Rationale and Surgical Technique for PCL and … Reconstruction OpTech.pdfThe PCL single bundle or...
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Rationale and Surgical Technique for PCL and Multiple Knee Ligament Reconstruction
Featuring the Fanelli™ PCL/ACL System, Bio-Core™ Interference Screw, Poly Suture Button,
Fanelli™ Magellan Suture Retriever and Graft Tensioning Boot
Gregory C. Fanelli, M.D.
• FacilitatesPCLandACLreconstructiontechniques
Fanelli™ System Instruments
Graft Tensioning Boot• Selfretainingtensioner
eliminatesmanualtensioning
• Allowssurgeontousebothhandsfortibialfixation
• Tensiongraftsupto20lbs
Double Bundle Aimers• Sizespecificaimers
fordoublebundletunneldiameters
• AllowsvisualizationoftunnelplacementindoublebundlePCLandACLprocedurestoprovideadequatebonebridge
TheFanelli™ PCL/ACL Guide
facilitatesaccurateand
reproducibletunnelplacementfor
PCLandACLReconstructions.
Fanelli™ Magellan Suture Retriever• Facilitatessuture
retrievalduringPCLandACLreconstruction
• Promotesreproduciblegraftpassage
OverviewThismanualcontainsthesurgicaltechniqueforthetranstibialtunnelposteriorcruciateligament(PCL)reconstruction,combinedanteriorcruciateligament(ACL)andposteriorcruciateligamentreconstructionusingtheArthrotek®Fanelli™PCL/ACLSystem,andseveralmethodsofmedialandlateralsidereconstructions.Thereferencesectioncontainsalistoftextbooks,andscientificarticlesonthesesubjects,andthereaderisreferredtotheseresourcesforamoreindepthreviewofthesubjectmaterial.
Patient PositioningThepatientisplacedontheoperatingroomtableinthesupineposition,andaftersatisfactoryinductionofanesthesia,theoperativeandnonoperativelowerextremitiesarecarefullyexamined.Atourniquetisappliedtotheupperthighoftheoperativeextremity,andthatextremityispreppedanddrapedinasterilefashion.
Whenallografttissueisused,itispreparedpriortobringingthepatientintotheoperatingroom.Autografttissueis
harvestedpriortobeginningthearthroscopicportionoftheprocedure.
Thearthroscopicinstrumentsareinsertedwiththeinflowthroughthesuperolateralpatellarportal.Instrumentationandvisualizationisachievedthroughinferomedialandinferolateralpatellarportals,andcanbeinterchangedasnecessary.Additionalportalsareestablishedasnecessary.Explorationofthejointconsistsofevaluationofthepatellofemoraljoint,themedialandlateralcompartments,medialandlateralmenisci,andtheintercondylarnotch.
Whenthereisaposteriorcruciateligamenttear,thetearofthePCLisidentifiedandtheintactanteriorcruciateligamentisconfirmed.Theresidualstumpoftheposteriorcruciateligamentisdebridedwiththesynovialshaverandhandtoolsasnecessary.InthecaseofacombinedACL/PCLinjury,theresidualstumpsofboththeanteriorandposteriorcruciateligamentsaredebrided.InpatientswithcombinedACL/PCLinjuries,thenotchplastyfortheACLportionoftheprocedureisperformedatthistime.
Rationale and Surgical Technique for PCL and Multiple Knee Ligament Reconstruction
Poly Suture Button
• SolidfixationforeitherprimaryorauxiliaryfixationinACLorPCLreconstruction
• DistalfixationallowscircumferentialhealingoftheACLand/orPCLgrafttothetunnelwall
Bio-Core™ Interference Screw• Resorbableinterference
screwmadeofLactoSorb®L15resorbablecopolymer
• Abilitytobefilledwithautograftorallograftbone
ThisbrochureispresentedtodemonstratethesurgicaltechniqueutilizedbyGregoryFanelli,M.D.Arthrotek,asthemanufacturerofthisdevice,doesnotpracticemedicineanddoesnotrecommendthisoranyothersurgicaltechniqueforuseonaspecificpatient.Thesurgeonwhoperformsanyprocedureisresponsiblefordeterminingandutilizingtheappropriatetechniquesforsuchprocedureforeachindividualpatient.Arthrotekisnotresponsibleforselectionoftheappropriatesurgicaltechniquetobeutilizedforanindividualpatient.
Rehabilitationactivitiesvarydependingontheindividualpatientandphysician’srecommendations.
TheFanelli™PCL/ACLSystemwasdevelopedinconjunctionwithGregoryC.Fanelli,M.D.,Danville,Pennsylvania.
Bio-Core™andFanelli™aretrademarksofArthrotek,Inc.
LactoSorb®isatrademarkofBiometManufacturingCorp.
Surgical Technique
Figure 1
Figure 3
Initial IncisionAnextracapsularextraarticularposteromedialsafetyincisionismadebycreatinganincisionapproximately1.5to2cmlongstartingattheposteromedialborderofthetibiaapproximatelyoneinchbelowthelevelofthejointlineandextendingdistally(Figure1).Dissectioniscarrieddowntothecruralfascia,whichisincisedlongitudinally.Careistakentoprotecttheneurovascularstructures.Anintervalisdevelopedbetweenthemedialheadofthegastrocnemiusmuscleposterior,andthecapsuleofthekneejointanterior.Thesurgeon’sglovedfingerisabletopositiontheneurovascularstructuresposteriortothefingerandthecapsuleanteriortothefinger(Figure2).Thisissothatthesurgeoncanmonitortoolssuchastheover-the-topPCLtools,andtheFanelli™PCL/ACLdrillguideasitispositionedintheposterioraspectoftheknee.Thisalsoallowsforaccurateplacementoftheguidewirebothinamediallateral,andaproximaldistaldirection.ThePCLandACLreconstructionsareperformedwiththekneeinapproximately70˚–90˚ofkneeflexion.
Elevating the CapsuleThecurvedover-the-topPCLinstrumentsareusedtosequentiallylyseadhesionsintheposterioraspectoftheknee,andelevatethecapsulefromthetibialridgeposterior.ThiswillallowaccurateplacementoftheFanelli™PCL/ACLguide,andcorrectplacementofthetibialtunnel(Figure3).
