ANATOMICAL DOUBLE-BUNDLE RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT

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3 ANATOMICAL DOUBLE-BUNDLE RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT Wolf PETERSEN 1 and Thore ZANTOP 2 1 Department of Traumatology, Martin Luther Hospital, Berlin-Grunewald, Germany 2 Sporthopaedicum Straubing, Germany

4 4 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Wolf PETERSEN 1 and Thore ZANTOP 2 1 Department of Traumatology, Martin Luther Hospital, Berlin-Grunewald, Germany 2 Sporthopaedicum Straubing, Germany Please note: Medical knowledge is constantly changing. As new research and clinical experience broaden our knowledge, changes in treatment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accordance with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein, or changes in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this work, can guarantee that the information contained herein is in every respect accurate or complete, and they cannot be held responsible for any errors or omissions or for the results obtained from use of such information. The information contained within this brochure is intended for use by doctors and other health care professionals, but is not meant to be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peer-reviewed medical literature. Some of the product names, patents, and registered designs referred to in this booklet are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appea rance of a name without designation as proprie tary is not to be construed as a representation by the publisher that it is in the public domain. Addresses for correspondence: Prof. Dr. med. Wolf Petersen Abteilung für Unfallchirurgie Martin-Luther-Krankenhaus Caspar-Theyß-Straße Berlin-Grunewald, Germany Phone: +49 (0) Fax: +49 (0) info@mlk-berlin.de Internet: PD Dr. med. Thore Zantop Sporthopaedicum Straubing Bahnhofplatz Straubing, Germany Phone: +49 (0) 9421/99570 Fax: +49 (0) 9421/ info@sporthopaedicum.de Internet: Tuttlingen ISBN , Printed in Germany P.O. Box, D Tuttlingen Phone: +49 (0) 74 61/ Fax: +49 (0) 74 61/ Endopress@t-online.de Editions in languages other than English and German are in preparation. For up-to-date information, please contact Tuttlingen, Germany, at the address indicated above. Typesetting and image processing:, Tuttlingen, Germany Printed by: Straub Druck + Medien AG D Schramberg, Germany All rights reserved. No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invented, including photocopying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder.

5 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 5 Table of Contents Introduction Advantages Indications Contraindications Risk Disclosure Preoperative Preparations Anesthesia and Positioning Operative Technique Postoperative Care Errors, Hazards, and Complications Incorrect Placement of the Femoral Tunnels Incorrect Placement of the Tibial Tunnels Recommended Literature Instrumentation for Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Endoscopes, Instruments and Accessories

6 6 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Introduction 1 Arthroscopic view of the posterolateral bundle of the anterior cruciate ligament. The anterior cruciate ligament (ACL) is composed of an anteromedial bundle (AM) and a posterolateral (PL) bundle 3 (Fig. 1). Both of these functional bundles tighten and loosen in a reciprocal fashion: The PL bundle is tight when the knee is extended, and the AM bundle tightens during flexion of the knee (Fig. 2 and Fig. 3). This reciprocal tightening of the ACL bundles stabilizes the knee joint against anterior tibial translation over a large range of flexion angles. The PL bundle also makes an important contribution to the rotational stability of the knee joint (anterior tibial translation in internal rotation) because it tightens when the joint rotates. Both functions of the ACL anterior stabilization and rotatory stabilization can be restored only by a reconstructive technique that replaces both of the ACL bundles. 6 Prospective randomized studies have confirmed these biomechanical results. 2,13 Patients were found to have significantly better anterior and rotational stability after a double-bundle reconstruction of the ACL than after a single-bundle reconstruction. Reciprocal tensile behavior of the two functional bundles of the anterior cruciate ligament. AMB Anteromedial bundle; PLB Posterolateral bundle. 2 Length change in the AM and PL bundles from 0 to 130 of flexion in the weightbearing knee. 3

7 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 7 Advantages Anatomical operating technique. Only one tendon (the semitendinosus) is necessary for graft preparation. The horizontal skin incision preserves the infrapatellar branch of the saphenous nerve. Less water loss because femoral tunnels are drilled first. Greater freedom in selecting femoral tunnel placement because both tunnels are drilled using a medial portal technique. Excellent visualization of the lateral condylar wall and ACL insertion through the anteromedial portal. Reproducible femoral landmarks: intercondylar line and chondro-osseous junction. Better restoration of anteroposterior stability in the neutral position and internal rotation. Better bone healing owing to a more favorable relationship between the tunnel lumen and graft volume. Indications Symptomatic anterior instabilities and giving-way due to rupture of the anterior cruciate ligament. Rupture of the anterior cruciate ligament with instability-related secondary damage to the articular cartilage and menisci. Contraindications Children with open growth plates. Multiligament procedures. Bone defects in revision cases. Risk Disclosure General surgical risks. Osteoarthritis of the knee. Lesions of the infrapatellar branch of the saphenous nerve. Postoperative tunnel widening. Extending the procedure due to associated meniscal or cartilage lesions. Recurrent instability. 4 Preoperative MRI of a ruptured anterior cruciate ligament. Preoperative Preparations Clinical examination: Lachman test, pivot shift. Biplane radiographs of the knee, patella sunrise view. MRI to exclude associated injuries (Fig. 4). Anesthesia and Positioning General or regional anesthesia. Supine position. Bloodless field.

