fixation with easier revision should this becomenecessary.
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Operating technique
2 | Transplant harvesting
Semitendinosus tendon (STT)
The skin incision to harvest the semitendinosus ten-don must be at least 3-4 cm long. It begins mediallyclose to the end of the tibial tuberosity.
When preparing the subcutaneous tissue, care mustbe taken to avoid injury to the aponeurotic sartoriustendon as this is sometimes only marginally thickerthan the subcutaneous fasciae. The aponeurosis of the sartorius tendon is locatedabove the gracilis and semitendinosus tendon. Thegracilis tendon can be palpated as the thicker tendonof the pes anserinus. The semitendinosus tendon lyinginferiorly is harvested. The gracilis tendon is harvestedonly in the event of inadequate transplant quality.
The gracilis tendon is retracted using a Kocher clampin order to identify the gracilis tendon and the STTfrom proximal. The STT is luxated with a small, 90°-curved Overholt clamp and armed with a suture.
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The STT is taken out distally by taking both the perios-teum and the Sharpey’s fibres up to the tibial crest be-low the tubercle. This is to obtain an additional lengthof approximately 2 cm. Also, the periosteum flap willimprove tendon attachment in the tibial drill hole.
To strip the tendon, the standard procedure is to use a 6 mm Tendon Stripper (FO023R). With thicker tendons,the Tendon Stripper FO024R, which has an internal diameter of 7 mm, can be used. Both instrumentshave a measuring scale on the shaft, which allows for monitoring the tendon length already harvested inthe stripping process. Before stripping begins, it is important to sever theconnections with the medial head of the gastrocne-mius, the gracilis tendon, and the semimembranosustendon with a sharp cut. Otherwise, the tendon strip-per can slip and destroy the transplant. Harvesting ofthe semitendinosus tendon is more manageable ifgood muscle relaxation is ensured.The harvested tendon is usually between 24 cm and34 cm in length. The gracilis tendon should only beused in exceptional circumstances (if the tendon lengthis less than 24 cm or if the posterolateral bundle doesnot meet the minimum 5- mm diameter required), asthis may result in excessive functional impairment ofthe pes anserinus. An additional periosteal flap is grafted from belowthe STT donor area. This will later be sutured into thefemoral loop of the transplant.
For easier identification, the sartorial fascia, proxi-mal to the gracilis tendon, can be split for 3 cm to 4 cm along the length of the tendon.
Note
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Operating technique
3 | Drill channels
Prior to the actual ACL reconstruction, meniscus andcartilage pathologies are treated arthroscopically, ifnecessary. As the second step of the preparation, anyresidual scar tissue should be removed from the fossa.When doing this, as many structures as possible shouldbe preserved to improve orientation and preserve pro-prioceptive sensors.
Tibial drill channel
Single bundle techniques
The remaining distal stump of the anterior cruciateligament is used as an orientation point for positioningthe tibial drill hole.
Other reference points are:
� Distance from posterior cruciate ligament� Medial tibial spina� Anterior horn of the lateral meniscus
Using the Tibial Aiming Device (FR500M), a 2.5- mmKirschner wire (LX045S) is inserted. The distance of thehook of the Tibial Aiming Device from the K-wire exitpoint is 5 mm.
With the K-wire in place, the aiming device is removedand the tibial channel is drilled out step by step, usinga series of cannulated drills (FR515R - FR521R) according to the measured total transplant thickness.Drilling in stages allows subtle corrections to thechannel position and reduces thermal damage to thespongiosa.
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Patellar tendon transplant
Initially, the tibial channel should be applied with a 6- mm trephine in order to obtain a cylinder of spon-giosa, which can be used to fill the defects left at thedonor site in the patella and tibial tuberosity.
Next the channel is drilled open to the required thickness, using cannulated drills as described above.
Femoral channel
Single bundle technique
PositionIn the single bundle technique, the femoral drill channel is positioned using a Femoral Aiming Device(FO006R, FO007R, FO010R, FO012R, FO013R). The off-set hook of the aiming devices is set at 3 mm to 7 mmdiameter, depending on the transplant thickness.
Transtibial introduction of the aiming device shouldbe avoided, since the target position of the femoraldrill channel on the lateral wall of the fossa (clocktime 10.30 for the right knee, 1.30 for the left) cannotbe reached. If the placement of the tibial drill channelis too horizontal, a risk is created of damaging the inner ligament or the cartilage on the medial tibialhead. With anteromedial introduction of the aimingdevice, the knee flexion must be between 110° and120°. It is common for the Hoffa fat pad to slip intothe arthroscopic field during the procedure, making it necessary to use the skin surface to read the drillscale.
e.g. 5 mm
NoteFor very long transplants, the drill channel shouldnot be too vertical, in order to avoid damage to thepes anserinus. Such damage would rule out laterrevision using the semi-tendinosus tendon.
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The femoral aiming device is hooked in an appropriateposition on the posterior fossa wall and the drill pin/pull-out pin (FO025R, FO036R) is inserted until it perforates the opposite lateral cortex.
Operating technique
3 | Drill channels
NoteAs an alternative to step-by-step drilling, dilatorsmay be used to compress the drill channel. Thishelps prevent drilling-related heat necrosis, whilecompression of the spongiosa will also contributeto the tendon healing process.
NoteIn the case of anteromedial drill channel positio-ning, the femoral drill channel is sometimes veryshort. If the transplant thickness is greater than 6 mm, a test channel of the appropriate insertiondepth should be made as a precaution, to preventperforation of the opposite cortex with a thickerdrill, which would hinder the application of theSuture Plate fixation method.
