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Domnick C, Raschke MJ, Herbort M. Biomechanics of the anterior cruciate ligament: Physiology, rupture and reconstruction techniques. World J Orthop 2016; 7:82-93. [PMID: 26925379 PMCID: PMC4757662 DOI: 10.5312/wjo.v7.i2.82] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/05/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023] Open
Abstract
The influences and mechanisms of the physiology, rupture and reconstruction of the anterior cruciate ligament (ACL) on kinematics and clinical outcomes have been investigated in many biomechanical and clinical studies over the last several decades. The knee is a complex joint with shifting contact points, pressures and axes that are affected when a ligament is injured. The ACL, as one of the intra-articular ligaments, has a strong influence on the resulting kinematics. Often, other meniscal or ligamentous injuries accompany ACL ruptures and further deteriorate the resulting kinematics and clinical outcomes. Knowing the surgical options, anatomic relations and current evidence to restore ACL function and considering the influence of concomitant injuries on resulting kinematics to restore full function can together help to achieve an optimal outcome.
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Herbort M, Domnick C, Raschke MJ, Lenschow S, Förster T, Petersen W, Zantop T. Comparison of Knee Kinematics After Single-Bundle Anterior Cruciate Ligament Reconstruction via the Medial Portal Technique With a Central Femoral Tunnel and an Eccentric Femoral Tunnel and After Anatomic Double-Bundle Reconstruction: A Human Cadaveric Study. Am J Sports Med 2016; 44:126-32. [PMID: 26574601 DOI: 10.1177/0363546515611646] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anatomic femoral tunnel placement in anterior cruciate ligament (ACL) reconstruction is considered to be a key to good primary stability of the knee. There is still no consensus on whether a centrally placed single bundle in the anatomical femoral footprint can compare with anatomic double-bundle (DB) reconstruction. PURPOSE/HYPOTHESIS The purpose of this study was to determine knee kinematics after single-bundle ACL reconstruction via the medial portal technique using 2 different femoral tunnel positions and to compare results with those of the anatomic DB technique. The hypotheses were that (1) single-bundle reconstruction using the medial portal technique with a centrally placed femoral tunnel relative to the native footprint (SB-central technique) would more closely restore intact knee kinematics compared with the same reconstruction technique with an eccentric femoral tunnel drilled in the anteromedial bundle footprint (SB-AM technique) and (2) DB reconstruction would result in superior kinematics compared with the SB-central technique. STUDY DESIGN Controlled laboratory study. METHODS Knee kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force-moment sensor system. Kinematics in simulated pivot-shift and 134-N anterior tibial loading tests were determined in different conditions within the same specimen: (1) intact ACL, (2) deficient ACL, (3) SB-AM, (4) SB-central, and (5) DB. RESULTS All reconstruction techniques significantly reduced anterior tibial translation (ATT) compared with a deficient ACL at 0°, 15°, 30°, 60°, and 90° in the anterior tibial loading test (P < .01, repeated-measures analysis of variance) and at 0°, 15°, and 30° in the simulated pivot-shift test (P < .001). There were no significant differences in the SB-central group and the DB group compared with the intact ACL. Reconstruction in the SB-AM group resulted in significantly increased ATT compared with the intact ACL in near-to-extension angles in both tests (0°, 15°, and 30°; P < .01). SB-central and DB reconstructions both resulted in significantly reduced ATT, in some tests at ≤30°, compared with SB-AM reconstruction (P < .05). No significant differences between the SB-central and DB groups were found (P > .05). CONCLUSION The SB-central technique restored intact knee kinematics more closely than did SB-AM reconstruction at time zero. There were no differences in knee kinematics between the DB and SB-central techniques. CLINICAL RELEVANCE Anatomic single-bundle ACL reconstruction provides similar knee kinematics as anatomic double-bundle reconstruction.