8 8 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Operative Technique 1 2 The incisions for the arthroscopic portals and the horizontal skin incision for harvesting the tendon graft are drawn on the skin preoperatively with a sterile marker. 1 = AM 2 = PL 5 Double-bundle reconstruction of the anterior cruciate ligament requires three arthroscopic portals: One high anterolateral portal Two low anteromedial portal Arthroscopy of the joint is performed through the high anterolateral portal. The two low anteromedial portals are used for drilling the femoral AM and PL tunnels (Fig. 5). Drilling through two separate portals ensures adequate femoral divergence of the tunnels. The AM portal corresponds roughly to the medial portal in the single-bundle technique. The PL portal is placed farther medially. The PL portal should be placed just above the rim of the meniscus to keep the drill from injuring the cartilage of the lateral femoral condyle. If the ACL reconstruction is definitely indicated based on preoperative findings, the first step in the operation is to harvest the grafts. In approximately 90% of cases, we find it sufficient to harvest one tendon graft (the semitendinosus). The tendon is removed through a transverse skin incision approximately 3 cm long placed medial to the tibial tuberosity. The transverse incision preserves the infrapatellar branch of the saphenous nerve (Fig. 6). A transverse incision also makes it easier to angle the tibial drill guide medially to obtain the desired tunnel divergence. 6 Harvesting of tendon.

9 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 9 The semitendinosus tendon makes an adequate graft when at least 28 cm of tendon length is available. If the harvested semitendinosus tendon is shorter than 28 cm, the gracilis tendon must also be removed. This underscores the importance of a precise graft harvest technique. The sartorius fascia is incised longitudinally to expose the semitendinosus and gracilis tendons. The semitendinosus tendon will be found distal to the round gracilis tendon, which is easily palpable. The gracilis tendon is encircled with an Overholt clamp and snared with a looped thread. The tendon is freed to its medial insertion with a scalpel and bluntly stripped from the bone to gain additional graft material. Connecting strands between the tendon and medial gastrocnemius are divided with dissecting scissors. The tendon is removed only after it has been completely mobilized. We remove the tendon with a closed tendon stripper, but an open stripper may also be used. The sartorius fascia is reapproximated with Vicryl USP 1 suture material. The tendons are prepared for use on a tendon board (Figs. 7a, b). They are divided to create a single-folded AM graft 80 mm long and a single-folded PL graft at least 60 mm long. 7a The harvested tendons are prepared for use on a tendon board. 7b Tendon board for the preparation of double-bundle grafts (KARL STORZ Tuttlingen).

10 10 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament The thicker graft will be used for the AM bundle, the thinner graft for the PL bundle. Each graft is looped to form a double thickness. The femoral graft loop is armed with a fixation button (FLIPPTACK, KARL STORZ Tuttlingen) and a double 1-mm braided Polyester cord. The cord is passed through the inner holes of the FLIPPTACK, and passing and flipping sutures are passed through the outer holes. After measurement of the tunnel lengths (see Fig. 12a, p. 13), the flip length and tunnel length are marked on the grafts based on the measured lengths, and the grafts are armed with the FLIPPTACK to the desired length (Fig. 7c). The normal diameter of the PL graft is mm, and the AM graft diameter ranges from 6 to 7.5 mm. A tendon thickness tester is used to determine the diameter of the graft (Fig. 7d) The looped graft is armed with a fixation button (FLIPPTACK, KARL STORZ Tuttlingen) and doubled 1-mm Polyester cord. 1 = Tunnel length 15 mm 2 = Flip length 7 mm 7c Tendon thickness tester (KARL STORZ Tuttlingen). 7d