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10 mm
“B”
"C"
“Af”
20 mm (tendon length “Af“in the femoral channel) + 10 mm (flip radius)
= 30 mm (minimal drilling depth “B“)
Measuring drill depth “B”
To determine the drill depth “B”, the length of theprepared graft needs to be known. This graft is usuallybetween 6 cm and 8 cm long.
First, the transplant portion inside the femoral drillchannel is determined (length “Af”). This is calculatedfrom the total transplant length and the individualintra-articular length set by the surgeon. It is usuallyabout 22 – 24 mm. In most cases, 20 mm of the graftis placed in the femoral channel to enable placementof the longer graft length in the tibial channel. Exceptions include very long grafts in small knee joints(22 mm femoral insertion depth) and graft lengthsshorter than 70 mm (18 mm femoral insertion depth).Intra-articular placement of the suture material, how-ever, must be avoided.
Example
Then drilling depth “B” can be determined, which requires at least a 10- mm flip radius of the POSITIONSuture Plate to be added to the length of the tendonportion within the femoral channel “Af”.
Example
Total graft length (e.g. 70 mm)
Femoral “Af” Intra-articular Tibial “At”20 mm 24 mm 26 mm
70 mm (graft length)– 24 mm (intra-articular length)
= 46 mm
= 20 mm (tendon portion “Af” in femoral channel)= 26 mm (tendon portion “At” in tibial channel)
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There must be at least 18 mm of tendon in bothfemoral and tibial channels to ensure adequate tendoningrowth. When using the patellar tendon, at least thelength of the bone block should be sunk into the drillchannels.
The drilling depth “B” is drilled under arthroscopic con-trol, using the reamers with scale markings (FO081R –FO093R), according to the measured transplant thick-ness. (If visualisation is poor, read the scale on theskin.)
Completion of the femoral drill channel
The penetration channel, through the opposite lateralcortex “C”, is applied with a 4.5- mm reamer (F0026R)in such a way that the Suture Plate can be pulledthrough completely. Preferably, to reduce the overalloperation time, the tendon should be prepared andarmed with holding sutures by an additional surgicalteam.
Operating technique
3 | Drill channels
NoteTo avoid penetration of the lateral cortex, the last 10 mm of the half channel should be drilled by hand,without motor power.
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4 | Transplant preparation
Preparation and arming of the semitendinosus tendon
scaleswork surface
tendon clamps
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Operating technique
4 | Transplant preparation
Preparation of the semitendinosus tendon
After harvesting the transplant, the useful length ofthe semitendinosus tendon is measured along the Suture Board (FO029). A curette or rasp is used to remove muscle tissue still attached to the proximalaponeurosis.
When the semitendinosus is used as a single strand,previous experience has shown that it is too weak forthe long term. It tends to stretch, especially after 2 to5 years. Thus it is inadequate for cruciate ligament reconstruction. For this reason at least three strandsof semitendinosus tendon are used today and wherepossible four. In the quadriceps technique a minimumlength of 24 mm is required to support a transplantlength of 6 cm. If the useable tendon material is shor-ter than 24 cm, the triple technique must be used instead or a gracilis tendon graft must also be added.
For the quadruple M technique, the entire tendongraft is arranged in an M-shape with four legs ofequal length.
For the triple S technique, the full length of tendon isarranged in an S-shape with 3 legs of equal length.
Quadruple Mtechnique
Triple Stechnique
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The graft thickness is measured with the measuringblock (FO038R) and thereby the diameter of the drillchannels can be set. Each end must be measured separately since the femoral drill channel is often 0.5 –1.0 mm thinner than the tibial because of the com-pression procedure used.
Arming the semitendinosus tendon
The POSITION Implantation Set includes the implantsas well as all necessary suture materials for the operating technique described below.
The tendon grafts sections for the quadruple techniqueor the triple technique are clamped under tension inthe detachable atraumatic tendon clamp on the Suture Board. The free tendon ends are armed, underlight tension, with Premicron®, USP2, HRT 37.
When arming the tendon, care must be taken that ap-proximately 15 mm of each tendon end is held by thesutures. The loops must be tightened very tightly. Thedistance between the loops must be large enough toallow attachment of the tendon into the bone channel.
15 mm
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The strip of periosteum harvested from the STT donorsite is sutured into the femoral loop of the transplant,close to the aperture, to block the channel so that anadditional piece of periosteum is present in the femoralchannel. This will improve the ingrowth of the tendoninto the femoral bone channel and help prevent pene-tration of synovial fluid.
Once the tendon graft has been armed with sutures, itshould be re-measured since its thickness may increasebecause of suturing, especially in the tibial channel.
Operating technique
4 | Transplant preparation
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Pre-tensioning the transplant
Ruler for knot length measurement
Slider
Spring
Suture Disk holder
Suture Plate holder
Pre-tensioning device, femoral
Pre-tensioning device, tibial
Suture holder
Spring scale
The tendon clamps are replaced with the pre-tensioning devices and the implant holders.
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Arming the implants
In the quadruple strand technique, the graft ends arebrought together to form a loop and the Surgical Loopor Dagrofil® USP6 is threaded through this and doubled.This is then fed through the inner two holes of theSuture Plate so that the ends lie between the graftand the Suture Plate.
The outer two holes are threaded with two further sutures (a pull and a flip suture). The pull suture shouldbe strong enough to resist breaking since it is oftenvery difficult to pull the transplant through to thebone channel if the compression technique is used.