Figure 2
Positioning of the GuideThearmoftheFanelli™PCL/ACLguideisinsertedthroughtheinferiormedialpatellarportal.ThetipoftheguideispositionedattheinferiorlateralaspectofthePCLanatomicinsertionsite.ThisisbelowthetibialridgeposteriorandinthelateralaspectofthePCLanatomicinsertionsite.Thebulletportionoftheguidecontactstheanteromedialsurfaceoftheproximaltibiaatapointmidwaybetweentheposteromedialborderofthetibia,andthetibialcrestanteriorapproximately1cmbelowthetibialtubercle(Figure4).Thiswillprovideanangleofgraftorientationsuchthatthegraftwillturntwoverysmooth45˚anglesontheposterioraspectofthetibiaandwillnothaveanacute90˚angleturnwhichmaycausepressurenecrosisofthegraft(Figure5).
Thetipoftheguide,intheposterioraspectofthetibia,isconfirmedwiththesurgeon’sfingerthroughtheextracapsularextraarticularposteromedialsafetyincision.IntraoperativeAPandlateralX-raymayalsobeused.TheFanelli™PCL/ACLguidemaybeadjustedsothattheguidewireshootstothetiportheelbowoftheguideasthesurgeonprefers.WhentheFanelli™PCL/ACLguideispositionedinthedesiredarea,abluntspade-tippedguidewire(909634)isdrilledfromanteriortoposterior.Thearthroscope,intheposteriormedialportal,visualizesthetipoftheguidewire.Thesurgeon’sfingerconfirmsthepositionoftheguidewirethroughtheposteriormedialsafetyincision.Thisisadoublesafetycheck.
Figure 4
Figure 5
Surgical Technique
Figure 7
Figure 6
Drilling the Tibial TunnelTheappropriatelysizedstandardcannulatedreamerisusedtocreatethetibialtunnel.ThecurvedPCLclosedcuretteispositionedtocupthetipoftheguidewire.Thearthroscope,positionedintheposteriormedialportal,visualizestheguidewirebeingcupped,whichprotectstheneurovascularstructures(Figure6).Thesurgeon’sfingerthroughtheextracapsularextraarticularposteromedialincisionismonitoringthepositionoftheguidewire.Whenthedrillisengagedinbone,theguidewireisreversed,bluntendpointingposterior,foradditionalpatientsafety.
Thedrillisadvanceduntilitcomestotheposteriorcortexofthetibia.Thechuckisdisengagedfromthedrill,andcompletionofthetibialtunnelisperformedbyhand(Figure7).Thisgivesanadditionalmarginofsafetyforcompletionofthetibialtunnel.ThetunneledgesarethenchamferedandraspedwiththeFanelli™PCL/ACLsystemrasp(Figure8).
Figure 8
Figure 9
Figure 10
Drilling the Femoral Tunnel Outside In: Single and Double Bundle PCL ReconstructionTheFanelli™PCL/ACLguideispositionedtocreatethefemoraltunnel.Thearmoftheguideisintroducedthroughtheinferomedialpatellarportalandispositionedsuchthattheguidewirewillexitthroughthecenterofthestumpoftheanteriorlateralbundleoftheposteriorcruciateligament(Figure9).
Thebluntspade-tippedguidewire(909634)isdrilledthroughtheguide,andjustasitbeginstoemergethroughthecenterofthestumpofthePCLanteriorlateralbundle,thedrillguideisdisengaged.Theaccuracyoftheplacementofthewireisconfirmedarthroscopicallywithprobingandvisualization.Caremustbetakentoensurethepatellofemoraljointhasnotbeenviolatedbyarthroscopicallyexaminingthepatellofemoraljointpriortodrilling.
Theappropriatelysizedstandardcannulatedreamerisusedtocreatethefemoraltunnel.Acuretteisusedtocapthetipoftheguidewiresothereisnoinadvertentadvancementoftheguidewire,whichmaydamagetheanteriorcruciateligamentorarticularsurface.Asthereamerisabouttopenetrateinteriorly,thereamerisdisengagedfromthedrillandthefinalreamingiscompletedbyhand(Figure10).Thisaddsanadditionalmarginofsafety.Thereamingdebrisisevacuatedwithasynovialshavertominimizefatpadinflammatoryresponsewithsubsequentriskofarthrofibrosis.Thetunneledgesarechamferedandrasped.
Surgical Technique
Figure 12
Figure 11
Drilling the Femoral Tunnel Outside In: Single and Double Bundle PCL Reconstruction (continued)WhenthedoublebundlePCLreconstructionisperformed,theFanelli™PCL/ACLguideispositionedtocreatethesecondfemoraltunnel.Thearmoftheguideisintroducedthroughtheinferiormedialpatellarportal,andispositionedsuchthattheguidewirewillexitthroughthecenterofthestumpoftheposteriormedialbundleoftheposteriorcruciateligament(Figure11).Thebluntspade-tippedguidewire(909634)isdrilledthroughtheguide,andjustasitbeginstoemergethroughthecenterofthestumpofthePCLposteriormedialbundle,thedrillguideisdisengaged.Theaccuracyoftheplacementofthewireisconfirmedarthroscopicallywithprobingandvisualization.Caremustbetakentoensurethattherewillbeanadequatebonebridge(approximately5mm)betweenthetwofemoraltunnelspriortodrilling.Thisisaccomplishedusingthecalibratedprobe,anddirectarthroscopicvisualization.
Theappropriatelysizedstandardcannulatedreamerisusedtocreatetheposteriormedialbundlefemoraltunnel.Acuretteisusedtocapthetipoftheguidewiresothereisnoinadvertentadvancementoftheguidewire,whichmaydamagetheanteriorcruciateligament,orarticularsurface.Asthereamerisabouttopenetrateinteriorly,thereamerisdisengagedfromthedrillandthefinalreamingiscompletedbyhand(Figure12).Thisaddsanadditionalmarginofsafety.Thereamingdebrisisevacuatedwithasynovialshavertominimizefatpadinflammatoryresponsewithsubsequentriskofarthrofibrosis.Thetunneledgesarechamferedandrasped.
Figure 13 Figure 14
Drilling the Femoral Tunnel Inside Out: Single and Double Bundle PCL ReconstructionThePCLsinglebundleordoublebundlefemoraltunnelscanbemadefrominsideoutusingtheFanelli™DoubleBundleAimers.Theappropriatelysizeddoublebundleaimerisinsertedthroughalowanteriorlateralpatellararthroscopicportal.ThedoublebundleaimerispositioneddirectlyonthefootprintofthefemoralanteriorlateralbundlePCLinsertionsite(Figure13).Theappropriatelysizedguidewireisdrilledthroughtheaimer,throughthebone,andoutasmallskinincision.Careistakentoinsurethereisnocompromiseofthearticularsurface.
