Aesculap POSITION PCL. System for reconstructing the posterior cruciate ligament Surgical Technique. Aesculap Orthopaedics

Aesculap POSITION PCL System for reconstructing the posterior cruciate ligament Surgical Technique Aesculap Orthopaedics

Preface Besides anterior cruciate ligament reconstruction, which has for years been scientifically and clinically an important field of arthroscopic surgery, injury of the posterior cruciate ligament has in recent years come increasingly into the focus of arthroscopic surgeons. The former view of this injury as a forgotten injury is being progressively replaced by an increased awareness on all sides. Bernhard Schewe, MD This is owed in particular to diagnostic improvements, primarily in the field of magnetic resonance imaging. The total number of simple and combined injuries is far higher than was assumed hitherto, and the number of injuries is expected to rise even further due to an increase in sporting activities and the increase in speed in many sports. Moreover, the patients expectations with regard to activeness and quality of life, and hence their expectations with regard to treatment results, have risen significantly. Nevertheless, the number of injuries that are overlooked and hence treated too late or inadequately is still high. Delayed therapy can however lead to sequelae with significantly impaired joint function and in some cases even lifelong functional impairment. The diagnostics and in particular Cross-Out the therapy of these injuries is being increasingly highlighted in medical literature, and by now a variety of therapy concepts have emerged. Some centres are already treating this type of injury on a routine basis. 2

Table of contents POSITION PCL The System Posterior cruciate ligament reconstruction system 4 Anatomy and Diagnosis 5 Surgical Technique 1 Positioning the patient 6 2 Graft selection 7 3 Access 9 4 Graft harvesting 10 5 Graft preparation 12 6 Preparation of the femoral tunnel 14 7 Preparation of the tibial tunnel 19 8 Tibial graft insertion 22 9 Femoral graft insertion 24 10 Femoral graft fixation 25 11 Tibia graft fixation 26 12 Aftertreatment 28 Implants 29 Instruments Reconstruction of the posterior cruciate ligament 30 Postero-lateral ligament stabilisation 32 Basic instruments for cruciate ligament reconstruction 33 3

POSITION PCL The System Posterior cruciate ligament reconstruction system FO964R The newly developed POSITION PCL instruments offer a well thought-out solution for reconstructing the difficult-to-access posterior cruciate ligament, while additionally enabling posterolateral ligament stabilisation. SAFE Very good soft tissue protection through a variety of drilling gauges with specially developed protection against overdrilling. FO011R FO997R SIMPLE Simple and convenient insertion of the PCL graft with the help of the specially designed tibial drilling gauge FO964R in connection with the corresponding insertion wire. FAST Timesaving by convenient insertion of the insertion wire through the tibial tunnel, so that the PCL graft can then be drawn from ventral to dorsal over the tibial plateau. POSITION Suture Plate Femoral graft fixation less invasive, since there is no lateral incision easy revision thanks to extra-articular implant improved isometry thanks to precision of tunnel position free selection of the transplant with high resistance against tearing out POSITION Suture Disk Tibial graft fixation enhanced graft integration due to central position of the tendon in the tunnel secondary haemorrhage reduced due to distal covering of the tunnel no implant removal due to minimal protrusion of the suture disk from the bone surface and accommodation of knots in the implant recess Suture Plate Suture DISK 4

Anatomy and diagnosis The posterior cruciate ligament is the sturdiest ligament of the knee joint. Two bundles can be differentiated from a functional point of view: the postero-medial and the antero-lateral bundle. Bio - mechanically precise insertion sites can be determined for both bundles, which are located on the inner side of the medial femoral condyle and on the posterior tibial surface, the antero-lateral bundle taking up 85 % of the volume of the ligament as a whole. The posterior cruciate ligament (PCL) has an intraarticular length of 30 39 mm, with a width of approx. 13 mm. From an ontogenetic point of view, the posterior cruciate ligament migrates into the knee joint from dorsal, carrying its blood supply with it from dorsal as well. Blood is supplied over several tiers, namely by the middle genicular artery and the lateral and medial inferior genicular artery. Diagnosis Posterior drawer sign and palpatory posterior drawer phenomenon In most cases of fresh PCL injury, painful impairment of flexion is found, and in many cases pain on pal - pation in the popliteal cavity. Isolated PCL injuries are often not accompanied by intra-articular effusion, and patients are able to continue putting strain on the joint. Complex injuries draw attention to themselves primarily by increasing instability, the levels of pain often remaining astonishingly moderate even in complex injuries. Typical pre-tibial contusion marks are a further clear sign which points to a corresponding trauma mechanism. Bone injuries should first be ruled out before going ahead with the clinical examination. Further clinical procedures for obtaining a differen - tiated diagnosis are often hampered on account of the pain situation. 5