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Affiliation(s)
- Mirco Herbort
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Michael Johannes Raschke
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Simon Lenschow
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Tim Förster
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | | | - Thore Zantop
- Department of Orthopedic and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
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Harms SP, Noyes FR, Grood ES, Jetter AW, Huser LE, Levy MS, Gardner EJ. Anatomic Single-Graft Anterior Cruciate Ligament Reconstruction Restores Rotational Stability: A Robotic Study in Cadaveric Knees. Arthroscopy 2015; 31:1981-90. [PMID: 26033460 DOI: 10.1016/j.arthro.2015.04.081] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 03/20/2015] [Accepted: 04/09/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE First, we aimed to investigate the ability of a single bone-patellar tendon-bone graft placed in the anatomic center of the femoral and tibial attachment sites to restore normal tibiofemoral compartment translations and tibial rotation. Second, we aimed to investigate what combination of anterior load and internal rotation torque applied during a pivot-shift test produces maximal anterior tibiofemoral subluxations. METHODS We used a 6-df robotic simulator to test 10 fresh-frozen cadaveric specimens under anterior cruciate ligament (ACL)-intact, ACL-sectioned, and ACL-reconstructed conditions measuring anterior translations of the medial, central, and lateral tibiofemoral compartments and degrees of tibial rotation. Specimens were loaded under Lachman, anterior limit, and internal rotation conditions, as well as 3 different pivot-shift conditions. RESULTS On ACL sectioning, compartment translations in the Lachman and 3 pivot-shift tests increased significantly and were restored to ACL-intact values after single-graft ACL reconstruction. In the pivot-shift tests, the single graft restored lateral and medial compartment translations (e.g., group 3, within 1.3 ± 0.6 mm and 0.8 ± 0.6 mm, respectively, of the ACL-intact state and internal rotation within 0.7° ± 1.2°). Anterior subluxation of the medial compartment during pivot-shift loading was reduced when internal rotation torque was increased from 1 to 5 Nm (P < .0001). CONCLUSIONS A single-graft ACL reconstruction performed at the central femoral and tibial ACL attachment sites restored anterior-posterior translation and tibial rotation motion limits. In addition, rotational knee stability as defined by tibiofemoral compartment translations was restored under all simulated pivot-shift testing conditions. CLINICAL RELEVANCE This study provides in vitro evidence to support the clinical use of single-graft ACL reconstructions in restoring tibiofemoral compartment translations. It also shows the advantage of describing ACL insufficiency in terms of medial and lateral compartment subluxations as compared with the common approach of describing changes in central tibial translations and rotations.
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Affiliation(s)
- Samuel P Harms
- Cincinnati Sports Medicine and Orthopedic Center, Mercy Health, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Frank R Noyes
- Cincinnati Sports Medicine and Orthopedic Center, Mercy Health, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A.; Noyes Knee Institute, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A..
| | - Edward S Grood
- Noyes Knee Institute, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Andrew W Jetter
- Cincinnati Sports Medicine and Orthopedic Center, Mercy Health, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Lauren E Huser
- Cincinnati Sports Medicine and Orthopedic Center, Mercy Health, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Martin S Levy
- Department of Operations and Business Analytics, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Eric J Gardner
- Cincinnati Sports Medicine and Orthopedic Center, Mercy Health, College of Business, University of Cincinnati, Cincinnati, Ohio, U.S.A
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Bonanzinga T, Signorelli C, Lopomo N, Grassi A, Neri MP, Filardo G, Zaffagnini S, Marcacci M. Biomechanical effect of posterolateral corner sectioning after ACL injury and reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:2918-24. [PMID: 26183733 DOI: 10.1007/s00167-015-3696-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 07/06/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Posterolateral corner structures functionally interact with the ACL. The aim of this study was to investigate the capability of an isolated ACL reconstruction control laxity parameters in a knee with combined ACL and PLC and the increase in terms of laxity produced by the resection of the PC in an ACL-deficient knee. METHOD An in vitro cadaveric study was performed on seven knees. The joints were analysed in the following conditions: intact, after ACL resection, after popliteus complex resection, after ACL reconstruction and after LCL. Testing laxity parameters were recorded with an intra-operative navigation system and defined as: AP displacement at 30° and 90° of flexion (AP30 and AP90) applying a 130 N load and IE at 30° and 90° of knee flexion with a 5 N load. RESULTS Sectioning the ACL significantly increased the AP30 at 30° and 90° of knee flexion (p < 0.05). At 90° of knee flexion, the resection of the LCL determined a significant increase in terms of AP laxity (p < 0.05). At 90° has been found a significant difference for the IE laxity (p < 0.05) after PC resection. Sectioning the LCL produced a significant increase in IE laxity at 30° and 90° of knee flexion (p < 0.05). CONCLUSION Isolated ACL reconstruction is able to control the AP laxity with a combined complete lesion of the PLC at 30° of knee flexion, but not at higher angle of knee flexion. Considering the IE rotations, the reconstruction was not sufficient not even to control a partial lesion of the PLC. These findings suggest that additional surgical procedures should be considerate even when facing combined PLC lesion.