Thedoublebundleaimerisremoved,andanacornreamerisusedtoendoscopicallydrillfrominsideouttheanteriorlateralbundlePCLfemoraltunnel(Figure14).Thetunneledgesarechamferedandrasped.Thereamingdebrisisevacuatedwithasynovialshavertominimizefatpadinflammatoryresponsewithsubsequentriskofarthrofibrosis.WhenthesurgeonchoosestoperformadoublebundledoublefemoraltunnelPCLreconstruction,thesameprocessisrepeatedfortheposteriormedialbundleofthePCL(Figures15and16).Caremustbetakentoensurethattherewillbeanadequatebonebridge(approximately5mm)betweenthetwofemoraltunnelspriortodrilling.Thisisaccomplishedusingthecalibratedprobe,anddirectarthroscopicvisualization.
Figure 16
Figure 15
Surgical Technique
Figure 18
Figure 17
Figure 20
Tunnel Preparation, Graft Passage, and PCL Femoral FixationAFanelli™Magellansutureretriever(909808)isintroducedthroughthetibialtunnelintothejoint(Figure17),andmayberetrievedthroughthefemoraltunnel(Figure18).ThetractionsuturesofthegraftmaterialareattachedtotheloopoftheMagellansutureretriever,andthegraftispulledintoposition.ThegraftmaterialissecuredonthefemoralsideusingtheArthrotek®Bio-Core™InterferenceScrewforprimaryapertureopeningfixation,andanArthrotek®PolySutureButtonforbackupfixation.
PCL Graft Tensioning and Tibial FixationTensionisplacedonthePCLgraftdistallyusingtheArthrotek®GraftTensioningBoot,andthetensionissettorestoretheanatomictibialstepoff.Thekneeiscycledthroughafullrangeofmotion25timestoallowpre-tensioningandsettlingofthegraft.IndoublebundlePCLreconstructions,eachbundleisindividuallytensioned.Theprocessisrepeateduntilthereisnofurtherchangeinthetorquesettingonthegrafttensionerandtheanatomictibialstepoffisrestored.Thekneeisplacedin70˚offlexion,andfixationisachievedonthetibialsideofthePCLgraftwithanArthrotek®Bio-Core™InterferenceScrew,andbackupfixationwithabicorticalscrewandspikedligamentwasher(Figure20).
Figure 19
Figure 22
Figure 21
ACL ReconstructionWiththekneeinapproximately70˚–90˚offlexion,theACLtunnelsarecreatedusingtheFanelli™PCL/ACLguide.ThearmoftheFanelli™PCL/ACLguideentersthekneejointthroughtheinferiormedialpatellarportal(Figure21).Thebulletofthedrillguidecontactstheanteriormedialproximaltibiaexternallyatapointapproximately1cmproximaltothetibialtuberclemidwaybetweentheposteriormedialborderofthetibia,andthetibialcrestanteriorly.TheguidewireisdrilledthroughtheguidetoemergethroughthecenterofthestumpoftheACLtibialfootprint.Astandardcannulatedreamerisusedtocreatethetibialtunnel(Figure22).Reamingdebrisisevacuated,andthetunneledgesarechamferedandrasped.
Surgical Technique
Figure 24
ACL Reconstruction (continued)Withthekneeinapproximately90˚offlexion,anoverthetopFemoralAimerisintroducedthroughthetibialtunnel,andusedtopositionaguidewireonthemedialwallofthelateralfemoralcondyle(Figure23).ThefemoraltunneliscreatedtoapproximatetheACLanatomicinsertionsite,andtheoffsetofthesizespecificFemoralAimerwillleavea1–2mmposteriorcorticalwallsointerferencefixationcanbeused(Figure24).TheACLgraftispositioned,andfixationachievedonthefemoralsideusinganArthrotek®Bio-Core™InterferenceScrew,andbackupfixationwithanArthrotek®PolySutureButton.
TheACLgraftistensionedonthetibialsideusingtheArthrotek®GraftTensioningBoot(Figure25).TractionisplacedontheACLgraftsutures,andtensionisset.Thekneeisthencycledthrough25fullflexionandextensioncyclestoallowsettlingofthegraft.Theprocessisrepeateduntilthereisnofurtherchangeinthetorquesettingonthegrafttensioner.Thekneeisplacedin70˚offlexion,andfixationisachievedonthetibialsideoftheACLgraftwithanArthrotek®Bio-Core™InterferenceScrew,andbackupfixationwithanArthrotek®PolySutureButton.ThefinalACLandPCLtunnelpositionsaredemonstratedinFigures26and27.
Figure 23
Figure 25
Figure 26
Figure 27
Surgical Technique
Figure 28
Lateral Posterolateral ReconstructionPosterolateralreconstructionwiththefreegraftfigureofeighttechniqueutilizessemitendinosusautograftorallograft,Achillestendonallograft,orothersofttissueallograftmaterial(Figure28).AcurvilinearincisionismadeinthelateralaspectofthekneeextendingfromthelateralfemoralepicondyletotheintervalbetweenGerdy’stubercleandthefibularhead.Theperonealnerveisdissectedfree,andprotectedthroughouttheprocedure.Thefibularheadisexposedandatunneliscreatedinananteriortoposteriordirectionattheareaofmaximalfibulardiameter.Thetunneliscreatedbypassingaguidepinfollowedbyacannulateddrillusually7mmindiameter.Thefreetendongraftispassedthroughthefibularheaddrillhole.Anincisionisthenmadeintheiliotibialbandinlinewiththefibersdirectlyoverlyingthelateralfemoralepicondyle.
Onesurgicaltechniqueforposterolateralreconstructionisthefreegraftfigureofeighttechniqueutilizingsemitendinosusautograftorallograft,Achillestendonallograft,orothersofttissueallograftmaterial(Figure28).Thisprocedurerequiresanintactproximaltibiofibularjoint.Thistechniquecombinedwithcapsularrepairand/orposterolateralcapsularshiftprocedures,mimicsthefunctionofthepopliteofibularligamentandlateralcollateralligament,tightenstheposterolateralcapsule,andprovidesapostofstrongallografttissuetoreinforcetheposterolateralcorner.Whenthereisadisruptedproximaltibiofibularjoint,orhyperextensionexternalrotationrecurvatumdeformity,atwo-tailed(fibularhead,proximaltibia)posteriorlateralreconstructionmayberequired(Figure29).