Surgical Technique 1 Positioning the patient The patient is brought into supine position and the leg which is not to undergo surgery is placed on a special support to allow for optimum access to the dorso-medial compartment. The leg to undergo surgery should be placed in a leg holder, and care should be taken to allow for sufficient mobility. It is recommended that the operation is performed with a tourniquet applied. The tourniquet should be affixed in such a way as to leave sufficient space above the knee joint for operative steps. It is ex edient to position it level with the leg holder. Positioning of the leg to undergo surgery in a leg holder. The other leg is placed on a special support to improve access to the leg to undergo surgery. 6

2 Graft selection The patellar tendon operation was long considered the gold standard in cruciate ligament surgery. Thanks to femoral fixation with the suture plate, the semitendinous tendon can be used, applying triple or quadruple technique, and the strength of the grafts achieved with this method is significantly greater than that of patellar tendon grafts. To facilitate graft selection, the advantages and disadvantages of the different tendons are listed below. The patellar tendon and the semitendinous tendon are of equal value as grafts for cruciate ligament replacement. The semitendinous tendon does how ever have advantages for patients with: kneeling occupations patella infera Osgood-Schlatter s disease tibial medullary nail injury of the patella or the patellar tendon 7

Surgical Technique 2 Graft selection Patellar tendon Advantages variable graft width simple preparation stable fixation from the start active internal rotation preserved slow, clinically tried and tested ligamentation good long term results published Disadvantages problems due to the removal defect disorder of the extension apparatus persistent loss of quadriceps function of approx. 15 percent anterior knee pain problems with kneeling occupations slow ligamentation with transplant maturation extremely rigid graft increased risk of developing cyclops syndrome and arthrofibrosis possible patella fracture skin incision in regions involved in movement with tendency of keloid formation tunnels are completely filled out by the bone but not by the tendon. Synovial fluid can enter the tunnels and lead to cystic enlargement. impaired lateral proprioception weakening of the antagonist Semitendinous tendon Advantages smaller skin incision in a region not involved in movement no disorder of the extension apparatus kneeling possible without problems good nutrition of the fascicles elasticity module similar to that of the healthy cruciate ligament Disadvantages active internal rotation impaired bleeding from the graft bed no long term results regarding ligamentation and remodelling processes longer preparation time weakening of the agonist 8

3 Access A high and a low access is prepared on the lateral side. The high antero-lateral access permits a better view into the dorsal section of the joint. As a rule, a 45 optic system should be used. This permits a better view into the dorsal section of the joint over the dorsal edge of the tibia. The lower access is required for intra-articular pre - paration of the femoral tunnel. Care must be taken to ensure that the distance between upper and lower lateral access is sufficiently large, as preparation of the femoral tunnel is much more difficult if this distance is too small. 4 3 1 2 The lateral access sites should furthermore not be located too far lateral, as otherwise the view of the dorsal part of the femoral notch is greatly impaired, which makes preparation in the dorso-medial joint section much more difficult. Access sites for arthroscopic PCL reconstruction: high 1 and low 2 antero-lateral access, one high antero-medial access 3 and one dorso-medial access 4 On the medial side, a high antero-medial standard access is sufficient. A dorso-medial access is needed in addition for prepa ration of the dorsal edge of the tibia and for controlling the tip of the guide drilling gauge. It is advisable to equip this access with a working cannula. This access later also serves for introducing the instruments for deflecting the graft while pulling it into position. As a rule, the exact positioning of the access sites should first be explored using a cannula. 9