The Suture Plate threaded with sutures is inserted intothe Suture Plate holder. The Surgical Loop is fixatedwith a clamp after pre-tensioning.
The tibial sutures are fed through the two holes of theSuture Disk, wrapped around the suture holder, andsecured with the mosquito clamp (BH104R).
The required pre-tensioning can be adjusted by press-ing the spring on the tibial pre-tensioning device andfixating the slider in the appropriate position. Thetension can be read from the spring scale.
Both tendon types require pre-tensioning of the com-plete system for about 5 minutes, at a defined tension.The transplant and the sutures will be stretched andthe knots will settle down.
Operating technique
4 | Transplant preparation
Dagrofil® USP6
Dagrofil® USP2
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Measuring knot length “K”
After pre-tensioning of the transplant, the requiredknot length is measured and fixed.
For knot length “K”, which defines the distance between the Suture Plate and the implant, the totallength “G” of the femoral drill channel is measuredusing the Depth Probe (FO027R). From this, the transplant length “Af“ within the femoral channel issubtracted.
Example
„G“ (50 mm)
„K“ (30 mm)„Af“ (20 mm)
„G“, 50 mm
50 mm (total length “G“) – 20 mm (tendon length “Af“ in the femoral drill
channel)
= 30 mm (knot length “K“)
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The knot length “K” (example: 30 mm) is adjusted onthe ruler of the femoral implant holder of the SutureBoard; the distance is fixed by knotting the SurgicalLoop under tension. In this case, the reading is nottaken directly from beneath the Suture Plate, but inrelation to a preset zero point.
Operating technique
4 | Transplant preparation
Suture Plate
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Insertion marking “M”
Before insertion, an entry mark is made on the trans-plant. This mark indicates, intra-articularly, when theSuture Plate has been pulled out of the opposite lateralcortex by a sufficient distance so that it can be flipped.This prevents the Suture Plate from being pulled toofar into the muscles and during the plate withdrawalavoids the risk of trapping tissue between the implantand the bone, which could lead to a loss of corticalfixation.
The position of the transplant marking is determinedby the length of transplant in the femoral drill channel(“Af”), plus an extra 10 mm to allow for the SuturePlate to be turned (flipped) after it has emerged fromthe femoral cortex. The insertion mark “M“ correspondsto the minimum drilling depth “B“.
Example
“G“
“K“
“Af“ (20 mm)
“M“ (30 mm)
20 mm (tendon length “Af“)+10 mm (flip radius)
= 30 mm (marking “M“)“Af” 10 mm
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Operating technique
5 | Transplant insertion and fixation
Inserting the transplantSingle bundle technique
The pull and flip sutures are threaded through the eyeof the pullout pin (FO025R, FO036R).
NoteAlternatively, the eye of the pullout pin can be armed with a suture loop at the distal end. This willmake it easier to thread the pull and flip sutures.
Since the transtibial approach to the femoral channel isnot an option, direct pulling of the pullout pin throughthe tibial and femoral channels is not possible. Thepullout pin therefore must first be introduced throughthe anteromedial portal of the arthroscope and thefemoral drill channel, inserted percutaneously, andpulled through until the suture loop projects from thechannel. A micro-forceps (OG335R) is introducedthrough the tibial channel and the suture is guided outtranstibially. Care must be taken that the suture loop islong enough. The pull and flip sutures are placed in the suture loop in such a way that the Suture Plate isvertical when guided by the pull sutures.
The transplant is pulled through until the mark on thetendon emerges at the exit of the femoral drill channel.
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Femoral fixation
By pulling the flip suture, the Suture Plate is posi-tioned across the drill hole. The graft is pulled backinto the joint by 10 mm, so that the Suture Platerests flat on the femoral cortex. Next, the graft is pulled distally by the tibial suturesso that the Suture Plate rests flat on the cortex.Then the knee is moved through flexion and exten-sion several times while keeping the graft underhigh tension.
Tibial fixation
Prior to tibial fixation, the surface on which the Suture Disk (FO035T, FO034T) will be supported isexposed.
Tibial fixation is executed using the Suture Disk. The transplant is tensioned and the distal suturesare tied under tension.
The second knot is applied using a knot pusher(FO028R). This ensures the secure fixation of the firstknot and prevents knot slipping and the consequentmajor loss of implant tension.
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Operating technique
5 | Transplant insertion and fixation
Reducing residual laxicity
The leg is moved through flexion and extension severaltimes and kept in hyperextension. The transplant willsettle finally in this process and the tibial knottingwill yield slightly. The residual laxicity caused by thiseffect is eliminated by twisting the Suture Disk, usingthe Twister (FO037R). The tibial sutures are wrung inthis way. While twisting, the twister should be tuggedoccasionally to determine whether any residual laxicityremains. Otherwise, overuse of the twister may leadto rupture of the tibial sutures. The twister can alsobe used to set the transplant tension individually perstrand, while comparing it with the healthy oppositeside. If the single bundle technique is used, thisshould be performed at approx. 30° knee flexion.
For this purpose, the twister is hooked into the SutureDisk openings and the tension is increased gradually,preferably in steps of clockwise half turns. After eachhalf turn, the tension is measured by pulling at thetwister handle until the suture disk is lifted off,slightly, from the tibia. Experience so far shows thatthe optimum tension is up to 40 units for female patients and up to 70 units for males. As a precaution,the sutures should be cut off only after the final tension has been achieved.