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Affiliation(s)
- Tommaso Bonanzinga
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
| | - Cecilia Signorelli
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
| | - Nicola Lopomo
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
| | - Alberto Grassi
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
| | - Maria Pia Neri
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
| | - Giuseppe Filardo
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
| | - Maurilio Marcacci
- Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
- Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell'Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy.
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Lorbach O, Kieb M, Domnick C, Herbort M, Weyers I, Raschke M, Engelhardt M. Biomechanical evaluation of knee kinematics after anatomic single- and anatomic double-bundle ACL reconstructions with medial meniscal repair. Knee Surg Sports Traumatol Arthrosc 2015; 23:2734-41. [PMID: 24850240 DOI: 10.1007/s00167-014-3071-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 05/06/2014] [Indexed: 01/13/2023]
Abstract
PURPOSE To evaluate knee laxity after anatomic ACL reconstruction with additional suture repair of a medial meniscus tear. METHODS Kinematics of the intact knee were determined in 12 human cadaver specimens in response to a 134-N anterior tibial load (aTT) and a combined rotatory load of 10 Nm valgus and 4 Nm internal tibial rotation (aTTPS) using a robotic/universal force moment sensor testing system. Subsequently, the ACL was resected following the creation of a standardized tear of the medial meniscus, a standard meniscus repair and an ACL reconstruction using an anatomic single-bundle (6) or an anatomic double-bundle technique (6). Knee kinematics were determined following every sub-step. RESULTS Significant increase of aTT in the ACL-deficient knee was found (p ≤ 0.001) with a further increase in the ACL-deficient knee with additional medial meniscal rupture (p ≤ 0.001). ACL reconstructions significantly decreased aTT compared with the ACL and meniscus-ruptured knee. No significant differences were seen between the intact knee and the ACL-reconstructed knee with additional meniscal repair (p < 0.05). In response to a simulated pivot shift, aTTPS in the intact knee significantly increased in the ACL-deficient knee and meniscus-ruptured knee (p = 0.005). No significant differences in knee kinematics were found between SB as well as DB ACL reconstruction with additional medial meniscal repair compared with the intact knee. Comparison of SB versus DB ACL reconstruction did not reveal any significant differences in a simulated Lachman test or simulated pivot shift test (n.s.). CONCLUSIONS aTT as well as aTTPS significantly increased with ACL deficiency compared with the intact knee; additional medial meniscal rupture further increased aTT. Anatomic ACL reconstruction with medial meniscal repair did not reveal significant differences in knee kinematics compared with the intact knee. Comparison of anatomic SB versus DB ACL reconstruction with additional repair of the medial meniscus did not show significant differences neither in a simulated Lachman nor in a simulated pivot shift test.