Surgical Technique 4 Graft harvesting Semitendinous tendon (STT) A skin incision of 3 to 4 cm, starting from a point medial from and next to the end of the tibial tuberosity, is required for harvesting the semitendinous tendon. When preparing the subcutaneous tissue, care must be taken not to injure the aponeurotic sartorius tendon, as this is in some cases only marginally thicker than subcutaneous septa. The sartorius tendon overlies the gracilis and semitendinous tendon in the form of an aponeurosis. When palpating the pes anserinus, the gracilis tendon can usually be detected as a some what thicker tendon. The semitendinous tendon underlying this is harvested. 10

The gracilis tendon is drawn away using a Kocher clamp, so that the gracilis and the semitendinous tendons can then be identified from proximal. The semitendinous tendon is drawn outward using a small 90 angular Overholt clamp, and a thread is attached to it. The STT is harvested, under inclusion of the periosteum and the Sharpey fibre system, distally as far as he ridge below the tibial tuberosity. This adds approx. 2 cm to the length of the tendon, and the periosteal part can enhance accretion of the tendon in the tunnel. A 6 mm tendon stripper is recommended as standard tool for stripping the tendon. A tendon stripper with 7 mm inner diameter can be used for thicker tendons. The instruments should have a scale on the shaft to allow the tendon length already harvested to be monitored while stripping. Before stripping, care must be taken to ensure that the connections to the medial gastrocnemius head as well as to the gracilis and semimembranous tendons are severed sharply. The tendon stripper could otherwise be misdirected and could destroy the graft. Thorough muscle relaxation facilitates STT harvesting. A tendon length of 27 30 cm is required. If the length or thickness is not sufficient, the gracilis tendon can optionally also be harvested. 11

Surgical Technique 5 Graft preparation The length of the graft is first determined on the suture board scale. The muscular portions are then removed from the proximal aponeurosis using a raspatory. The triple tendon is then fixed in the atraumatic tendon clamps which are slipped onto the ends, in order to sheathe the ends of the tendon under tension. The triple graft should be 9-10 cm long. The muscular portions are removed from the proximal aponeurosis using a sharp spoon or raspatory. At the femoral end, the tendon is sheathed with nonabsorbable threads ( baseball stitches, e.g. Premicron USP2, B. Braun) over a stretch of 20 mm, keeping the stitches far enough apart to allow the tendon to grow into the bone. Two thick polyester threads are inserted into the tendon loop (e.g. Surgical Loop or Dagrofil USP6 double, B. Braun). The tibial end is then sheathed over a stretch of 30 mm with a non-resorbable thread (e.g. Premicron USP2, B. Braun) using baseball stitch technique, to obtain a sturdy tendon end for screw fixation in the tibial tunnel. Tendon fixed in place in the suture board. The femoral and tibial end is sheathed with overcast stitches ( baseball stitches ). 12

At the femoral end, the threads are threaded through the 2 inner apertures of the suture plate. Two threads (insertion thread and flip thread) are attached to the two outer apertures. The thread which is used to pull the transplant into position must be rupture-resis tant, as the graft is often very difficult to pull into position through the bone tunnels when the pressfit technique is used. Dagrofil, USP6 Dagrofil, USP2 A suture plate is attached to the graft at the femoral end. 13

Surgical Technique 6 Preparation of the femoral tunnel First the femoral tunnel is prepared. For this purpose, the camera remains in the high antero-lateral access and a low antero-lateral access is prepared so that the femoral insertion region of the PCL is well within reach. The femoral drilling gauge with distance piece is then inserted via this access. Insertion is facilitated by first inserting the distance piece separately. Preparation of the femoral tunnel in the 12:30-position in the right knee (for the left knee in the 11:30-position) The drilling gauge is then inserted into the distance piece and thus introduced into the joint. The femoral region of the PCL should be thoroughly debrided prior to preparation of the tunnel to allow precise definition of the relevant landmarks. The distance to the bone-cartilage boundary is determined in single tunnel technique using the distance piece; the distance is 6-8 mm. The guide wire is then introduced 6 8 mm away from the bone-cartilage boundary in the 11:30-position (left knee), or in the 12:30-position (right knee). The guide wire is advanced by drilling until it has penetrated the cortical bone and can be palpated under the skin. FO011R FO997R 14