The Suture Disk “L” (FO034T) with rotation lock reliablyprevents any back-rotation of the implant, thus help-ing to maintain the applied tension. The Suture Disk centres the tendon in the tibial drillchannel. To prevent haemorrhages, the channel is near-ly completely closed towards distal. The knots rest in the depression of the disk so that the fixation is supported at bone surface level and the distal implantdoes not need to be removed. With the distal fixation completed, the pull and flipsutures are removed, the sartorius fascia is closed andthe wound is closed with an intracutaneous suture.The separated sartorius fascia is sutured to the gracilistendon, which displaces the latter in the direction ofthe former STT (sartorius reconstruction) and improvesinward rotation.
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Operating technique
6 | Double Bundle Technique
anteromedial
posterolateral
If preparation of the semitendinosus tendon providesa tendon graft that is both long enough for thequadruple technique and also at least 7 mm thick,the surgeon can switch from the single bundle tothe double bundle technique.
The multi-channel technique allows targeted recon-struction of the anteromedial and posterolateralcruciate ligament bundles to produce anatomicallyand kinematically correct conditions. Whereas theanteromedial bundle stabilizes the higher degreesof flexion, the posterolateral bundle becomes tautat near extension and controls the screw-homemechanism. Furthermore, the diagonal course of the posterolateral bundle in thefrontal plane has an additional stabilizing effect onthe periphery, especially on the posterolateral corner(rotational stabilization).
Using two femoral and tibial drill channels to receivethe transplant substantially increases the contactsurface between the tendon transplant and the bonewall. This improves the blood supply to the tendontransplant and also leads to increased formation of“Sharpey’s fibres”, making the graft more resistantto being torn from the bone.
The elements of the surgical procedure differing fromthe single bundle technique are described below.
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Operating technique
6 | Double Bundle Technique
Anteromedial bundle
In the double bundle technique also as much as possible of the distal stump of the anterior cruciateligament should be retained for orientation purposes.However, care must be taken in the tibial double bundle technique to clean the area directly in front of the posterior cruciate ligament to make the entrypoint for the K-wire visible.
1. Tibial drill channelThe Tibial Aiming Device (FR500M) is inserted into thejoint. The target area is the transition from the ventralthird of the insertion to the middle third. The landmarkhere is the position of the anterior horn of the lateralmeniscus. One should make sure that the tibial entrypoint is only approx. 1 cm from the tibial tuberosity,to leave space medially for placement of the tibialposterolateral drill channel. The K-wire entry is first drilled with the 4.5 mm drilland then reamed to match the measured transplantthickness.
2. Femoral drill channelAfter the joint has been cleaned, the Femoral AimingDevice is introduced through the anteromedial portaland inserted behind the posterior fossa margin in the11.30 position for the right knee or the 12.30 positionfor the left knee. The knee is positioned in 110 – 120°of flexion and the femoral K-wire is placed so as toreach both cortices. Then, a pocket hole is formedwith the head reamer according to the femoral graftdiameter. The drill channel is completed using the 4.5 mm drill and the channel length is measured withthe Depth Probe.
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Posterolateral bundle
1. Tibial drill channelIn the subsequent step, the second Tibial Aiming Device (FR507M for the left knee joint, FR508M forthe right knee joint) is inserted into the previouslydrilled anteromedial tibial drill channel, so that thetip of the aiming device is positioned behind thedorsal circumference. At 90° knee flexion, the K-wireshould be visible inside the joint directly in front ofthe ventral margin of the posterior cruciate ligamentand 3 mm medially from the lateral spina. Here toodrilling should be performed step by step accordingto the diameter of the individual grafts.
2. Femoral drill channelBecause of the very diagonal course of the tibialdrill channel through the tibial head, the AimingDevice for the posterolateral femoral drill channel(FO011R) can be positioned easily in the targetedposition dorsal to the right lateral fossa margin, atthe 10.30 position for the right knee and the 1.30position for the left knee. Care should be taken thatthe knee is flexed to 100° (+/- 5°). Here also themeasured drill depth “B” should be drilled accordingto the transplant diameter and completed with the4.5. head reamer. To determine the knot length “K”,the posterolateral femoral drill channel is alsomeasured with the Depth Probe (FO027R).
posteromedial drillchannel
anteromedial drillchannel
anteromedial drillchannel
posteromedial drillchannel
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Operating technique
6 | Double Bundle Technique
Pulling the two cruciate ligament bundlesthrough
Both pullout pins are introduced through the antero-medial access and the suture loops are pulled with aMicro-Forceps (OG335R) through the correspondingtibial drill channels. To draw in the two transplants,first the posterolateral pull-through pin is placed andthen an anteromedial pin. Using a similar sequence,the transplants are pulled in, first the posterolateraland then the anteromedial.The Mini-Suture Disks (FO065T) are used to performthe tibial fixation. The posterolateral bundle is knottedat 10° close to the extensor and later tensioned. Theanteromedial bundle is knotted at approx. 45°. Duringfinal tensioning particular care must be taken becauseof the small size of suture used – 3 to 4 twists are fully sufficient to build up tension. Increases in tensionmust be very carefully tested to prevent suture untwisting through the Suture Disk. To preventextensor deficits, it is preferable to pretension theposterolateral bundle close to the extensor cautiously,applying approx. 20 newtons of force. The anterome-dial bundle is tensioned to 40 – 50 newtons at 45°flexion in accordance with the joint play on the opposite side. It is recommended to use the twister(FO037R) routinely to determine if any residual elasticity still remains in the suturing system.