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Affiliation(s)
- Olaf Lorbach
- Department of Orthopaedic Surgery, Saarland University, Kirrberger Str., Homburg (Saar), 66421, Homburg, Germany,
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Bae JY, Kim GH, Seon JK, Jeon I. Finite element study on the anatomic transtibial technique for single-bundle anterior cruciate ligament reconstruction. Med Biol Eng Comput 2015; 54:811-20. [PMID: 26296801 DOI: 10.1007/s11517-015-1372-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 08/10/2015] [Indexed: 01/10/2023]
Abstract
The anatomic transtibial (TT) technique is proposed as a new approach for single-bundle anterior cruciate ligament (ACL) reconstruction. Geometric models of the anatomic TT and anteromedial (AM) portal techniques were fabricated with a reconstructed knee joint model and virtual surgical operations. Grafts of 7 mm diameter were modeled and inserted into tunnels drilled in each model. In the models, the shape of the graft between the femur and the tibia, the lengths of the bone tunnels, and the femoral graft bending angles were evaluated. To evaluate the biomechanical effects of both techniques on the grafts, the contact pressures and maximum principal stresses in the grafts were calculated using the finite element method. The anatomic TT technique placed the femoral tunnel to the anatomic position of the native ACL femoral attachment site. In addition, it decreased the peak contact pressure and the maximum principal stress at the full extension position of the graft compared with the AM portal technique. The anatomic TT technique may be regarded as a superior surgical technique compared with the conventional TT and AM portal techniques. Because of the easy surgical operation involved, the technique decreases the operation time for ACL reconstruction and it provides a deformation behavior of grafts similar to that in the native ACL in a knee joint. With its few side effects, the anatomic TT technique may considerably help patients.
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Affiliation(s)
- Ji Yong Bae
- Optical Instrumentation Development Team, Korea Basic Science Institute, 169-148 Gwahak-ro, Yuseong-gu, Daejeon, 305-806, Republic of Korea
| | - Geon-Hee Kim
- Optical Instrumentation Development Team, Korea Basic Science Institute, 169-148 Gwahak-ro, Yuseong-gu, Daejeon, 305-806, Republic of Korea
| | - Jong Keun Seon
- The Center for Joint Disease, Hwasun Hospital, Chonnam National University, 160 Ilsimri, Hwasun-Eup, Hwasun-Gun, Jeonnam, 519-809, Republic of Korea
| | - Insu Jeon
- School of Mechanical Engineering, Chonnam National University, 300 Yongbong-dong, Buk-gu, Gwangju, 500-757, Republic of Korea.
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Rayan F, Nanjayan SK, Quah C, Ramoutar D, Konan S, Haddad FS. Review of evolution of tunnel position in anterior cruciate ligament reconstruction. World J Orthop 2015; 6:252-262. [PMID: 25793165 PMCID: PMC4363807 DOI: 10.5312/wjo.v6.i2.252] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 10/29/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023] Open
Abstract
Anterior cruciate ligament (ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Other factors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.
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Alavekios D, Peterson A, Patton J, McGarry MH, Lee TQ. The relation between knee flexion angle and anterior cruciate ligament femoral tunnel characteristics: a cadaveric study comparing a standard and a far anteromedial portal. Arthroscopy 2014; 30:1468-74. [PMID: 25085050 DOI: 10.1016/j.arthro.2014.05.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 05/12/2014] [Accepted: 05/21/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the anterior cruciate ligament (ACL) femoral tunnel characteristics between 2 common arthroscopic portals used for ACL reconstruction, a standard anteromedial portal and a far anteromedial portal. METHODS Seven cadaveric knees were used. A 1.25-mm Kirschner wire was drilled through the center of the ACL femoral footprint and through the distal femur from the standard anteromedial and far anteromedial portals at knee flexion angles of 100°, 120°, and 140°. No formal tunnels were drilled. Each tunnel exit point was marked with a colored pin. After all tunnels were created, the specimens were digitized with a MicroScribe device (Revware, Raleigh, NC) to measure the tunnel length; distance to the posterior femoral cortical wall (posterior cortical margin); and tunnel orientation in the sagittal, coronal, and axial planes. RESULTS The standard anteromedial portal resulted in a longer tunnel length, a less horizontal tunnel in the coronal plane, and a greater posterior cortical margin compared with the far anteromedial portal at all knee flexion angles. For both portal locations, the tunnel length and posterior cortical margin increased, and the tunnel position became more horizontal in the coronal plane, more anterior in the sagittal plane, and less horizontal in the transverse plane as knee flexion increased. CONCLUSIONS Portal position affects femoral tunnel characteristics, with results favoring the more laterally positioned standard anteromedial portal at all flexion angles. Increasing the knee flexion angle leads to a longer femoral tunnel length and posterior femoral cortical margin with either portal position. CLINICAL RELEVANCE Understanding how portal positioning and knee flexion angle affect femoral tunnel orientation and characteristics may lead to improved surgical outcomes after ACL reconstruction.