The guide wire is drilled over with a 4.5 mm cannu - lated drill until the medial cortical bone is reached. After removing the guide wire and drill, the total length of the tunnel is determined using the lengthmeasuring tool. The drilling depth for graft accomodation can be determined after the total length of the femoral tunnel has been ascertained. A flip distance of 7 mm must be added to the desired insertion length. A tunnel with the depth that was determined and with diameter as determined using the measuring block is drilled using head drills, or alternatively dilated up using sharp dilating tools. Determining the total length of the femoral tunnel FO027R As an interference screw is used for fixation in addition to the suture plate and the suture disk, the diameter of the tunnel should be 0.5 1 mm greater than the measured graft diameter. This facilitates the procedure of pulling the graft into position and introducing the additional interference screw. The bony edge of the tunnel that is directed towards the dorso-medial edge of the tibia is smoothed with a rasp or a sharp spoon in order to facilitate the procedure of pulling the graft into position. Determining the thickness of the transplant Preparation of the femoral tunnel using dilating tools 15

Surgical Technique 6 Preparation of the femoral tunnel Determination of drilling depth B Total graft length (example: ca 90 mm) femoral A intra-articular tibial A 30 mm 30-39 mm 30 mm For determining the drilling depth B, the length of the prepared graft must be known. This is mostly somewhere between 7 and 10 cm. The portion of the graft located in the femoral tunnel is determined first (length A ). This is determined by the total graft length and the individual intra-articular length to be fixed by the surgeon. As a rule, the latter is approx. 30-39 mm. Example of calculation of tendon portion A 90 mm (graft length) 30 mm (intra-articular length) = 60 mm : 2 = 30 mm (tendon portion A in the femoral and the tibial tunnel) The drilling depth B can subsequently be detemined. When determining the drilling depth, at least 7 mm are added to the length A of the tendon portion in the femoral tunnel to allow for the rotation radius of the POSITION Suture Plate (flip radius). Example of calculation of drilling depth Determination of the femoral insertion depth of the graft and the thread length at the suture plate remember to allow for the flip distance. 30 mm (tendon portion A in the femoral and the tibial tunnel) + 7 mm (flip radius) = 37 mm (minimum drilling depth B ) FO027R 16

The tying distance, which determines the distance from the suture plate to the graft, is calculated by subtracting the graft length to be inserted in the tunnel from the total length of the femoral tunnel, which is measured with the help of the depth measuring rod. Example of calculation of tying length 64 mm (total length G ) 30 mm (tendon portion A in the femoral tunnel) = 34 mm (tying length K ) The ruler of the femoral implant holder of the suture board is now adjusted to the calculated tying length, which is then fixed under tension by fastening the Surgical Loop or Dagrofil USP6, double (B. Braun) with knots. The prepared graft must be pre-tensioned for approx. 5 minutes in order to pre-stretch the graft and attached threads so that the graft will not expand after insertion. Determine thread length for femoral fixation on the suture board FO029 The product marks Surgical Loop and Dagrofil are registered marks of Aesculap AG 17

Surgical Technique 6 Preparation of the femoral tunnel Before being inserted, the graft is marked with an insertion mark which indicates, when the suture plate has been pulled out from the opposing lateral cortical bone far enough to be flipped over. The position of the insertion mark is calculated by adding the flip radius of 7 mm to the length of the tendon portion in the femoral tunnel to allow for turning over the POSITION Suture Plate outside of the femoral cortex. Marking the femoral insertion depth on the graft Example of calculation of graft marking 30 mm (tendon portion A ) + 7 mm (flip radius) = 37 mm (marking distance M ) 18