11 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 11 The FLIPPTACK is positioned to leave at least 15 mm of the graft within the femoral tunnel. The desired graft length within the tunnel and the flip length (+ 7 mm) are marked on the graft with a sterile pen (Fig. 7a). The two limbs of the graft are armed with a double Polyester suture approximately 25 mm long and interconnected with a Mini-ENDOTACK. They are tightened to a primary tension of 30 N using the tensioning device on the tendon board. After the ligament remnants have been removed from the knee, the next step is to create the femoral tunnels. This avoids the pressure loss that would result from the escape of irrigating fluid through the tibial tunnels. Placement of the femoral tunnels begins with identification of the intercondylar line and chondroosseous junction. As the anatomic specimen shows, the intercondylar line intersects with the chondro-osseous junction between the insertions of the AM and PL bundles (Fig. 8a). The intercondylar line and chondro-osseous junction are visualized through the anteromedial portal. This is the only portal that affords a clear and complete view of the ACL insertion on the lateral femoral condyle. The PL insertion cannot be fully inspected endoscopically through the standard lateral portal (Fig. 8b). To create the AM tunnel, a conventional femoral drill guide is used for the ACL. A drill guide with a 5.5-mm offset has proved effective for the double-bundle technique. The drill guide is introduced through the medial AM portal and hooked behind the intercondylar line with the knee in more than 110 flexion. If uncertainty exists, an initial trial hole is drilled with a K-wire (Fig. 9a). After the trial hole has been drilled, the position of the center of the tunnel is checked arthroscopically through the medial portal. If the tunnel is correctly placed, the K-wire is reintroduced and overdrilled with a 4.5-mm reamer (Fig. 9b). 8a AM PL Position of the AM and PL bundles on a bone model. AM PL 8b Arthroscopic view of the intercondylar line and chondro-osseous junction. 9a The AM tunnel for ACL reconstruction is created with a femoral drill guide. 9b The position of the AM tunnel is checked arthroscopically through the medial portal.

12 12 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 10a After introduction of the special drill guide into the femoral AM tunnel with the knee flexed 110, the tunnel is drilled for the PL graft. The drill guide should be directed almost horizontally within the joint. 10b Tunnel placement is checked through the anteromedial portal. A special femoral drill guide for the double-bundle technique is used to create the PL tunnel. This device has a rounded projection that fits into the AM tunnel, allowing a second K-wire to be placed at a specific distance from the AM tunnel (Fig. 10a). The femoral drill guide is available in several sizes corresponding to a distance of 8, 9, or 10 mm between the AM and PL bundles to conform to the individual anatomy of the femoral ACL insertion (Figs. 10c, 10d). Introduction of the drill guide into the femoral AM tunnel. For this step the knee is flexed past 110 so that the PL insertion is in front of the AM insertion. The drill guide occupies an almost horizontal position in the joint. The KARL STORZ lettering on the barrel of the drill guide provides a useful landmark. Experience has shown that when the lettering is clearly legible, the bone tunnel is well positioned (Fig. 10a). Next a K-wire is drilled through the bone, tunnel placement is again checked through the anteromedial portal (Fig. 10b), and the K-wire is overdrilled with the 4.5-mm reamer. 10d Special femoral drill guide for placing the PL tunnel (KARL STORZ Tuttlingen). 10c

13 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 13 11a 11b 11c The tunnel lengths (AM between 35 and 45 mm, PL between 30 and 45 mm) are checked with a measuring instrument. Sockets are drilled to accommodate the graft diameters. Empirical values are mm for the AM graft and mm for the PL graft (length 28 mm). Tunnel placement is checked arthroscopically through the anteromedial portal Next the length of both tunnels is measured (Fig. 11a) so that the flip length and tunnel length can be marked on the grafts (see Fig. 7c, p. 10). Sockets are drilled to accommodate the graft diameters (Fig. 11b), and the tunnel placements are again checked arthroscopically (Fig. 11c). The tibial tunnels are drilled with a distinct tibial drill guide that is specially designed for the double-bundle reconstruction (Fig. 12a). The distal end hooks into the cruciate ligament stump for fixation, and the instrument has an open side notch for drilling. At the level where the K-wire exits the bone is a small wing that can be placed against the anterior horn of the lateral meniscus, which is the anatomical landmark for the AM bundle (Fig. 12b). Oval opening for referencing the AM tunnel. Drilling notch Wing 12a The tibial tunnels are drilled with the WT tibial double-bundle drill guide (KARL STORZ Tuttlingen). The instrument has a distal hook for fixation in the cruciate ligament stump and a drilling notch on one side.

14 14 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 12b AHLM The special tibial drill guide is placed at the posterior edge of the anterior horn of the lateral meniscus (AHLM), and the K-wire for the AM tunnel is drilled into the joint. After a K-wire has been drilled into the joint to mark the site for the AM tunnel, the instrument is shifted to place the oval reference opening over the tip of the K-wire. In this way the second K-wire for the PL tunnel can be drilled at a set distance from the AM tunnel. The oval shape of the opening allows the instrument position to be adjusted for the individual size of the knee joint and tunnel diameters (Fig. 12c). The first K-wire for the AM tunnel should not be drilled too far into the joint, as space must be allowed for placing the reference opening over the protruding wire tip. When the K-wires have been placed, they are overdrilled with cannulated drill bits whose size conforms to the graft diameter. The extra-articular tunnel openings are carefully debrided to facilitate passage of the grafts (Figs. 13a, b). Passage of the grafts. The PL graft is passed into the joint first. This is done by pulling a K-wire with a looped thread (Ethibond, USP 2) into the femoral PL tunnel through the PL portal. The thread is grasped with a SilGrasp suture grasper and brought out through the tibial PL tunnel (Fig. 14a). 12c AHLM The oval reference opening is placed over the tip of the K-wire, and the K-wire for the PL tunnel is drilled into the joint. 13a AHLM The relative positions of the K-wires are checked. 13b AHLM The K-wires are overdrilled to the graft diameter. 14a The looped thread introduced with a K-wire is grasped with the SilGrasp and brought out through the tibial tunnel. 14b The graft is pulled into the joint until the flip mark reaches the tunnel inlet. Now the passing suture is forcibly pulled until the flip mark on the graft reaches the tunnel inlet. Then the flipping suture is pulled to flip the FLIPPTACK button to a transverse position, and the graft is pulled back to the level of the tunnel mark (Fig. 14b). While strong manual traction is placed on the graft, the knee joint is moved several times through flexion/ extension to seat the anchor button against the tunnel opening. The same technique is then used for passing the AM bundle.