Figure 29
Thegraftmaterialispassedmedialtotheiliotibialband,andthelimbsofthegraftarecrossedtoformafigureofeight.Adrillholeismadeapproximately1cmanteriortothefibularcollateralligamentandpopliteustendonfemoralinsertion.Alongitudinalincisionismadeinthelateralcapsulejustposteriortothefibularcollateralligament.Thegraftmaterialispassedmedialtotheiliotibialbandandsecuredtothelateralfemoralepicondylarregionwithascrewandspikedligamentwasherattheabovementionedpoint.Theposterolateralcapsulethathadbeenpreviouslyincisedisthenshiftedandsewnintothestrutoffigureofeightgrafttissuematerialtoeliminateposterolateralcapsularredundancy.Theanteriorandposteriorlimbsofthefigureofeightgraftmaterialaresewntoeachothertoreinforceandtightentheconstruct.Thefinalgrafttensioningpositionisapproximately30˚–40˚ofkneeflexion.Theiliotibialbandincisionisclosed.
Surgical Technique
Figure 31
Figure 30
Medial Posteromedial ReconstructionWhensuperficialMCLreconstructionisindicated,thisisperformedusingallograftorautografttissue(Figure31).Thisgraftmaterialisattachedattheanatomicinsertionsitesofthesuperficialmedialcollateralligamentonthefemurandtibiausingascrewandspikedligamentwasher,orsutureanchors.Theposteromedialcapsularadvancementisperformed,andsewnintothenewlyreconstructedMCL.Thefinalgrafttensioningpositionisapproximately30˚–40˚ofkneeflexion.
Posteromedialandmedialreconstructionsareperformedthroughamedialincision.Careistakentomaintainadequateskinbridgesbetweenincisions,andtoprotecttheneurovascularstructures.Thesuperficialmedialcollateralligamentisexposed,andalongitudinalincisionismadejustposteriortotheposteriorborderofthesuperficialMCL(Figure30).
Careistakentoprotectthemedialmeniscusduringthecapsularincision.Theintervalbetweentheposteromedialcapsuleandmedialmeniscusisdeveloped.Theposteromedialcapsuleisshiftedanterosuperiorly.Themedialmeniscusisrepairedtothenewcapsularposition,andtheshiftedcapsuleissewnintothemedialcollateralligament.
Overview of Graft Tensioning and FixationThePCLisreconstructedfirstfollowedbytheACLfollowedbytheposterolateralcomplex,andmedialligamentcomplex.TensionisplacedonthePCLgraftdistallyusingtheArthrotek®GraftTensioningBoot.Thisrestorestheanatomictibialstepoff.Thekneeiscycledthroughafullrangeofmotion25timestoallowpretensioningandsettlingofthegraft.Thekneeisplacedin70˚offlexion,andfixationisachievedonthetibialsideofthePCLgraftwithanArthrotek®Bio-Core™InterferenceScrew,andscrewandspikedligamentwasher.TheArthrotek®GraftTensioningBootisappliedtotheACLgraft.
Thekneeisplacedin70˚offlexion,andfinalfixationisachievedoftheACLgraftwithaArthrotek®Bio-Core™InterferenceScrew,andArthrotek®PolySutureButtonback-upfixationonthefemoralandtibialsides.TensioningtheACLgraftat70˚ofkneeflexionenabledustomaintaintheneutralpositionofthekneebymonitoringthetibialstepoffatthetimeoffinalgraftfixation.Thekneeisplacedin30˚offlexion,slightvalgusforceappliedtotheknee,andfinaltensioningandfixationoftheposterolateralcornerisachieved.TheMCLreconstructionistensionedwiththekneein30˚offlexion.Fullrangeofmotionisconfirmedontheoperatingtabletoassurethekneeisnot“captured”bythereconstruction.
Additional Technical IdeasTheposteromedialsafetyincisionprotectstheneurovascularstructuresandconfirmsaccuratetibialtunnelplacement.Itisimportanttobeawareofthetwotibialtunneldirections,andtohaveanadequatebonebridgebetweenthePCLandACLtibialtunnels.Thiswillreducethepossibilityoffracture.Wehavefounditusefultouseprimaryandback-upfixation.PrimaryfixationiswithArthrotek®Bio-Core™InterferenceScrews,andback-upfixationisperformedwithascrewandspikedligamentwasher,anArthrotek®PolySutureButton.
Securefixationiscriticaltothesuccessofthissurgicalprocedure.Restorationofthenormaltibialstep-offat70˚offlexionhasprovidedthemostreproduciblemethodofestablishingtheneutralpointofthetibia-femoralrelationshipinourexperience.Fullrangeofmotionisconfirmedontheoperatingtabletoassurethekneeisnot“captured”bythereconstruction.
TheFanelliSportsInjuryClinicresultsforourPCLandmultipleligamentkneereconstructionsaredetailedinthereferenceslistedinthistechniquemanual.Thereaderisreferredtotheseresources.
References
PCL and Multiple Knee Ligament Injury Text Books by Gregory C. Fanelli, M.D.Posterior Cruciate Ligament Injuries: A Practical Guide To Management. Editor:GregoryC.Fanelli,M.D.,Springer-Verlag,NewYork,2001.
The Multiple Ligament Injured Knee. A Practical Guide to Management. Editor:GregoryC.Fanelli,M.D.,Springer-Verlag,NewYork,2004.
PCL and Multiple Knee Ligament Injury Related Peer Reviewed Articles by Gregory C. Fanelli, M.D.GregoryC.Fanelli,M.D.,“PosteriorCruciateLigamentInjuriesInTraumaPatients.”Arthroscopy9(3)pp.291–294,1993.
GregoryC.Fanelli,M.D.,BradleyGiannotti,M.D.,CraigEdson,P.T.:“CurrentConceptsReview.ThePosteriorCruciateLigament:ArthroscopicEvaluationAndTreatment.”ArthroscopyVol.10,No.6.pp.673–688,December,1994.
GregoryC.Fanelli,M.D.,CraigJ.Edson,P.T./A.T.C.:“PosteriorCruciateLigamentInjuriesInTraumaPatients:PartII.”ArthroscopyVol.11,No.5.pp.526–529,1995.
GregoryC.Fanelli,M.D.,BradleyGiannotti,M.D.,CraigJ.Edson,M.S.,P.T.,A.T.C.:ArthroscopicallyAssistedCombinedACL/PCLReconstruction.Arthroscopy,Vol.12,No.1.,pp.5–14,1996.
GregoryC.Fanelli,M.D.,BradleyGiannotti,M.D.,CraigJ.Edson,M.S.,P.T.,A.T.C.:“ArthroscopicallyAssistedPCL/PosteriorLateralComplexReconstruction.”Arthroscopy,Vol.12,No.5,1996.