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Affiliation(s)
- Damon Alavekios
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A.; Department of Orthopaedic Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Alexander Peterson
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A
| | - John Patton
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A.; Department of Orthopaedic Surgery, University of California, Irvine, Irvine, California, U.S.A..
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Fernandes TL, Ribeiro DB, da Rocha DC, Albuquerque C, Pereira CAM, Pedrinelli A, Hernandez AJ. Descrição de sistema de avaliação da cinemática do joelho em lesões ligamentares a partir de rastreamento óptico e tomografia 3D. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Fernandes TL, Ribeiro DB, da Rocha DC, Albuquerque C, Pereira CAM, Pedrinelli A, Hernandez AJ. Description of an evaluation system for knee kinematics in ligament lesions, by means of optical tracking and 3D tomography. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2014; 49:513-9. [PMID: 26229854 PMCID: PMC4487496 DOI: 10.1016/j.rboe.2014.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 10/03/2013] [Indexed: 11/25/2022]
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Dugas JR, Pace JL, Bolt B, Wear SA, Beason DP, Cain EL. Evaluation and Comparison of Femoral Tunnel Placement During Anterior Cruciate Ligament Reconstruction Using 3-Dimensional Computed Tomography: Effect of Notchplasty on Transtibial and Medial Portal Drilling. Orthop J Sports Med 2014; 2:2325967114525572. [PMID: 26535307 PMCID: PMC4555567 DOI: 10.1177/2325967114525572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Advocates of medial portal drilling claim that the transtibial technique results in a more vertical positioning of the graft, which could lead to subsequent failure and/or a residual pivot shift on postoperative examination. However, advocates of transtibial drilling state that with appropriate placement and adequate notchplasty, their technique places the graft in a more anatomically correct position on the wall, negating the resultant potential for pivot shift and early postoperative failure. HYPOTHESIS Transtibial femoral drilling can adequately reproduce the femoral origin of the anterior cruciate ligament (ACL) and place the graft in an anatomical position equivalent to medial portal drilling. STUDY DESIGN Controlled laboratory study. METHODS Ten matched-pair cadaveric knees (N = 20) were scanned using computed tomography (CT), and 3-dimensional images of the native ACL origin were reconstructed. The matched pairs were then randomized into transtibial and medial portal groups. The femoral tunnel was drilled in each knee according to group. A bamboo skewer was placed in the femoral tunnel, and the knees underwent a second CT scan. Arthroscopic notchplasty was performed, and the femoral tunnels were redrilled. Radiographs confirmed placement, and the post-notchplasty tunnel was reamed with a 4-mm reamer. The knees underwent a third CT scan. CT scans compared femoral tunnel placement with the native ACL footprint before and after notchplasty. RESULTS The post-notchplasty transtibial group revealed an average of 68.3% coverage of the native ACL femoral origin. The medial portal group revealed an average of 60.8% coverage, with 1 instance of perforation of the posterior cortex. There were no instances of perforation in the transtibial group. CONCLUSION Both drilling techniques place the graft in an anatomically correct position. CLINICAL RELEVANCE Transtibial drilling of the femur can adequately place the entry tunnel at the origin of the ACL's native footprint.