15 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 15 With the knee in 45º of flexion, the AM graft is tightened to 80 N with a tensiometer and fixed in place with an absorbable Mega Fix interference screw (Fig. 15a). Small-diameter screws (6 mm) should always be used to eliminate the risk of primary tunnel widening. A nitinol wire is inserted between the graft and tunnel wall, and the Mega Fix screw is driven into the tunnel over the wire under tension. A grating sound during insertion confirms that the interference screw is engaging the graft. The position of the screw in the tibial tunnel should be checked arthroscopically to make sure that the screw is gripping the graft securely. The PL bundle is tightened to 80 N with a tensiometer while the knee is in 15º flexion and is secured with an absorbable Mega Fix interference screw (Fig. 15b). 15a Bioabsorbable Mega Fix interference screw (KARL STORZ Tuttlingen). 15b The PL graft is tightened with the knee in 15º flexion and is secured with a bioabsorbable Mega Fix interference screw.

16 16 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Finally both grafts are secured with a special tibial fixation button, the Mini- ENDOTACK (KARL STORZ Tuttlingen) (Fig. 16c). The fixation button is fitted into a prepared bed and anchored with the tibial sutures of the graft (Fig. 16b). Figure 17 shows the double-bundle graft in situ. A bed is prepared for Mini-ENDOTACK button (KARL STORZ Tuttlingen). 16a 16c Tibial hybrid fixation. The two bundles are additionally secured with a Mini- ENDOTACK (KARL STORZ Tuttlingen). 16b

17 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 17 A postoperative radiograph of the reconstructed ACL bundles will clearly demonstrate the divergence of the two tunnels. The button used for femoral fixation and the button used for tibial hybrid fixation can also be identified. Because the interference screws are not detectable by fluorescence, they are not visible in the tibial tunnels (Fig. 18). Postoperative Care The postoperative regimen is the same as that following a single-button reconstruction: 17 Arthroscopic view of the double-bundle graft in situ. Cryotherapy and compression therapy in the immediate postoperative period. Gentle muscle tightening exercises in the immediate postoperative period. Partial weight bearing on forearm crutches for 2 weeks. Hinged knee brace for 6 weeks (if extension loss develops, the brace should be removed after 3 weeks). Physical therapy to improve range of motion and muscle strength. Jogging and swimming (crawl kick after 8 weeks). Resumption of competitive sports in 6 12 months. Errors, Hazards, and Complications 18 Postoperative radiograph following doublebundle reconstruction of the anterior cruciate ligament. Incorrect Placement of the Femoral Tunnels To avoid incorrect tunnel placement, the femoral K-wire positions should always be checked arthroscopically through the medial portal. If incorrect placement of the K-wires is noted, they can be easily adjusted. If faulty anterior placement of the AM tunnel is noted in 90º flexion after the 4.5-mm tunnel has already been drilled, the procedure should be converted to a single-bundle reconstruction. Incorrect Placement of the Tibial Tunnels Both K-wires should be drilled first to permit accurate tunnel placement. Impingement should also be checked prior to final drilling. If an extreme anterior tunnel placement is found, it should be corrected by reintroducing the guide and drilling a new site. If a slight placement error is found, the tunnel position is easily adjusted by drilling the K-wire hole to an intermediate diameter, jamming the K-wire in the posterior part of the tunnel, and overdrilling it with a larger-diameter bit to shift the center of the tunnel posteriorly.