RaymondM.Bleday,M.D.,GregoryC.Fanelli,M.D.,BradleyF.Giannotti,M.D.,CraigJ.Edson,M.H.S.,P.T.,A.T.C.,ThomasABarrett,M.D.:“InstrumentedMeasurementofthePosterolateralCorner.”Arthroscopy,Vol.14,No.5:489–494,1998.
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GregoryC.Fanelli,M.D.:“SurgicalTreatmentoftheAcuteandChronicACL/PCL/MedialSide/LateralSideInjuriesoftheKnee.”Sports Medicine and Arthroscopy Review,September,9(3),2001.
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GregoryC.Fanelli,M.D.:“ArthroscopicPosteriorCruciateLigamentReconstruction:TranstibialTunnelTechnique.SurgicalTechniqueand2–10YearResults.”Arthroscopy,18(9):44–49,(DecemberSupplement2),2002.
GregoryC.Fanelli,M.D.:“SurgicalTreatmentofACL-PCL-MedialSide-LateralSideInjuriesoftheKnee.”Operative Techniques in Sports Medicine, 11(4):263–274,2003.
GregoryC.Fanelli,M.D.:“SystematicApproachtotheMultipleLigamentInjuredKnee.”Arthroscopy;19(30–37):(DecemberSupplement1),2003.
GregoryC.Fanelli,M.D.,CraigJEdson,M.S.,P.T./A.T.C.:“CombinedPosteriorCruciateLigament–PosterolateralReconstructionwithAchillesTendonAllograftandBicepsFemorisTendonTenodesis:2–10yearFollow-up.”Arthroscopy,20(4):339–345,2004.
GregoryC.Fanelli,M.D.,DanielR.Orcutt,M.D.:“ComplicationsinPosteriorCruciateLigamentReconstruction.”Sports Medicine and Arthroscopy Review,12(3):196–201,2004.
BergfeldJA,CooperDE,FanelliGC,HarnerCD:“RoundTableDiscussion.ReconstructingthePCL:TipsandTechniques.”Orthopaedics Today,24(12):1,16–21,2004.
GregoryC.Fanelli,M.D.,DanielR.Orcutt,M.D.,CraigJ.Edson,M.S.,P.T.,A.T.C.:“CurrentConcepts:TheMultipleLigamentInjuredKnee.”Arthroscopy,21(4):471–486,2005.
GregoryC.Fanelli,M.D.:“SurgicalReconstructionforAcutePosterolateralInjuryoftheKnee.”Journal of Knee Surgery,18(2):157–162,2005.
FanelliGC,EdsonCJ,OrcuttDR,HarrisJD,ZijerdiD.:“TreatmentofCombinedACL-PCL-MCL-PLCInjuriesoftheKnee.”Journal of Knee Surgery,18(3):240–248,2005.
GregoryC.Fanelli,M.D.:“SurgicalTreatmentofLateralPosterolateralInstabilityoftheKneeUsingBicepsFemorisTendonProcedures.”Sports Medicine and Arthroscopy Review,February,14(1),2006.
FanelliGC,HarrisJD:“SurgicalTreatmentofAcuteMedialCollateralLigamentandPosteromedialCornerInjuriesoftheKnee.Sports Medicine and Arthroscopy Review,May,14(2),2006.
FanelliGC,HarrisJD.:“LateMCL(MedialCollateralLigament)Reconstruction.”Techniques In Knee Surgery,(InPress),2006.
Package Inserts
The information contained in this package insert was current on the date this brochure was printed. However, the package insert may have been revised after that date. To obtain a current package insert, please use the contact information provided herein.
Arthrotek,Inc. 01-50-1058AWhollyOwnedSubsidiaryofBiomet,Inc. Date:07/0456EastBellDriveP.O.Box587Warsaw,Indiana46581USA
RESORBABLE INTERFERENCE SCREWATTENTION OPERATING SURGEON
DESCRIPTIONArthrotek® Resorbable Interference Screw is a resorbable interference fixation screw. ThedeviceismadeofLactoSorb®,aresorbablecopolymer,whichisapolyesterderivativeoflacticacidandglycolicacid.Polylactic/polyglycolicacidcopolymerdegradesandresorbs in vivobyhydrolysistolacticandglycolicacidsthatarethenmetabolizedbythebody.
INDICATIONSIndicationsforuse:IndicationsfortheResorbableInterferenceScrewincludeuseinsofttissuereattachment procedures in the shoulder, wrist/hand, ankle/foot, elbow, and knee. Specificindicationsincludethefollowing:
Shoulder:Bankartrepair,SLAPlesionrepair,acromio-clavicularseparation,rotatorcuff repair, capsule repair or capsulolabral reconstruction, biceps tenodesis,deltoidrepair.Wrist/Hand: Scapholunate ligament reconstruction, ulnar/radial collateralligamentreconstruction.Ankle/Foot: Lateral stabilization, medial stabilization, Achilles tendon repair/reconstruction,halluxvalgusreconstruction,mid-andforefootreconstruction.Elbow: Tennis elbow repair, ulnar or radial collateral ligament reconstruction,bicepstendonreconstruction.Knee: Extra-capsular repair, medial collateral ligament (MCL) repair, lateralcollateral ligament (LCL) repair, posterior oblique ligament repair, joint capsuleclosure,iliotibialbandtenodesisreconstruction,patellarligament/tendonrepair,andvastusmedialisobliquus(VMO)muscleadvancement.
Inadditiontotheaboveindications,7.0mm,8.0mm,9.0mm,10.0mm,11.0mm,and12.0mmscrewsareindicatedforthefollowinguses: 1. Toprovideinterferencefixationofpatellarbone-tendon–bonegraftsinanterior cruciateligament(ACL)reconstruction. 2. Toprovideinterferencefixationduringfemoraland/ortibialfixationinanterior cruciateligamentreconstructionusingasofttissuegraft(semitendinosus,gracilis). 3. Toprovideinterferencefixationduringposteriorcruciateligament(PCL) reconstruction.
CONTRAINDICATIONS 1. Activeinfection. 2. Patientswithmentalorneurologicconditionswhoareunwillingorincapableof followingpostoperativecareinstructions. 3. Patientconditionsincluding:bloodsupplylimitations,insufficientquantityorquality ofboneforattachmentorlatentinfections. 4. Pathologicsofttissueconditions,whichwouldpreventsecurefixations.