7 Preparation of the tibial tunnel For preparation of the tibial tunnel, the dorsal edge of the tibia must first be debrided. This is done using a 90 angular raspatory, and also a shaver and an electric cutter. A dorso-medial access should be prepared now, if this has not yet been done. Care must be taken when doing this that the distance to the posterior condyle boundary is sufficiently large, as otherwise there is a risk of the working radius being considerably impaired. The 30 angular raspatory can then be introduced via this access for thorough debriding of the dorsal edge of the tibia. If a postero-medial bundle is still present, this is left as it is, or it is lifted from the edge of the tibia and pushed away dorsally using the 30 angled raspatory that was introduced from the dorso-medial access. The point of exit of the antero-lateral bundle is somewhat nearer to the dorsal edge of the tibia than that of the postero-medial bundle. The tibial tunnel is prepared using the tibial guiding device, which is introduced via the antero-medial access and brought into position at the point of in - sertion of the antero-lateral bundle via the dorsal edge of the tibia. This point of insertion is approx. 12-14 mm caudal from the dorsal edge of the tibia. Care must be taken when preparing the dorso-medial access that the working radius is not impaired by the medial epicondyle. FO979R FO968R FO969R Exact placement can additionally be checked with the arthroscope via the dorso-medial access. 19

Surgical Technique 7 Preparation of the tibial tunnel The point of entry at the ventral tibia is located at the antero-medial edge of the tibial head, level with the tibial tuberosity. Guiding device with overdrill protector FO964R FO966R The drill sleeve of the guiding device is then inserted into the bracket and advanced up to the ventral edge of the tibia. The total length of the tibial tunnel is indicated on the scale which is on the sleeve. A protective device against overdrilling is slipped onto the drilling sleeve in order to protect dorsal structures from injury when introducing the guide wire. The guide wire is placed in the fixing gauge with the aid of the pedestal and inserted up to the limit into the drill chuck. The guide wire is then drilled in as far as the stop position of the overdrill protector, so that the tip of the drill barely reaches the opposing cortical bone. The 30 angular raspatory is additionally introduced for protection via the dorso-medial access. Taking up the wire from the fixing gauge FO965R The guide wire is then re-fixed allowing approx. 5 mm more length and advanced by drilling under optical control in the direction of the 30 angled raspatory, until it is certain that the tip of the guide wire has penetrated through the dorsal cortical bone. The tip of the guide wire is then placed in the recess of the raspatory. The drilling sleeve and the guiding device are dis connected and removed from the joint. Introduction of the tibial drill wire with overdrill protector 20

The tip of the guide wire now remains in the recess of the 30 angled raspatory. This prevents further advancing of the wire while drillingover is performed. Before going ahead with drillingover, it is advisable to check the position of the tibial guide wire radiologically in the lateral view using the x-ray. The guide wire is next drilled over with a 6 mm drill. The tunnel should subsequently be further drilled or dilated up until the graft diameter measured before is reached. The tip of the guide wire is covered with the raspatory in order to protect dorsal structures in the popliteal cavity The dorsal edge of the tibia is rounded off using a special rasp in order to defuse the killing turn. Dilation of the tibial tunnel using dilating tools FO968R FO969R 21

Surgical Technique 8 Tibial graft insertion For graft insertion, the tibial guiding device with the corresponding guide sleeve for the insertion wire is again introduced into the tibial tunnel. Inserting the insertion thread with the guide bracket The insertion wire (shown in orange in the figure on the right) is advanced through the guide sleeve until it passes through the guide loop of the guiding device, where it catches onto the guide aperture. The guide sleeve is removed, and the insertion wire is guided from dorsal to ventral around the edge of the tibial plateau while taking out the drilling gauge. This enables convenient placement of an insertion thread, which subsequently guides the graft from ventral to dorsal around the edge of the tibial plateau. Thread guides are used as aids for graft insertion, especially to guide the graft around the dorsal edge of the tibial plateau. Hitching the insertion wire onto the loop of the guiding device Inserting the insertion thread 22

The insertion thread, which has already been guided through the tibial tunnel, is taken up inside the joint cavity in a thread loop, which is then guided through the femoral tunnel using a looped guide wire which then pierces the skin over the femur so that the insertion thread penetrates the skin. The graft is finally drawn into the femoral tunnel under arthroscopic control by pulling the insertion thread until the coloured mark on the graft appears at the entry to the femoral tunnel. Insertion thread drawn through the tibia and femur Intra-articular femoral thread insertion Intra-articular femoral thread insertion 23

Surgical Technique 9 Femoral graft insertion Graft insertion using the thread guide or the thread fork FO995R FO994R 24