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Operating technique
7 | Postoperative Care
Long experience in working with experts in the fieldsof sports medicine (Dr. J. Eichhorn, Sporthopaedi-cum, Straubing) and physiotherapy (e.g. at the EdenRehabilitation Centre, Donaustauf, Bavaria) hasproved the value of phased postoperative treat-ment. Multi-stage therapy respects the physiologicalfundamentals (wound healing progress in the affected structures), individual conditions, prerequi-sites for that patient, functional progress in the activities of daily living (ADL), and the empiricaland pragmatic experiences of time- and cost-opti-mized rehabilitation. When clinical and functionalparameters indicate it, the patient can move on tothe next stage. Interindividual differences can beoptimally managed in this way and increased com-plications due to overly ambitious weight-bearingcan be avoided. The following general schedule issuggested for the respective rehabilitation stages:
Stage 1 Acute or inflammation stage along with the start of the proliferation stage – weeks 1 and 2 on average
Stage 2 Proliferation stage along with the start of the remodelling stage – weeks 3 to 6 on average
Stage 3 Remodelling stage – usually from week 7
The following summarized specific targets may bescheduled to match the particular therapy stages:
Overview of therapy targets, Stages 1–3
Stage Schedule Therapy targets
l Postoperative � Pain alleviation/weeks 1 and 2 reduction
� Reduction of possible swelling
� Maintenance of mobility in the femoral-patellar joint
ll Postoperative � Normalization of weeks 3 – 6 mobility
� Progressive increase in weight-bearing to full functionality
� Restoration of coordinationcapacity
� Stabilization of the normal pelvic-leg axis
lll Postoperative � Normalization of routineweek 7 motor functionality
� Achievement of normal muscle balance along the entire pelvic-leg axis
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Operating technique
7 | Postoperative Care
Stage 1
After surgery, the knee joint is first placed in a kneeimmobilization splint with Velcro fasteners for a week.Normally the splint is worn in full extension, and canbe replaced with a 20° splint only if additional suturesare placed on the posterior horn of the lateral meniscusor by activation of the medial collateral ligament, andin these cases, the maximum wear period is 2 weeks.It has been shown that patients can receive their firstlymph drainage right in the recovery room – the lymphvessels were compressed by the haemostatic bandagebut can be quickly reopened by massaging the lymphcirculation. This promotes the metabolism in the leg.
On the first postoperative day, the drains are removedand the patient is immediately shown how to performpatellar mobilization exercises. Otherwise there is arisk that the small recesses near the patella may develop adhesions and the patella may become hypo-mobile, resulting in ventral knee pain. In addition tothe immobilization splint, a CryoCuff (Aircast) for example can be used, which allows cold water to bepumped intermittently or continuously around theknee. Ice packs should be completely avoided in thepostoperative period because the chilling effect is excessive.
On the first postoperative day also, the patient istreated with electrostimulation of the vastus medialismuscle since experience shows that physiotherapyreaches the vastus medialis muscle only very poorly in this first stage of therapy.
Particular attention should be given to postoperativepain therapy since otherwise very severe pain willcause the operated limb to disconnect from the cere-bellum, and this can only with difficulty be restoredto a movement pattern through intensive physio-therapy.
Manual lymph drainage
Training the patient in patellar self-mobilization towards distal
33
On postoperative day 3, a dynamic splint with unlimited range may be used. This will allow thepatient to direct movement, actively for the mostpart, through the non-operated leg to the splint. Irradiation also helps promote innervation in theoperated leg through the overflow phenomenon.Heavy emphasis should be placed on proprioceptivecapabilities in Stage 1. The Hanke E-technique isparticularly effective; the immediate postoperativerecall of walking and turning patterns can preserveneuromuscular connections. Elyth ointment band-ages may be used to reduce oedema and normalizethe postoperative tissue pH.
It is important not to engage in any strenuousknee-flexion activities during the first two to threeweeks. Furthermore, active stretching of the flexorsshould be avoided otherwise the small remainingattachments of the semitendinosus at the peripherymay tear, resulting in the muscle belly snapping upwards which hinders the tendon reattachment. Inthis first stage of therapy, the patient should startto engage in half weight-bearing with the aid oftwo crutches, concentrating at this point on theachievement of a very smooth gait pattern duringgait training. Since this stage of therapy is performedmostly at rest, it must be accompanied by a regimenof thromboembolic prophylaxis with low molecularweight heparin and adequate pain medication.
In the second week, lymph drainage is continued.Furthermore, ointment bandages should be applied,manual physiotherapy exercises should be startedto improve joint mobility by gentle traction, and attention should be given especially to mobilizingthe capsule, patella, and menisci.
Preservation of neuromuscular connections in movement patterns usingthe Hanke E-technique
34
Operating technique
7 | Postoperative Care
By the end of the second week, 0/10/90° mobilityshould be achieved. With the aid of a ski boot, for example, to assist gravity, and by engaging in self-mobilization and self-traction exercises, patients cancomfortably improve their mobility (flexion) also athome and ward off the onset of pain and swelling.There should be a gradual or at least a very noticeabledecrease in swelling. If these goals are reached, thepatient is ready to move to Stage 2.
Stage 1 complicationsIn rare cases, a haematoma may form at the tendondonor site, which can then manifest on the third orfourth postoperative day because of sluggish circula-tion from the short-acting anaesthetic.
Many patients complain of shooting pains and a sensa-tion of tightness in the operated area of the leg whenthey stand up. This is due to the still impaired function-ing of the lymph and vein pumps – the return circula-tion of the blood components back to the heart is stillinadequate.
Some patients also report reddening and tension painaround the tibial tendon anterior compartment, butthis regresses significantly after 8–10 days.