18 18 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Recommended Literature 1. JÄRVELÄ T: Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc May;15(5): MUNETA T, KOGA H, MOCHIZUKI T, JU YJ, HARA K, NIMURA A, YAGISHITA K, SEKIYA I: A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy Jun;23(6): PETERSEN W, ZANTOP T: Anatomy of the anterior cruciate ligament with regard to its two bundles. Clin Orthop Relat Res Jan;454: PETERSEN W, ZANTOP T: Technik der anatomischen Doppelbündelrekonstruktion. Arthroskopie, 2007 May; 20(2): (7) 5. PETERSEN W, TRETOW H, WEIMANN A, HERBORT M, FU FH, RASCHKE M, ZANTOP T: Biomechanical evaluation of two techniques for double-bundle anterior cruciate ligament reconstruction: one tibial tunnel versus two tibial tunnels. Am J Sports Med Feb;35(2): YAGI M, WONG EK, KANAMORI A, DEBSKI RE, FU FH, WOO SL: Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med Sep-Oct;30(5): ZANTOP T, PETERSEN W, FU F: Anatomy of the anterior cruciate ligament. Oper Tech Orthop. 2005;15: ZANTOP T, PETERSEN W, SEKIYA JK, MUSAHL V, FU FH: Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc Oct;14(10): ZANTOP T, HERBORT M, RASCHKE MJ, FU FH, PETERSEN W: The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation. Am J Sports Med Feb;35(2): ZANTOP T, HAASE AK, FU FH, PETERSEN W: Potential risk of cartilage damage in double bundle ACL reconstruction: impact of knee flexion angle and portal location on the femoral PL bundle tunnel. Arch Orthop Trauma Surg Dec ZANTOP T, WELLMANN M, FU FH, PETERSEN W: Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med Jan;36(1): ZANTOP T, PETERSEN W: Anatomische Rekonstruktion des vorderen Kreuzbandes. Arthroskopie, 2007 May; 20(2):94-104(11) 13. SIEBOLD R, ELLERT T, METZ S, METZ J: Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy Feb;24(2):

19 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 19 Instrumentation for Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Endoscopes, Instruments, and Accessories

20 20 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Instruments for Cruciate Ligament Surgery BWA BWA HOPKINS Wide Angle Forward-Oblique Telescope 30º, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: red CR CR High-Flow Arthroscope Sheath, with snap-in coupling mechanism, diameter 5.5 mm, working length 13.5 cm, two stopcocks, rotatable, for use with HOPKINS telescopes 0, 30, 70 and Obturators BC/BT/BS, O, color code: blue BT BT BT Obturator, semisharp, for use with Arthroscope Sheaths CR/DR, CR/DR, R, CR/R/B/MF, R, CR and CR, color code: green-red-yellow D Gasket Attachment, with cone, including gasket GU, for use with all arthroscope sheaths GU Gasket,, unsterile, single-packaged, for use with gasket attachment D It is recommended to check the suitability of the product for the intended procedure prior to use.

21 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 21 Instruments for Cruciate Ligament Surgery AB AB Tendon Stripper, graduated, diameter 7 mm, length 30 cm AC Open Tendon Stripper, graduated, diameter 7.5 mm, length 30 cm SH Tendon Hook D D Drilling Wire, spiral shape, with eyelet, diameter 2.4 mm, length 38 cm, for use with Bone Drills BA BH, Collar Burrs BKC BKF/BLC BLF and Drills GA GE

22 22 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Instruments for Cruciate Ligament Surgery SB SBD SB Tendon Board, including FLIPPTACK Retainer SC SBD Tendon Board Add-On, for the double bundle retainer technique, including FLIPPTACK Retainer SC SA S Tendon Thickness Tester, for determination of tendon thickness, size 6 10 mm at intervals of 1 mm SU Same, mm at intervals of 1 mm SA Same, mm at intervals of 0.5 mm SD SD Tendon Thickness Tester, for determination of tendon thickness size mm at intervals of 0.5 mm FK Thread Clip FK SC FLIPPTACK -Retainer FT FLIPPTACK, extracortical fixation button, 4 x 12 mm, sterile SC FT FS FLIPPTACK Set, 24x FLIPPTACK extracortical fixation buttons and 24x 1 mm Ethibond Sutupak

23 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 23 Instruments for Cruciate Ligament Surgery FF FF Thread Catcher, for cruciate ligament reconstruction, working length 23 cm ZC ZC Femoral Target Guide, for ACL reconstruction, graduated, 5.5 mm offset for drilling diameter 9 and 10 mm ZD Femoral Target Guide, for ACL reconstruction, graduated, 4 mm offset for drilling diameter 7 and 8 mm ZE Femoral Target Guide, for ACL reconstruction, graduated, 3 mm offset for drilling diameter smaller than 7 mm

24 24 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Instruments for Cruciate Ligament Surgery WU/WV/WW WU Femoral Target Guide Attachment, for the double bundle technique, with 8 mm offset, for use with Handle ZG WV Same, with 9 mm offset WW Same, with 10 mm offset WU ZG ZG Handle, with ratchet, for use with Inserts WU WW