WARNINGSArthrotekinternalfixationdevicesprovidethesurgeonwithameanstoaidinthemanagementofsofttissuetobonereattachmentprocedures.Whilethesedevicesaregenerallysuccessfulin attaining these goals, they cannot be expected to replace normal healthy soft tissueor withstand the stress placed upon the device by full or partial weight bearing or loadbearing, particularly in the presence of incomplete healing. Therefore, it is important thatimmobilization (use of external support, sling, etc.) of the treatment site be maintaineduntil healing has occurred. Surgical implants are subject to repeated stresses in use, whichcan result in fracture or damage to the implant. Factors such as the patient’s activity levelandadherencetoweightbearingorloadbearinginstructionshaveanaffectontheservicelifeoftheimplant.Thesurgeonmustbethoroughlyknowledgeablenotonlyinthemedicalandsurgicalaspectsoftheimplant,butalsomustbeawareofthemechanicalandpolymericaspectsofthesurgicalimplants.
1. Correctselectionoftheimplantisextremelyimportant.Thepotentialforsuccess insofttissuetobonefixationisincreasedbytheselectionofthepropertype ofimplant.Whileproperselectioncanhelpminimizerisks,thedeviceisnotdesigned towithstandtheunsupportedstressoffullweightbearing,loadbearingorexcessive activity. 2. Theimplantscanloosenorbedamagedwhensubjectedtoincreasedloading associatedwithinadequatehealing.Ifhealingisdelayed,ordoesnotoccur,the implantortheproceduremayfail.Loadsproducedbyweightbearingandactivity levelsmaydictatethelongevityoftheimplant. 3. Inadequatefixationatthetimeofsurgerycanincreasetheriskoflooseningand migrationofthedeviceortissuesupportedbythedevice.Sufficientbonequantity andqualityareimportanttoadequatefixationandsuccessoftheprocedure.Bone qualitymustbeassessedatthetimeofsurgery.Adequatefixationindiseasedbone maybemoredifficult.Patientswithpoorqualitybone,suchasosteoporoticbone,are atgreaterriskofdevicelooseningandprocedurefailure.
4. Careistobetakentoassureadequatesofttissuefixationatthetimeofsurgery. Failuretoachieveadequatefixationthroughimproperpositioningorplacementof thedevicecancontributetoasubsequentundesirableresult. 5. Theuseofappropriateimmobilizationandpostoperativemanagementisindicated aspartofthetreatmentuntilhealinghasoccurred. 6. Correcthandlingofimplantsisextremelyimportant.Donotmodifyimplants.Do notnotchorbendimplants.Notchesorscratchesputintheimplantduringthe courseofsurgerymaycontributetobreakage.Intraoperativefractureofscrewscan occurifexcessiveforce(torque)isappliedwhileseatingbonescrews. 7. DonotheatLactoSorb®InterferenceScrewsbyanymeanspriortoimplantation. 8. DONOTUSEifthereislossofsterilityofthedevice.DiscardandDONOTUSEopened ordamageddevices,anduseonlydevicesthatarepackagedinunopenedand undamagedcontainers. 9. DONOTUSEwhereapermanentimplantisindicated. 10. DONOTUSEwithotherresorbableimplantmaterials. 11. Adequatelyinstructthepatient.Postoperativecareisimportant.Thepatient’sability
andwillingnesstofollowinstructionsisoneofthemostimportantaspectsofsuccessfulsofttissuemanagement.Patientsaffectedwithsenility,mentalillness,alcoholism,anddrugabusemaybeatahigherriskofdeviceorprocedurefailure.Thesepatientsmayignoreinstructionsandactivityrestrictions.Thepatientistobeinstructedintheuseofexternalsupportsthatareintendedtoimmobilizetherepairsiteandlimitweightbearingorloadbearing.Thepatientistobemadefullyawareandwarnedthatthedevicedoesnotreplacenormalhealthytissue,andthatthedevicecanbreak,bendorbedamagedasaresultofstress,activity,loadbearing,orweightbearing.Thepatientistobemadeawareandwarnedofgeneralsurgicalrisks,possibleadverseeffects,andtofollowtheinstructionsofthetreatingphysician.Thepatientistobeadvisedoftheneedforregularpostoperativefollow-upexaminationaslongasthedeviceremainsimplanted.
PRECAUTIONSInstruments are available to aid in the accurate implantation of internal fixation devices.Intraoperative fracture or breaking of instruments has been reported. Surgical instrumentsaresubjecttowearwithnormalusage. Instruments,whichhaveexperiencedextensiveuseorexcessive force,aresusceptible to fracture.Surgical instrumentsshouldonlybeused fortheir intended purpose. Arthrotek recommends that all instruments be regularly inspectedforwearanddisfigurement.
POSSIBLE ADVERSE EFFECTS 1. Infectioncanleadtofailureoftheprocedure. 2. Neurovascularinjuriescanoccurduetosurgicaltrauma. 3. Bending,fracture,loosening,rubbing,andmigrationoftheimplantmayoccurasa resultofexcessiveactivity,trauma,orloadbearing. 4. Implantationofforeignmaterialscanresultinaninflammatoryresponseorallergic reaction. 5. Inadequatehealingwhichmayleadtobreakageoftheimplantorfailureofthegraft material. 6. Pain,discomfort,orabnormalsensationduetothepresenceofthedevice. 7. Necrosisoftheboneortissue.
STERILITYArthrotekresorbableimplantsaresterilizedbyexposuretoEthyleneOxide(ETO)Gas.Donotresterilize.Donotusepastexpirationdate.
STOREATORBELOWROOMTEMPERATURE.DONOTEXPOSEPRODUCTTOTEMPERATURESGREATERTHAN120°FOR49°C.
Caution:FederalLaw(USA)restrictsthisdevicetosale,distribution,orusebyorontheorderofaphysician.
Comments regarding this device can be directed to Attn: Regulatory Dept., Biomet, Inc.,P.O.Box587,Warsaw,IN46581USA,Fax:574-372-1683.
Manufacturer: AuthorizedRepresentative:BiometManufacturingCorp. BiometU.K.,LtdAirportIndustrialPark WatertonIndustrialEstatesP.O.Box587 Bridgend,SouthWalesWarsaw,IN46581-0587 CF313XA,U.K.
СЄ0086
Arthrotek,Inc.01-50-1018AWhollyOwnedSubsidiaryofBiomet,Inc. Date:09/05P.O.Box58756EastBellDriveWarsaw,Indiana46581USA
Arthrotek® Internal Fixation Devices Attention Operating Surgeon
DESCRIPTIONArthrotekmanufacturesavarietyofinternalfixationdevicesintendedtoaidinarthroscopicandorthopedicreconstructiveproceduresrequiringsofttissuefixation,duetoinjuryordegenerativedisease.Implantsusedforthisapplicationinclude:screws,washers,anchors,pins,andsuture.Specialtyimplantsareavailableforspecializedtreatments.