10 Femoral graft fixation The POSITION Suture Plate is flipped over, i.e. made to lie flat across the drilling tunnel aperture, by pulling on the flip thread. The graft is drawn back 7 mm into the joint cavity by this procedure, so that the suture plate comes to lie flat on the femoral cortex, thus arresting the graft at the femoral end. After the graft has been retracted, it is additionally secured in the femur with an interference screw so called hybrid fixation technique. Femoral fixation with suture plate and interference screw (hybrid fixation) FO030T 25

Surgical Technique 11 Tibia graft fixation The graft is then secured in the tibial tunnel with the knee in approx. 80 flexion. The knee is additionally held in an anterior drawer position. For securing the graft, an interference screw is first screwed in until the dorsal edge of the tibial tunnel is reached. The diameter of the screw should be selected according to the tunnel diameter, possibly 1 mm larger, depending on the quality of the bone. Hybrid fixation with interference screw and suture disk is carried out at the tibial end. In order to keep the graft under tension while the screw is screwed in, the holding threads of the graft are attached to a tensioning hook with spring balance. The length of the tibial tunnel should be determined in advance in order to be better able to determine the screw-in depth. 26

The screw can then be screwed in precisely up to the dorsal end of the tibial tunnel using a screw driver with scale. Hybrid fixation is carried out at the tibial end as well. For this purpose, the holding threads are secured with knots over the suture disk. FO035T FO034T 27

Surgical Technique 12 Aftertreatment At the end of the operation, the patient is fitted with a rigid orthesis with an additional cushion for the tibial head. Physiotherapy with exercises should be applied with caution in order not to endanger the healing-in of the graft. The rigid orthesis can be replaced after one week by an articulated PCL-orthesis, on which the range of motion permitted at each stage can be pre-selected. The orthesis should be worn day and night. Orthesis treatment is continued for 12 weeks in total. Partial weight-bearing of 20 kg should be adhered to after the operation up to the end of the fourth post - operative week. After one more week of partial weighbearing with half of the body weight, full weight-bearing can be attained from the 7. week on. Up to the 6. postoperative week, only passive exer cising is performed for mobility, active movement exercises are permitted from the 7. week on. Flexion is limited to 30 in the first three weeks. Flexion is subsequently increased in stages first to 60, then to 90, and full flexion is permitted from the 9. week on. Physiotherapy is carried out with the patient in prone position up to the end of the 8. week to reduce strain on the graft. From the 13. week on, the orthesis is gradually withdrawn with appropriate exercising. Swimming, cycling and Nordic walking are permitted from the 16. week on. Contact sports and competitive sports can be taken up after one year. 28

Implants FO030T POSITION Suture Plate - sterile - titanium alloy - 4 x 12 mm FO035T Suture Disk S - sterile - pure titanium - Ø 14 mm FO034T Suture Disk L - sterile, with rotation stopper - pure titanium - Ø 14 mm FO039 Implantation set for STT, sterile comprising: 1x Suture Plate FO030T 1x Suture Disk L FO034T 4x Premicron, USP2, HRT 37, 75 cm 1x Dagrofil, USP6, 150 cm 1x Dagrofil, USP2, 150 cm 1x Surgical Loop, 4 mm, 75 cm FO040 Implantation set for STT, sterile comprising: 1x Suture Plate FO030T 1x Suture Disk S FO035T 4x Premicron, USP2, HRT 37, 75 cm 1x Dagrofil, USP6, 150 cm 1x Dagrofil, USP2, 150 cm 1x Surgical Loop, 4 mm, 75 cm 29

Instruments Reconstruction of the posterior cruciate ligament FO964R Tibial drilling gauge - for preparing the tibial tunnel and subsequently holding the PCL graft - for insertion of an insertion wire through the tibial tunnel, for drawing the PCL graft from ventral to dorsal around the edge of the tibial plateau and through the tibial tunnel FO966R Overdrill protector allows safe advancement of the guide wire up to the dorsal edge of the tibia without injuring dorsal structures FO965R Fixing gauge, 280 mm for fixing and measuring the length of the guide wire for the tibial drilling gauge FO964R FO967R Pedestal for fixing gauges FO965R and FO975R FO983R Insertion wire (not shown) for pulling the graft into position through the tibial tunnel or through the fibula FO011R Femoral drilling gauge for preparing the femoral tunnel for accommo dating the PCL reconstruction graft in inside-out technique FO997R Distance piece for determining the distance (6-8 mm) of the femoral tunnel from the edge of the femoral notch 30