Patients should be clearly instructed that in the eventof fever, throbbing pain or reddening at the knee joint,they must immediately inform their surgeon sinceearly detection and immediate initiation of appropriatetreatment are a critical part of joint infection management.
At this initial stage, the knee joint should only bepunctured in the event of tension pain at rest.
Auto-mobilization of the kneejoint in extension by using a ski shoe
35
Stage 2
The success of the operation is supported postoper-atively with a FourcePoint brace, which helps softenthe stress of daily living for six weeks. When physio-therapy exercises are performed, it has to be re-moved.
The goal of Stage 2, which lasts until the sixth weekafter surgery, is the achievement of full mobilitywith no effusions or pain in the joint. A follow-upexamination is usually performed after four weeks.If persistent deficits in rehabilitation are detected atthat point, these should be immediately managedwith targeted physiotherapy programmes. In moresevere cases, about two weeks of inpatient rehabili-tation may be necessary. The combination there of allphysiotherapy and physical resources nearly alwaysresolves the problem and in most cases obviates a recourse to revision operations to improve mobility.
The training exercises in Stage 2 are characterisedby targeted co-contractions with tensioning of theextensors and flexors. The Posturomed Proprio-Swinghas proved very beneficial in this regard: it allowsthe patient to train the neuromuscular connectionby gentle flexion (co-contraction) on a platformwith built-in instability. This is very safe since thejoint is not confronted with angle acceleration whenusing this device. At this stage also, the patient canbegin to slowly decrease the use of crutches.
Promotion of proprioceptively guided knee joint stability with single leghalf-knee flexions on a Posturomed training platform
36
Operating technique
7 | Postoperative Care
Intensive medical exercise therapy is still not encour-aged at this stage; graft stability still depends on thestability of the primary fixation, and Sharpey’s fibres– the source of secondary fixation – develop onlyslowly over this second stage and until the end of thesixth week. Cautious medical exercise therapy can bestarted therefore towards the end of Stage 2 (weeks5-6). Active exercises can also be gradually intensified,especially for the vastus medialis muscle, to eliminatefurther need for electrostimulation.
The illustration on the left shows an option which canalso be performed at home – appropriate facilitation ofthe vastus medialis muscle by generation of isometricstress with a Theraband while seated. In Stage 2, manypatients can return to work if it does not requirestrenuous bodily effort.
Initiation, enhancement and stabilization of gait patterns on the mini-trampoline to promote co-activation
Knee extension exercise with abduction stress using the Theraband topromote facilitation of the vastus medialis muscle
37
If an aquatic exercise pool is available, intensive exercises can readily be performed because of thepositive hydrostatic pressure of the water and reduction of body weight. The use of this resourcein particular often produces surprisingly fast andexcellent results. The most common types of exer-cise equipment for Stage 2 include the exercise bicycle at the start of the stage and the ellipsoidtrainer (cross-walker) at the end.
Ellipsoid trainer
38
Operating technique
7 | Postoperative Care
Stage 2 complicationsIn this stage also one should be on the watch for tar-dive infection manifested by increased swelling, pul-sating pain, or an excessively warm joint. Furthermore,should overloading occur – especially in flexor train-ing – repeated tearing in the area of the ischiocruralmusculature with a loss of function in the semitendi-nosus muscle may result; the event, however, doesnot have any particular functional implications.
Should significant effusion formation still occur towards the end of the 6–8 week period, a single in-jection of intra-articular corticosteroid (e.g. Lipotalon)can be performed, which in most cases will clear upthe hyperreactive tendency. If it does not do so, thepatient should undergo a nuclear magnetic resonanceexamination. Scar tissue or the development of a cyclops syndrome is frequently responsible for the hyperreactive problem.If such is the case, appropriate therapeutic measuresshould be started, including an investigative arthro-scopic intervention, if necessary.
Follow-up arthroscopic intervention should also beconsidered if by the end of Stage 2 the extensor ismore than 10° impaired or there is a flexor deficit ofmore than 20°. Such complications are more easilymanaged especially at this early stage.
39
Stage 3
At this point most patients perform self-exercisesunder the guidance of a physiotherapist. The firstwalks can be on level ground. Exercise bicycle andcross-walker exercises are intensified. Professionalathletes may now start sport-specific exerciseswhich are targeted to achieve the muscular qualityrequired for the specific sport. Emphasis is placedon improvement in complex coordination ability,with the use of continuously more challenging exercises. There is increasing use also of some ofthe open kinetic chain exercises for weight-bearingsince these qualities are necessary in most types ofsports. Special attention is given in this stage alsoto improving the basic endurance performance ofthe athlete through targeted exercises.
After five months, an “Ortho check” should be performed, during which parameters such as endu-rance, resilience, responsiveness, coordinative ca-pacity (proprioception), etc. are tested. Any deficitsdiscovered should be targeted for further treatmentso that professional athletic ability is recaptured bythe fifth to seventh month after surgery. Fewer exercise components are generally prescribed forrecreational athletes and in their case the recaptureof athletic ability may take up to 8 months.