25 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 25 Instruments for Cruciate Ligament Surgery WT WT Tibial Target Guide, for the double bundle technique, exit point from the tibial plateau adjustable between 8 10 mm E E Larding Wire, pyramidal tip, diameter 2.4 mm, length 32 cm, package of 10, for use with Bone Drills BA BH, Collar Burrs BKC BKF/BLC BLF and Drills GA GE GW Nitinol Guide Wire, diameter 1.1 mm, length 38.5 cm, package of KW Same, short, length 25.5 cm

26 26 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Instruments for Cruciate Ligament Surgery BA BA Bone Drill, cannulated, diameter 4.5 mm for use with Drilling Wire D and Larding Wire E BB Same, diameter 5 mm BI Same, diameter 5.5 mm BC Same, diameter 6 mm BK Same, diameter 6.5 mm BD Same, diameter 7 mm BL Same, diameter 7.5 mm BE Same, diameter 8 mm BM Same, diameter 8.5 mm BF Same, diameter 9 mm BN Same, diameter 9.5 mm BG Same, diameter 10 mm BO Same, diameter 10.5 mm AGN SGN SilGrasp Suture Grasper, straight jaws, sheath diameter 3 mm, straight, handle with cleaning connector, working length 14 cm AGN SilGrasp Alligator Grasping Forceps, surgical, straight jaws, sheath diameter 3 mm, straight, handle with cleaning connector, working length 12 cm AGSN Same, with ratchet PGN SilGrasp Foreign Body Grasper, aggressive, straight jaws, sheath diameter 3 mm, straight, handle with cleaning connector, working length 14 cm PGSN Same, with ratchet

27 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 27 Instruments for Cruciate Ligament Surgery P P Tissue Forceps, 1 x 2 teeth, medium, distal curved to left, length 14.5 cm L L Length Gauge, for cruciate ligament reconstruction, graduated, working length 23 cm MT Mini ENDOTACK, tibial fixation button, 8 x 12 mm, sterile MT KK KK Knot Holder, small, 1 x 1 mm, working length 14.5 cm

28 28 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Instruments for Cruciate Ligament Surgery SM SM Positioning Device, for use with Mini ENDOTACK MT, color code: red MM Button Wrench, for use with Mini ENDOTACK MT, color code: red TM TM Tensiometer, for measuring and controlling the tension of the graft

29 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 29 Implants for Cruciate Ligament Surgery Mega Fix B B Mega Fix B, bioresorbable interference screw, diameter 6 mm, length 19 mm, sterile B Same, length 23 mm B Mega Fix B, bioresorbable interference screw, diameter 7 mm, length 19 mm, sterile B Same, length 23 mm B Same, length 28 mm B Mega Fix B, bioresorbable interference screw, diameter 8 mm, length 19 mm, sterile B Same, length 23 mm B Same, length 28 mm B Mega Fix B, bioresorbable interference screw, diameter 9 mm, length 23 mm, sterile B Same, length 28 mm Mega Fix P P Mega Fix P, bioresorbable interference screw, perforated, diameter 8 mm, length 23 mm, sterile P Same, length 28 mm P Mega Fix P, bioresorbable interference screw, perforated, diameter 9 mm, length 23 mm, sterile P Same, length 28 mm P Same, length 35 mm P Mega Fix P, bioresorbable interference screw, perforated, diameter 10 mm, length 28 mm, sterile P Same, length 35 mm P Mega Fix P, bioresorbable interference screw, perforated, diameter 11 mm, length 35 mm, sterile

30 30 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Implants for Cruciate Ligament Surgery Mega Fix C C Mega Fix C, bioresorbable composite interference screw, diameter 6 mm, length 19 mm, sterile C Same, length 23 mm C Mega Fix C, bioresorbable composite interference screw, sterile, diameter 7 mm, length 19 mm C Same, length 23 mm C Same, length 28 mm C Mega Fix C, bioresorbable composite interference screw, diameter 8 mm, length 19 mm, sterile C Same, length 23 mm C Same, length 28 mm C Mega Fix C, bioresorbable composite interference screw, diameter 9 mm, length 23 mm, sterile C Same, length 28 mm Mega Fix CP CP Mega Fix CP, bioresorbable composite interference screw, perforated, diameter 8 mm, length 23 mm, sterile CP Same, length 28 mm CP Mega Fix CP, bioresorbable composite interference screw, perforated, diameter 9 mm, length 23 mm, sterile CP Same, length 28 mm CP Same, length 35 mm CP Mega Fix CP, bioresorbable composite interference screw, perforated, diameter 10 mm, length 28 mm, sterile CP Same, length 35 mm CP Mega Fix CP, bioresorbable composite interference screw, perforated, diameter 11 mm, length 35 mm, sterile