Materials:316LVMStainlessSteelTitaniumAlloyUltra-HighMolecularWeightPolyethylene(UHMWPE)Polyester
INDICATIONSTheMetalScrewAnchorandtheHarpoon®SutureAnchorareindicatedforuseinsofttissuereattachmentproceduresintheshoulder,wrist,elbow,andknee.Specificindicationsasfollows:
ShoulderIndications–Bankartrepair,SLAPlesionrepair,acromio-clavicularseparation,rotatorcuffrepair,capsulerepairorcapsulolabralreconstruction,bicepstenodesis,deltoidrepair.Wrist/HandIndications–Scapholunateligamentreconstruction,ulnar/radialcollateralligamentreconstruction.Ankle/FootIndications–Lateralstabilization,medialstabilization,Achillestendonrepair/reconstruction,halluxvalgusreconstruction,mid-andforefootreconstruction.ElbowIndications–Ulnarorradialcollateralligamentreconstruction,bicepstendonreconstruction.KneeIndications–Medialcollateralligamentrepair,lateralcollateralligamentrepair,posteriorobliqueligamentrepair,jointcapsuleclosure,iliotibialbandtenodesis,andpatellarligament/tendonrepair.
BoneMulch®Screwsareintendedforuseinfixationofsemitendinousand/orgraciletendongraftsinACLreconstruction,only.
InterferenceScrewsandSetScrewsareintendedforuseinfixationofpatellarbone-tendon-bonegraftsinACLreconstruction.
ScrewandWashersareindicatedforsofttissuefixationtobone,andbonetobonefixationinorthopedicproceduresspecificallyduringLigamentreconstruction.
Toggleanchors(ie.togglebuttonsandEZLoc™)areindicatedforuseforfixationoftendonsandligamentsduringorthopedicreconstructionproceduressuchasAnteriorCruciateLigament(ACL)Reconstruction.
Patientselectionfactorstobeconsideredinclude:1)needforsofttissuetobonefixation,2)abilityandwillingnessofthepatienttofollowpostoperativecareinstructionsuntilhealingiscomplete,and3)agoodnutritionalstateofthepatient.
CONTRAINDICATIONS 1. Infection. 2. Patientconditionsincludingbloodsupplylimitations,andinsufficientquantityor
qualityofboneorsofttissue. 3. Patientswithmentalorneurologicconditionswhoareunwillingorincapableof
followingpostoperativecareinstructions. 4. Foreignbodysensitivity.Wherematerialsensitivityissuspected,testingistobe
completedpriortoimplantationofthedevice.
WARNINGSArthrotek®internalfixationdevicesprovidethesurgeonwithameanstoaidinthemanagementofsofttissuetobonereattachmentprocedures.Whilethesedevicesaregenerallysuccessfulinattainingthesegoals,theycannotbeexpectedtoreplacenormalhealthyboneorwithstandthestressplaceduponthedevicebyfullorpartialweightbearingorloadbearing,particularlyinthepresenceofnonunion,delayedunion,orincompletehealing.Therefore,itisimportantthatimmobilization(useofexternalsupport,walkingaids,braces,etc.)ofthetreatmentsitebemaintaineduntilhealinghasoccurred.Surgicalimplantsaresubjecttorepeatedstressesinuse,whichcanresultinfractureordamagetotheimplant.Factorssuchasthepatient’sweight,activitylevel,andadherencetoweightbearingorloadbearinginstructionshaveaneffectontheservicelifeoftheimplant.Thesurgeonmustbethoroughlyknowledgeablenotonlyinthemedicalandsurgicalaspectsoftheimplant,butalsomustbeawareofthemechanicalandmetallurgicalaspectsofthesurgicalimplants.
1. Correctselectionoftheimplantisextremelyimportant.Thepotentialforsuccessinsofttissuetobonefixationisincreasedbytheselectionofthepropertypeofimplant.Whileproperselectioncanhelpminimizerisks,neitherthedevicenorgrafts,whenusedaredesignedtowithstandtheunsupportedstressoffullweightbearing,loadbearingorexcessiveactivity.
2. Theimplantscanloosenorbedamagedandthegraftcanfailwhensubjectedtoincreasedloadingassociatedwithnonunionordelayedunion.Ifhealingisdelayed,ordoesnotoccur,theimplantortheproceduremayfail.Loadsproducedbyweightbearing,andactivitylevelsmaydictatethelongevityoftheimplant.
3. Inadequatefixationatthetimeofsurgerycanincreasetheriskoflooseningandmigrationofthedeviceortissuesupportedbythedevice.Sufficientbonequantityandqualityareimportanttoadequatefixationandsuccessoftheprocedure.Bonequalitymustbeassessedatthetimeofsurgery.Adequatefixationindiseasedbonemaybemoredifficult.Patientswithpoorqualitybone,suchasosteoporoticbone,areatgreaterriskofdevicelooseningandprocedurefailure.
4. Implantmaterialsaresubjecttocorrosion.Implantingmetalsandalloyssubjectsthemtoconstantchangingenvironmentsofsalts,acids,andalkalisthatcancausecorrosion.Puttingdissimilarmetalsandalloysincontactwitheachothercanacceleratethecorrosionprocessthatmayenhancefractureofimplants.Everyeffortshouldbemadetousecompatiblemetalsandalloyswhenmarryingthemtoacommongoal,i.e.,screwsandplates.
5. Correcthandlingofimplantsisextremelyimportant.Donotmodifyimplants.Donotnotchorbendimplants.Notchesorscratchesputintheimplantduringthecourseofsurgerymaycontributetobreakage.Intraoperativefractureofscrewscanoccurifexcessiveforce(torque)isappliedwhileseatingbonescrews.
6. Donotuseexcessiveforcewheninsertingsutureanchors.Excessiveforce(longhardhammerblows)maycausefractureorbendingofthedevice.Whenencounteringhardcorticalbone,predrillwitha3/32or1/8inchdrillpriortoinsertingsutureanchors.