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Affiliation(s)
- Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Jesse L Pace
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Becky Bolt
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Shane A Wear
- Radiology Associates Birmingham, Birmingham, Alabama, USA
| | - David P Beason
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - E Lyle Cain
- American Sports Medicine Institute, Birmingham, Alabama, USA
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Riboh JC, Hasselblad V, Godin JA, Mather RC. Transtibial versus independent drilling techniques for anterior cruciate ligament reconstruction: a systematic review, meta-analysis, and meta-regression. Am J Sports Med 2013; 41:2693-702. [PMID: 24130247 DOI: 10.1177/0363546513506979] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND While numerous cadaveric, in vivo, and clinical studies have compared transtibial and independent drilling of femoral tunnels during anterior cruciate ligament reconstruction, there is no evidence-based consensus on which technique affords the best outcome. HYPOTHESIS There is no difference in clinical outcome between transtibial and independent drilling of femoral tunnels. STUDY DESIGN Systematic review with meta-analysis and meta-regression. METHODS Cadaveric, in vivo, and clinical studies comparing transtibial and independent drilling techniques were systematically identified. A qualitative synthesis of nonrandomized studies and meta-analysis of randomized controlled trials (RCTs) were performed. In addition, a meta-regression analysis of RCTs that did not directly compare drilling techniques was performed. RESULTS A total of 49 studies were included in the qualitative review, and 15 were included in the meta-analysis; 22 studies were included in the meta-regression. In biomechanical studies, independent drilling placed the center of the femoral tunnel closer to the center of the femoral footprint (mean difference, 2.69 mm; 95% CI, 0.46-4.92; P < .00001). Independent drilling reduced anterior tibial translation with the Lachman examination (mean difference, 2.2 mm; 95% CI, 0.34-4.07; P = .02), 134 N of anterior load (mean difference, 1 mm; 95% CI, 0.29-1.71; P = .006), and simulated pivot shift (mean difference, 3.36 mm; 95% CI, 1.88-4.85; P < .00001). The meta-analysis showed improved Lysholm scores with independent drilling (mean difference, -0.62 points; 95% CI, -1.09 to -0.55; P = .009), although the clinical relevance of this small difference is questionable. There were no significant differences in International Knee Documentation Committee (IKDC) objective scores or Tegner scores between groups. With the meta-regression, there were no significant differences in failure rates or IKDC objective scores. CONCLUSION While there are biomechanical data suggesting improved knee stability and more anatomic graft placement with independent drilling, no significant clinical differences were found between the 2 techniques. CLINICAL RELEVANCE The current evidence shows that transtibial and independent drilling techniques have equivalent clinical outcomes at short-term to midterm follow-up. The long-term effects of subtle differences in tunnel position and postoperative knee kinematics should be further studied in dedicated, prospective cohort and randomized studies.
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Affiliation(s)
- Jonathan C Riboh
- Jonathan C. Riboh, Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, Duke University, 6002 Tahoe Drive, Durham, NC 27713.
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Mall NA, Lee AS, Cole BJ, Verma NN. The Functional and Surgical Anatomy of the Anterior Cruciate Ligament. OPER TECHN SPORT MED 2013. [DOI: 10.1053/j.otsm.2012.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Brown CH, Spalding T, Robb C. Medial portal technique for single-bundle anatomical anterior cruciate ligament (ACL) reconstruction. INTERNATIONAL ORTHOPAEDICS 2013; 37:253-69. [PMID: 23334708 DOI: 10.1007/s00264-012-1772-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 12/28/2012] [Indexed: 02/04/2023]
Abstract
The aim of the paper is to describe the medial portal technique for anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Placement of an ACL graft within the anatomical femoral and tibial attachment sites is critical to the success and clinical outcome of ACL reconstruction. Non-anatomical ACL graft placement is the most common technical error leading to recurrent instability following ACL reconstruction. ACL reconstruction has commonly been performed using a transtibial tunnel technique in which the ACL femoral tunnel is drilled through a tibial tunnel positioned in the posterior half of the native ACL tibial attachment site. ACL reconstruction performed using a transtibial tunnel technique often results in a vertical ACL graft, which may fail to control the combined motions of anterior tibial translation and internal tibial rotation which occur during the pivot-shift phenomenon. The inability of a vertically oriented ACL graft to control these combined motions may result in the patient experiencing continued symptoms of instability due to the pivot-shift phenomenon. The medial portal technique in which the ACL femoral tunnel is drilled through an anteromedial or accessory anteromedial portal allows consistent anatomical ACL tunnel placement. This paper describes the advantages of the medial portal technique, indications for the technique, patient positioning, proper portal placement, anatomical femoral and tibial tunnel placement, graft tensioning and fixation.
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