FO979R Rasp - for removing the PCL stump and protecting the popliteal structures from the guide wire when this is drilled over for the antero-medial access - 90 angle FO969R Rasp - for transtibial deburring of the dorsal tibial tunnelaperture - 30 angle FO968R Popliteal protector - for removing the PCL stump and protecting the popliteal structures from the guide wire when this is drilled over for the antero-medial access - for protecting the popliteal structures from the guide wire for the postero-medial access FO994R Thread guide for guiding the PCL graft over the dorsal edge of the tibial plateau from ventral access FO995R Thread guide for guiding the PCL reconstrucion graft over the dorsal edge of the tibial plateau for the dorsalmedial access 31

Instruments Postero-lateral ligament stabilisation FO974R Drilling gauge - for preparing the tunnel in the fibular head and subsequently holding the graft - for insertion of the insertion wire through the tunnel in the fibular head, for drawing the graft through the fibular head from ventral to dorsal FO976R Overdrill protector allows safe advancement of the guide wire up to the dorsal edge of the fibular head FO975R Fixing gauge, 200 mm for fixing and measuring the length of the guide wire for the fibular drilling gauge FO974R FO996R Tensiometer hook for pre-tensioning tibial transplants to be secured with interference screws FO037R Twister for FO034T and FO035T FO955R Storage rack for PCL instruments (not shown) POSITION PCL storage rack for the instruments for posterior cruciate ligament reconstruction and posterolateral ligament stabilisation 32

Basic instruments for cruciate ligament reconstruction FO029 POSITION Suture Board - modular design for the individual operating steps - secure receptacles and measuring scales for tendon preparation - attachment of implants for graft pre-tensioning Tendon stripper usable length: 340 mm, graduated shaft FO023R inner diameter 6 mm FO024R inner diameter 7 mm FO027R Depth measuring probe usable length 300 mm FO028R Knot pusher FO014R Notch gauge 33

Instruments Head drill 2-winged, cannulated (2.6 mm) Hex shaft, length 180 mm FO081R, Ø 5 mm FO088R, Ø 8.5 mm FO082R, Ø 5.5 mm FO089R, Ø 9 mm FO083R, Ø 6 mm FO090R, Ø 9.5 mm FO084R, Ø 6.5 mm FO091R, Ø 10 mm FO085R, Ø 7 mm FO092R, Ø 10.5 mm FO086R, Ø 7.5 mm FO093R, Ø 11 mm FO087R, Ø 8 mm Round shaft, cannulated, length 205 mm FO079R, Ø 4.5 mm Round shaft, non-cannulated, length 205 mm FO078R, Ø 4.5 mm Tibial drill cannulated (2.6 mm) Hex shaft, length 160 mm FR541R, Ø 5 mm FR548R, Ø 8.5 mm FR542R, Ø 5.5 mm FR549R, Ø 9 mm FR543R, Ø 6 mm FR550R, Ø 9.5 mm FR544R, Ø 6.5 mm FR551R, Ø 10 mm FR545R, Ø 7 mm FR552R, Ø 10.5 mm FR546R, Ø 7.5 mm FR553R, Ø 11 mm FR547R, Ø 8 mm Tissue protection sleeves (not shown) also for determining graft thickness, inner diameter (Ø) FR705S, Ø 5.5 mm FR576S, Ø 6 mm FR706S, Ø 6.5 mm FR577S, Ø 7 mm FR707S, Ø 7.5 mm FR578S, Ø 8 mm FR708S, Ø 8.5 mm FR579S, Ø 9 mm FR709S, Ø 9.5 mm FR580S, Ø 10 mm FR710S, Ø 10.5 mm FR581S, Ø 11 mm 34