31 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 31 Instruments for Cruciate Ligament Surgery SK SK CrossDrive Screwdriver, cannulated, size 8 11, for use with bioresorbable Mega Fix screws diameter 8 11 mm and Nitinol Guide Wires GW/KW SK CrossDrive Screwdriver, cannulated, size 7, for use with bioresorbable Mega Fix screws diameter 7 mm and Nitinol Guide Wires GW/KW SK CrossDrive Screwdriver, cannulated, size 6, for use with bioresorbable Mega Fix screws diameter 6 mm and Nitinol Guide Wires GW/KW N N Notcher, with fin-like blade to assist screw insertion, working length 15 cm

32 32 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament ARTHROPUMP Power Fluid Management System, Recommended Set Configuration ARTHROPUMP Power, power supply VAC, 50/60 Hz including: Connecting Cable, to UNIDRIVE S III ARTHRO SCB and POWERSHAVER SL SCB SCB Connecting Cable, length 100 cm Four-Pedal Footswitch Tubing Set Irrigation*, sterile,, package of 3 Tubing Set Suction*, sterile,, package of 3 Specifications: Pressure regulated Flow regulated - Normal: mmhg - Hemostasis: +20% - +90% - Shaver: +0% - +80% - Normal: ml/min - Shaver: ml/min - Lavage: ml/min Power supply Dimensions w x h x d Weight Certified to: VAC, 50/60 Hz 447 x 155 x 313 mm 8.8 kg IEC 601-1, CE acc. to MDD * mtp medical technical promotion gmbh, Take-Off GewerbePark 46, Neuhausen ob Eck, Germany

33 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 33 UNIDRIVE S III ARTHRO SCB The aim of all arthroscopic procedures is the same: to complete the procedure quickly and with minimal trauma, thereby reducing patient time under anes thesia. With UNIDRIVE S III ARTHRO, KARL STORZ has de vel oped a motor system that is customized to meet these requirements. Easy to use Automatic handpiece recognition Control of rotation speed similar to the multifunctional handpiece Comprehensive portfolio of single-use and reusable blades Communication with ARTHROPUMP Power

34 34 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament UNIDRIVE S III ARTHRO SCB Recommended System Configuration Special Features: Arthroscopic motor system for all joints Stable torque throughout entire speed range Motors with speed ranging from max rpm to max rpm Multifunctional handpiece with accessories: Jacobs chucks Pin drivers Sagittal saws Synthes-style drivers Various control options possible Hand controls Footswitch Touch Screen Fast and easy change of blade via quick coupling Single-use and reusable blades available UNIDRIVE S III ARTHRO SCB, with color display, touch screen operation, two motor outputs, integrated SCB module, power supply / VAC, 50/60 Hz including: SCB Connecting Cable, length 100 cm Mains Cord Specifications: Operating Mode Connections - counter Clockwise - clockwise - oscillating - small joint handpiece - hybrid handpiece - multifunction handpiece - footswitch - KARL STORZ-SCB Power Supply Dimensions w x h x d Weight Certified to / VAC, 50/60 Hz 305 x 165 x 280 mm 5.2 kg IEC 601-1, CE acc. to MDD System requirements: SCB control NEO System with installed SCB control NEO Software Release or higher

35 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 35 UNIDRIVE S III ARTHRO SCB System Components Two-Pedal Footswitch Three-Pedal Footswitch U N I T S I D E PATIENT SIDE Small Joint Shaver Handpiece, 6000 rpm Hybrid Shaver Handpiece, 7000 rpm Multifunction Handpiece, with Cable Jacobs Chuck up to dia. 4.0 mm Jacobs Chuck up to dia. 6.5 mm Jacobs Chuck up to dia. 7.4 mm Sagittal Saw Attachment Pin Driver for drilling wires diameter mm Synthes-Style Driver

36 36 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Optional Accessories for Multifunction Handpiece Jacobs Chuck, up to diameter 4.5 mm Jacobs Chuck, up to diameter 6.5 mm Pin Driver, for drilling wires diameter mm Jacobs Chuck, keyless, up to diameter 7.4 mm, for use with Multifunction Handpiece SL Sagittal Saw Attachment, keyless, with tilt lever, for use with Multifunction Handpiece and Saw Blades only Pin Driver, for Synthes attachments Connecting Cable, for FMS pump for UNIDRIVE S III ARTHRO SCB shaver handpieces and blades SA Irrigation Adaptor, for validated cleaning of shaver handpieces SAA Irrigation Adaptor, for validated cleaning of outer blades SAI Irrigation Adaptor, for validated cleaning of inner blades

37 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 37 Shaver Blades for use with UNIDRIVE S III ARTHRO SCB and POWERSHAVER SL, for cutting and grinding Working length 180 mm Type Use Order No. Diameter Color Code Application Aggressive Cutter BKS 4.5 mm mauve green soft tissue Full Radius Resector CCS 4.5 mm mauve yellow soft tissue Aggressive Full Radius Resector DCS 4.5 mm mauve blue soft tissue Curved Full Radius Resector EGS 4.5 mm mauve light blue soft tissue Curved Aggressive Full Radius Resector EHS 4.5 mm mauve light green soft tissue Semi Hooded Barrel Burr IDS 5.5 mm dark gray pink bone