Controlled knee half-flexion with varus stress to activate the medial stabilisers of the knee joint
Diagram of results of the Ortho Check
Ortho Check© Functional Analysis
Strength
Clinical status
EnduranceResilience
Proprioception
Biomechanics
Patient
ADL able to do sports
pathological deficit
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Implants
� FO030T Suture Plate Sterile, titanium alloy 4 x 12 mm
� POSITION Endless Loop FO070T, 20 mmFO071T, 25 mmFO072T, 30 mmFO073T, 35 mmFO074T, 40 mmFO075T, 45 mmFO076T, 50 mm
� FO035T Suture Disk “S” Sterile, titanium Ø 14 mm
� FO065T Mini Suture Disk Sterile, titanium Ø 11 mm
� FO034T Suture Disk “L” with rotation lockTitanium Ø 14 mm
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� FO039 Implantation set for STT, sterile comprising:1 x Suture Plate FO030T1 x Suture Disk “L” FO034T4 x Premicron®, USP2, HRT 37, 75 cm1 x Dagrofil®, USP6, 150 cm1 x Dagrofil®, USP2, 150 cm1 x Surgical Loop, 4 mm, 75 cm
� FO040 Implantation set for STT, sterile comprising:1 x Suture Plate FO030T1 x Suture Disk “S” FO035T4 x Premicron®, USP2, HRT 37, 75 cm1 x Dagrofil®, USP6, 150 cm1 x Dagrofil®, USP2, 150 cm1 x Surgical Loop, 4 mm, 75 cm
� FO042 Implant set for DB-ACL fixation 2 x FO030T Position Suture Plate2 x FO065T Position Mini Suture Disk1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm, REF 00267171 x Dagrofil® USP2, white, 1 x 150 mm, REF 03721022 x Dagrofil® USP6, green, 1 x 150 mm, REF 03421491 x Surgical Loop 4 mm, green, 1 x 75 mm,REF 1094912
� FO043 Implant set for tibial ACL fixation, lock 1 x FO034T Position Suture Disk “L” 1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm, REF 0026717
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Implants
� FO046 Implant set for femoral ACL fixation1 x FO030T Position Suture Plate1 x Dagrofil® USP2, white, 1 x 150 mm, REF 03721022 x Dagrofil® USP6, green, 1 x 150 mm, REF 03421491 x Surgical Loop 4 mm, green, 1 x 75 mm, REF 1094912
� FO045 Implant set for tibial DB-ACL fixation 2 x FO065T Position Mini Suture Disk 1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm, REF 0026717
� FO044 Implant set for tibial ACL fixation, standard 1 x FO035T Position Suture Disk “S” 1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm, REF 0026717
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Basic instrument set
Femoral aiming devices
� FO012R Femoral aiming device3 mm offset
� FO013R Femoral aiming device4 mm offset
� FO010R Femoral aiming device (not illustrated)5 mm offset
� FO006R Femoral aiming device (not illustrated)6 mm offset
� FO007R Femoral aiming device (not illustrated)7 mm offset
� FO011R Femoral aiming device for posterolateral drill channel in femoral double bundle technique
off-set
44
Basic instrument set
Tibial aiming devices
� FR500M Transtibial aiming device
� FR507M Tibial aiming device (not illustrated)for posterolateral drill channel in double bundle technique, left
� FR508M Tibial aiming device for posterolateral drill channel in double bundle technique, right
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Instruments
� Tendon strippersEffective length: 340 mm, graduated shank
� FO023RInner diameter 6 mm
� FO024RInner diameter 7 mm
� FO032R Rasp (not illustrated)
� FO027R Depth probeEffective length 300 mm
� FO028R Knot pusher
� FO014R Notch gauge
� FO037R Twisterfor FO034T and FO035T
� FO067R Mini-Twister (not illustrated)for FO065T
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Basic Instrument Set
Suture Board
� FO029 Suture Board– Incl. 2 tissue clamps (FO029850), implant holder,
pretensioning attachments, andbaby mosquito clamp (BH104)
– Modular setup for individual OR procedures– Reliable recordings and measurement scales for
tendon preparation– Implant fixation for transplant pre-tensioning
� FO031 Suture Board– Addition to FO029 when using the double bundle
technique
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Drills
� Head reamer2-wing, cannulated (2.6 mm)
hexagonal shaft, length: 180 mmFO081R, Ø 5 mmFO082R, Ø 5.5 mmFO083R, Ø 6 mmFO084R, Ø 6.5 mmFO085R, Ø 7 mmFO086R, Ø 7.5 mmFO087R, Ø 8 mm
� hexagonal shaft, cannulatedlength: 205 mm
FO079R, Ø 4.5 mm
� hexagonal shaft, not cannulatedlength: 205 mm
FO078R, Ø 4.5 mm
� Drill, tibialcannulated (2.6 mm)
hexagonal shaft, length: 160 mmFR541R, Ø 5 mmFR542R, Ø 5.5 mmFR543R, Ø 6 mmFR544R, Ø 6.5 mmFR545R, Ø 7 mmFR546R, Ø 7.5 mmFR547R, Ø 8 mm
� Tissue protection sleeves (not illustrated)e.g. for determining transplant thickness Inner diam./Ø
FR705S, Ø 5.5 mm FR576S, Ø 6 mm FR706S, Ø 6.5 mm FR577S, Ø 7 mmFR707S, Ø 7.5 mm FR578S, Ø 8 mm
FO088R, Ø 8.5 mmFO089R, Ø 9 mmFO090R, Ø 9.5 mmFO091R, Ø 10 mmFO092R, Ø 10.5 mmFO093R, Ø 11 mm
FR548R, Ø 8.5 mmFR549R, Ø 9 mmFR550R, Ø 9.5 mmFR551R, Ø 10 mmFR552R, Ø 10.5 mmFR553R, Ø 11 mm
FR708S, Ø 8.5 mm FR579S, Ø 9 mmFR709S, Ø 9.5 mm FR580S, Ø 10 mmFR710S, Ø 10.5 mm FR581S, Ø 11 mm
Eccentric dilators
The key to success within the cruciate ligamentsurgery is the essential precision of the drill tunnelposition.