7. Adequatelyinstructthepatient.Postoperativecareisimportant.Thepatient’sabilityandwillingnesstofollowinstructionsisoneofthemostimportantaspectsofsuccessfulfracturemanagement.Patientseffectedwithsenility,mentalillness,alcoholism,anddrugabusemaybeatahigherriskofdeviceorprocedurefailure.Thesepatientsmayignoreinstructionsandactivityrestrictions.Thepatientistobeinstructedintheuseofexternalsupports,walkingaids,andbracesthatareintendedtoimmobilizethefracturesiteandlimitweightbearingorloadbearing.Thepatientistobemadefullyawareandwarnedthatthedevicedoesnotreplacenormalhealthybone,andthatthedevicecanbreak,bendorbedamagedasaresultofstress,activity,loadbearing,orweightbearing.Thepatientistobemadeawareandwarnedofgeneralsurgicalrisks,possibleadverseeffects,andtofollowtheinstructionsofthetreatingphysician.Thepatientistobeadvisedoftheneedforregularpostoperativefollow-upexaminationaslongasthedeviceremainsimplanted.
PRECAUTIONSDonotreuseimplants.Whileanimplantmayappearundamaged,previousstressmayhavecreatedimperfectionsthatwouldreducetheservicelifeoftheimplant.Donottreatwithimplantsthathavebeenevenmomentarilyplacedinadifferentpatient.
Instrumentsareavailabletoaidintheaccurateimplantationofinternalfixationdevices.Intraoperativefractureorbreakingofinstrumentshasbeenreported.Surgicalinstrumentsaresubjecttowearwithnormalusage.Instruments,whichhaveexperiencedextensiveuseorexcessiveforce,aresusceptibletofracture.Surgicalinstrumentsshouldonlybeusedfortheirintendedpurpose.Arthrotekrecommendsthatallinstrumentsberegularlyinspectedforwearanddisfigurement.
IfdevicecontainsMaxBraid™suture,refertomanufacturerpackageinsertforfurtherinformation.
POSSIBLE ADVERSE EFFECTS 1. Nonunionordelayedunion,whichmayleadtobreakageoftheimplant. 2. Bendingorfractureoftheimplant. 3. Looseningormigrationoftheimplant. 4. Metalsensitivity,orallergicreactiontoaforeignbody. 5. Pain,discomfort,orabnormalsensationduetothepresenceofthedevice. 6. Nervedamageduetosurgicaltrauma. 7. Necrosisofboneortissue. 8. Inadequatehealing. 9. Intraoperativeorpostoperativebonefractureand/orpostoperativepain.
STERILITYArthrotek®internalfixationimplantsaretypicallysuppliedsterileandaresterilizedbyexposuretoaminimumdoseof25kGyofgammaradiationorbyEthyleneOxideGas(ETO)ifdevicecontainsMaxBraid™PEsuture.Ifsuppliedsterile,donotresterilizetheimplant.
Ifnotsuppliedsterile,metallicinternalfixationdevicesmustbesterilizedpriortosurgicaluse.DonotsterilizeUHMWPEimplantsusingsteamautoclavingmethods.Donotuseimplantsafterexpirationdate.
Pre-VacuumSteam(HI-VAC)--wrappedorunwrappedTemperature 270°-275°F(132°-135°C)ExposureTime 5MinutesDryingTime 8Minutes
SinceArthrotekisnotfamiliarwithindividualhospitalhandlingmethods,cleaningmethodsandbioburden,Arthrotekcannotassumeresponsibilityforsterilityeventhoughtheguidelineisfollowed.
Caution:Federallaw(USA)restrictsthisdevicetosalebyorontheorderofaphysician.
AuthorizedRepresentative: BiometU.K.,Ltd. WatertonIndustrialEstates,
Bridgend,SouthWales CF313XA,U.K.СЄ0086
The information contained in this package insert was current on the date this brochure was printed. However, the package insert may have been revised after that date. To obtain a current package insert, please use the contact information provided herein.
Ordering Information
Fanelli™ PCL/ACL Guide
909800 Body909804 PCLBullet
Fanelli™ Magellan
909808
Calibrated Probe
909799
Tunnel Awl
909798
Curved Rasp
909791
Cupped Curette
909792
Cupped Curette (Over the Back)
909793
Open Curette
909794
Open Curette (Over the Back)
909795
PCL Capsule Rasp
909790
Hook Knife
909796
Graft Tensioning Boot
909525
Fanelli™ Double Bundle Aimer
909747 7mm909748 8mm 909749 9mm909750 10mm909751 11mm909752 12mm
Femoral Aimer
909627 7mm909628 8mm 909629 9mm909630 10mm909631 11mm909632 12mm
Bio-Core™ Interference Screw
905635 7x20mm 905636 7x25mm 905637 7x30mm 905638 8x20mm 905639 8x25mm 905640 8x30mm 905641 9x20mm 905642 9x25mm 905643 9x30mm 905644 10x20mm 905645 10x25mm 905646 10x30mm
Poly Suture Button
904215 15mm 904219 19mm
Resorbable No-Profile Screw
905401 6.5x25mm 905402 6.5x30mm 905403 6.5x35mm 905404 6.5x40mm 905405 6.5x45mm 905406 6.5x50mm 905407 6.5x55mm
Resorbable No-Profile Spiked Washer
905418 18mm
No-Profile Cancellous Screw
904530 6.5x30mm 904535 6.5x35mm 904540 6.5x40mm 904545 6.5x45mm 904550 6.5x50mm 904555 6.5x55mm 904560 6.5x60mm 904565 6.5x65mm 904570 6.5x70mm
No-Profile Cortical Screw (Self Tapping)
904630 6.5x30mm 904632 6.5x32mm 904634 6.5x34mm 904636 6.5x36mm 904638 6.5x38mm 904640 6.5x40mm 904642 6.5x42mm 904644 6.5x44mm 904646 6.5x46mm 904648 6.5x48mm 904650 6.5x50mm 904652 6.5x52mm 904654 6.5x54mm 904656 6.5x56mm 904658 6.5x58mm 904660 6.5x60mm
No-Profile Spiked Washer
904414 14mm 904418 18mm 904420 20mm
No-Profile Flat Washer
904428 18mm
Femoral Aimer Handle
909623
Femoral Aimer Replacement Ring Nut
909627-03
Cannulated Drill Bit
909911 7mm909913 8mm 909915 9mm909917 10mm909919 11mm909921 12mm
Graft Sizing Block
906820
Cannulated End Cutting Reamer
909617 7mm909618 8mm 909619 9mm909620 10mm909621 11mm909622 12mm
P.O. Box 587, Warsaw, IN 46581-0587 • 800.348.9500 ext. 1501 • ©2006 Arthrotek, Inc. All Rights Reservedweb site: www.arthrotek.com • eMail: [email protected]
Form No. Y-BMT-979/071506/K
I N V E N T I N G T H E F U T U R E O F A R T H R O S C O P Y