FR750 Drilling tunnel dilator set comprising: FR751R Storage rack FR752R Handle with hammer for dilator removal FR775R FR781R Dilators, sharp FR785R FR790R Dilators, sharp (round dilators must be ordered separately!) FR793R FR795R Tibial guide pin FR753R Femoral guide pin FR751R Storage Tray for dilators (not shown) FR752R Handle with hammer for dilator removal Dilators sharp FR775R, Ø 5 mm FR776R, Ø 6 mm FR777R, Ø 7 mm FR778R, Ø 8 mm FR779R, Ø 9 mm FR780R, Ø 10 mm FR781R, Ø 11 mm rounded FR755R, Ø 5 mm FR756R, Ø 6 mm FR757R, Ø 7 mm FR758R, Ø 8 mm FR759R, Ø 9 mm FR760R, Ø 10 mm FR761R, Ø 11 mm FR785R, Ø 5.5 mm FR786R, Ø 6.5 mm FR787R, Ø 7.5 mm FR788R, Ø 8.5 mm FR789R, Ø 9.5 mm FR790R, Ø 10.5 mm FR765R, Ø 5.5 mm FR766R, Ø 6.5 mm FR767R, Ø 7.5 mm FR768R, Ø 8.5 mm FR769R, Ø 9.5 mm FR770R, Ø 10.5 mm Tibial guide pin, movable head FR793R, Ø 4.5 mm FR794R, Ø 6 mm FR795R, Ø 8 mm Femoral guide pin, fixed head FR573R, Ø 4.5 mm 35

Instruments FO038R Measuring block for determining graft thickness Guide wires FO025R Drilling and pullout pin - with drilling helix and eye - total length 380 mm - shaft Ø 2.4 mm - tip Ø 2.7 mm FO036R Drilling and pullout pin with loop - total length 380 mm - Ø 2.5 mm LX045S Guide wire - total length 310 mm - Ø 2.5 mm FO002R Storage rack for basic instruments for cruciate ligament reconstruction POSITION Storage rack for Suture Board FO029, for secure, protective and quick instrument placement and reconditioning comprising: JF222R Tray FO002/200 Silicone pad for POSITION FO003R Storage rack for basic instruments for cruciate ligament reconstruction POSITION Storage rack for implants and instruments comprising: JF222R Tray FO003/200 Silicone pad for POSITION 36

Instruments OG335R Micro forceps - straight -5x1 mm BM016R Durogrip CRILE-WOOD needle holder 145 mm PE545A Wide-angle arthroscope - 45 viewing angle - Ø 4 shaft diameter - length 180 mm EJ563R Standard cannula with blunt obturator - for optic systems - length 180 mm e.g. PE505A, PE545A, PE525A EJ566R Softtip cannula with blunt obturator 37

Instruments JK440 Container tray - 1 basket - outer dimensions 592 x 274 x 90 mm e.g. for storing FR751R (dilators) JK442 Container tray (not shown) - 2 baskets - outer dimensions 592 x 274 x 135 mm e.g. for storing FO002R and FO003R (basic instruments for cruciate ligament recon struction) or FO955R (PCL instruments) JP001 PrimeLine container lid, red - lid available in different colours - for JK440 or JK442, red JG785B Identification label, red - up to 13 characters including spaces can be inscribed - 4 labels per container recommended JF436R Optics tray - Optics tray for secure storage during transport, cleaning and sterilization of arthroscopes e.g. for PE545A - outer dimensions 273 x 84 x 41 mm - for one arthroscope of 2.7 mm or 4 mm shaft diameter - shaft length between 140 and 200 mm 38

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The main product mark Aesculap and the product marks Dagrofil, Premicron and Surgical Loop are registered marks of Aesculap AG. Aesculap AG Am Aesculap-Platz 78532 Tuttlingen Germany Phone +49 (0) 74 61 95-0 Fax +49 (0) 74 61 95-26 00 www.aesculap.com All rights reserved. Technical alterations are possible. This leaflet may be used in no way whatsoever other than for the offering buying and selling of our products. No part may be copied or reproduced in any form. In the case of misuse we retain the right to recall our catalogues and pricelists and to take legal action. Aesculap a B. Braun company Brochure No. O31802 0710/1/1