The aiming devices available on the market often donot grant the essential precision, so that suboptimaldrill tunnel positions are accepted. In the context of permanent improvement and extension of the POSITION instruments, eccentric dilators have beendeveloped, which allow a correction of the drill tunnelposition.
After over-drilling the k-wire with the 4.5 mm drill,the precision of the tunnel position has to be checkedthrough dislutching the arthroscope in the antero-medial porta and use of the palpation hook. Prettyoften also an experienced surgeon must state that thedrill tunnel position is not optimal.
By using the eccentric dilators in different diameters itis possible to extend the drill tunnel through the offsetof the eccentric dilators in the favoured optimized direction. In this way result-worsening compromises ofthe drill tunnel situation can be corrected and there-fore avoided.
Heinz-Jürgen Eichhorn
Dilators, eccentric
� FR817R, Ø 5.5 mm OFFSET 0.75 mm� FR818R, Ø 6.0 mm OFFSET 1.0 mm� FR819R, Ø 6.5 mm OFFSET 1.25 mm� FR820R, Ø 7.0 mm OFFSET 1.5 mm
Instruments
Dilators
48
Offset
final drill tunnel
Ø 4.5 mmdrill tunnel
Dr. Heinz-Jürgen Eichhorn, MDsporthopaedicum straubing, Straubing, Germany
� FR750 Drill channel dilator setcomprising:FR751R Storage tray FR752R Handle with extraction hammerFR775R – FR781R Dilators, sharpFR785R – FR790R Dilators, sharp(round dilators must be ordered separately) FR793R – FR795R Tibial guide pins FR753R Femoral guide pin
� FR751R Storage tray for dilators (not illustrated)
� FR752R Handle with extraction hammer
� Dilators, sharp
FR775R, Ø 5 mmFR776R, Ø 6 mmFR777R, Ø 7 mmFR778R, Ø 8 mmFR779R, Ø 9 mmFR780R, Ø 10 mmFR781R, Ø 11 mm
� Dilators, blunt
FR755R, Ø 5 mmFR756R, Ø 6 mmFR757R, Ø 7 mmFR758R, Ø 8 mmFR759R, Ø 9 mmFR760R, Ø 10 mmFR761R, Ø 11 mm
� Tibial guide pins, movable head
FR793R, Ø 4.5 mmFR794R, Ø 6 mmFR795R, Ø 8 mm
� Femoral guide pin, fixed head
FR753R, Ø 4.5 mm
FR785R, Ø 5.5 mmFR786R, Ø 6.5 mmFR787R, Ø 7.5 mmFR788R, Ø 8.5 mmFR789R, Ø 9.5 mmFR790R, Ø 10.5 mm
FR765R, Ø 5.5 mmFR766R, Ø 6.5 mmFR767R, Ø 7.5 mmFR768R, Ø 8.5 mmFR769R, Ø 9.5 mmFR770R, Ø 10.5 mm
Dilators
49
Instruments
� FO038R Measuring blockFor measuring the transplant thickness
� K-wires
FO025RDrill and pullout pin with drill helix and eye,Total length: 380 mm, shaft: Ø 2.4 mmTip: Ø 2.7 mm
FO036RDrill and pullout pin with eye Total length: 380 mm , Ø 2.5 mm
LX045SK-wireTotal length: 310 mm, Ø 2.5 mm
� FO002R ACL Basic Instrument Storage Case
– POSITION open basket with storage for Suture Board FO029 ensuring reliable, gentle and rapid storage and preparation of instruments
– comprising:JF222R Open BasketFO002/200 silicone storage insert for POSITION
� FO003R ACL Basic Instrument Storage Case
– POSITION open basket with storage for implants and instruments
– comprising:JF222R Open BasketFO003/200 silicone storage insert for POSITION
50
� OG335R Micro forcepsStraight, 5 x 1 mm
� BM016R Durogrip Crile Wood needle holder145 mm
Additional instruments
51
52
Storage
Recommended Containers
� JK440 container
– 1 tray– Outer dimensions: 592 x 274 x 90 mm
e.g. for storing FR751R (dilators)
� JK442 container (no illustration)
– 2 trays– Outer dimensions: 592 x 274 x 135 mm
e.g. for storing FO002R and FO003R (ACL Basic Instruments)
� JP001 PrimeLine Container Cover, red
– 1 cover, available in several colours– For JK440 or JK442, red
� JG785B Label, red
– Accepts up to 13 characters– 4 labels per container recommended
� JF436R Optiktray
– Optiktray for reliable storage during transport, cleaning and sterilization of arthroscopes, e.g. PE545A
– Shaft diameters from 2.7 mm– Shaft lengths from 140 mm to 200 mm– Dimensions: 273 x 84 x 41 mm
53
Notes
Aesculap AG | Am Aesculap-Platz | 78532 Tuttlingen | GermanyPhone +49 7461 95-0 | Fax +49 7461 95-26 00 | www.aesculap.com
Aesculap – a B. Braun company
Subject to technical changes. All rights reserved.This brochure may only be used for the exclusivepurpose of obtaining information about ourproducts. Reproduction in any form partial orotherwise is not permitted.
Brochure No. O13602 0912/1/5
The main product trademark ‘Aesculap’ is aregistered trademark of Aesculap AG. ‘Dagrofil’ is a registered trademark of B. Braun MelsungenAG. ‘PremiCron’ is a registered trademark of B. Braun Surgical GmbH.