38 38 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Shaver Blades for use with UNIDRIVE S III ARTHRO SCB and POWERSHAVER SL, for cutting and grinding Working length 120 mm Type Use Order No. Diameter Color Code Application reusable AB AC AD 3.5 mm 4.2 mm 5.5 mm Aggressive Cutter ABS 3.5 mm light gray green soft tissue ACS 4.2 mm medium gray ADS 5.5 mm dark gray reusable AK 4.5 mm Aggressive Cutter AKS *28208 AKS 4.5 mm mauve 4.5 mm mauve green soft tissue BB 3.5 mm reusable BC 4.2 mm End Cutter BD BCS BDS 5.5 mm 4.2 mm medium gray 5.5 mm dark gray red soft tissue CB 3.5 mm reusable CC 4.2 mm CD 5.5 mm Full Radius Resector CBS 3.5 mm light gray yellow soft tissue CCS 4.2 mm medium gray CDS 5.5 mm dark gray reusable CK 4.5 mm Full Radius Resector CKS *28208 CKS 4.5 mm mauve 4.5 mm mauve yellow soft tissue *28208 blades are available with distal drill guide

39 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 39 Shaver Blades for use with UNIDRIVE S III ARTHRO SCB and POWERSHAVER SL, for cutting and grinding Working length 120 mm Type Use Order No. Diameter Color Code Application reusable DB DC 3.5 mm 4.2 mm DD 5.5 mm Aggressive Full Radius Resector DBS 3.5 mm light gray blue soft tissue DCS 4.2 mm medium gray DDS 5.5 mm dark gray Aggressive Full Radius Resector reusable DK DKS 4.5 mm 4.5 mm mauve blue soft tissue Curved Full Radius Resector reusable EG EGS 4.2 mm 4.2 mm medium gray light blue soft tissue Curved Aggressive Full Radius Resector reusable EH EHS 4.2 mm 4.2 mm medium gray light green soft tissue reusable FC FD 4.2 mm 5.5 mm Round Burr FCS 4.2 mm medium gray orange bone FDS 5.5 mm dark gray FES 6.5 mm black

40 40 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Shaver Blades for use with UNIDRIVE S III ARTHRO SCB and POWERSHAVER SL, for cutting and grinding Working length 120 mm Type Use Order No. Diameter Color Code Application reusable GD GE GF 4.2 mm 5.5 mm 6.5 mm Finish Barrel Burr GDS 4.2 mm medium gray purple bone reusable GES GFS HC HD HE 5.5 mm dark gray 6.5 mm black 4.2 mm 5.5 mm 6.5 mm Aggressive Barrel Burr HCS 4.2 mm medium gray pink bone HDS 5.5 mm dark gray HES 6.5 mm black Auger KDS 5.5 mm medium gray light purple bone Pro Line Shaver Blades reusable MK MD MKS MDS 4.5 mm 5.5 mm 4.5 mm mauve 5.5 mm dark gray pink bone, soft tissue Aggressive Pro Line Shaver Blades reusable NK ND NKS NDS 4.5 mm 5.5 mm 4.5 mm mauve 5.5 mm dark gray light blue bone, soft tissue

41 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 41 Shaver Blades for use with UNIDRIVE S III ARTHRO SCB and POWERSHAVER SL, for cutting and grinding for small joints Working length 70 mm Type Use Order No. Diameter Color Code Application reusable AA 2.5 mm Aggressive Cutter AAS ABS 2.5 mm white 3.5 mm light gray green soft tissue reusable CA 2.5 mm Full Radius Resector CAS CBS 2.5 mm white 3.5 mm light gray yellow soft tissue Aggressive Full Radius Resector reusable DA DB DAS DBS 2.5 mm 3.5 mm 2.5 mm white 3.5 mm light gray blue soft tissue Small Joint Burr FAS FBS 2.5 mm white 3.5 mm light gray orange bone

42 42 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament Overview of KARL STORZ Arthroscopy and Sports Medicine HOPKINS Telescopes and Sheaths SilCut 1 Punches SilCut Punches, Forceps and Scissors Joint and Bone Reconstruction Instruments for Meniscus and Patella Surgery Instruments for Cruciate Ligament Reconstruction Instruments for Hip Arthroscopy Instruments for Wrist Arthroscopy and for Treatment of the Carpal Tunnel Syndrome Instruments for Rheumatology Spine Surgery HD Imaging with Operating Microscopes VITOM System Visualization System for Open Surgery with Minimal Access Holding Systems RECON Joint and Bone Reconstruction Extracorporeal Shock Wave Therapy ESWT KARL STORZ OR1 NEO, Telepresence Hygiene, Endoprotect1

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44 WITH COMPLIMENTS OF KARL STORZ ENDOSKOPE