Consultant Orthopedic Surgeon
Lilavati Hospital and Research Centre, Mumbai
Hello! Dr. Joshi, welcome to IAS 2013 Hyderabad.
You started using arthroscopic treatment recently and any words about it.
Yes do arise as you are aware, we have changed our concept of ACL reconstructions in the past decade from being isometric to more anatomic and to achieve this anatomic placement of especially femoral foot print, we have changed from the transtibial to the trans-portal vein of drilling the femoral tunnel. Now unfortunately when you want to drill your femoral drill with any kind of a retrieved drill existed whether it is low profile or the regular drill, you have to hyperflex the knees and whenever you hyperflex the knees for your femoral tunnel, you find that your vision gets obscured because of the fat pad coming in your way. Now, this is what I found was the greatest advantage of the VersiTomic System which is a Flexible Reamer System and what it allowed me to do was to minimize the damage to the fat pad and preserve a great deal of the footprint. I think when you are doing an ACL reconstruction, you need to respect biology. I think the VersiTomic allows me to respect biology in a much better fashion than the previous drill system.
Dr. Joshi now you are doing more of hamstrings and I want to know a matter of fixation units, preferred method what I mean.
Where we started doing bone patellar tendon bone from 1989 went on till 1996 when we finally shifted to the hamstrings. One of the greatest advantage of using the hamstrings was graft, the native ACL membrane preservation. I think when you do an ACL reconstruction, you want to preserve as much as biology as possible. The hamstrings is a versatile graft, you can double it, you can triple it, you can quadruple it, depending on what size of graft you want, what is the amount of regimen that is inside. So that is why I made my shift from the bone patellar tendon bone to the hamstrings. Now, when it comes to fixation, we were used to interference kind of fixation for the bone patellar tendon bone. Unfortunately, for the hamstrings being a soft tissue graft which is to be fixed in a rigid bony tunnel, I felt that we kind of interference to the tubules would real we lacerate the graft and cause a D1 failure of your hamstring fixation and therefore I tend to prefer any kind of distant fixation for all my hamstring tendons, so the distant fixation does not harm my graft in any way, again it is versatile because if I have a short tunnel, I can use a smaller loop of the distant fixation and I think what I have observed is the interfering screws. If you have a rigid tunnel and a screw that is squeaking which people say is a good thing and use your rigid fixation, I think that squeaking actually destroys ….
The femoral tendon.
Yes. The next thing about the screws is that people have started using a lot of bioabsorbable degradable screws and over titanium screws. I think titanium screws have been time tested. They have been used all over four years and we have not let any of these screws. With the mil screw, the first thing is that the mil screw is not as strong as Titanium, so if you use any excessive force during fixation, the screw can break and you can be in a complete fix. (4:00) The other thing we have seen a lot of reactive changes, absorption problems , the bioabsorbable never gets absorbed here, we remove screws after two years and the screws is not there, you cannot see where the screw is, so the screw may be floating around in the joint. So these are, I think some potential problems with the biodegradable screws and I hate them.
we are using Titanium.