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Legler J, Laverdiere C, Boily M, Tarchala M, Hart A, Martineau PA. Evaluating femoral graft placement using three-dimensional magnetic resonance imaging in the reconstruction of the anterior cruciate ligament via independent or transtibial drilling techniques: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1297-1306. [PMID: 38078954 DOI: 10.1007/s00590-023-03788-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/15/2023] [Indexed: 04/02/2024]
Abstract
PURPOSE Anterior cruciate ligament (ACL) reconstruction is a common surgical procedure, yet failure still largely occurs due to nonanatomically positioned grafts. The purpose of this study was to retrospectively evaluate patients with torn ACLs before and after reconstruction via 3D MRI and thereby assess the accuracy of graft position on the femoral condyle. METHODS Forty-one patients with unilateral ACL tears were recruited. Each patient underwent 3D MRI of both knees before and after surgery. The location of the reconstructed femoral footprint relative to the patient's native footprint was compared. RESULTS Native ACL anatomical location of the native ACL had a significant impact on graft position. Native ACLs that were previously more anterior yielded grafts that were more posterior (3.70 ± 1.22 mm, P = 0.00018), and native ACL that were previously more proximal yielded grafts that were more distal (3.25 ± 1.09 mm, P = 0.0042). Surgeons using an independent drilling method positioned 76.2% posteriorly relative to the native location, with a mean 0.1 ± 2.8 mm proximal (P = 0.8362) and 1.8 ± 3.0 mm posterior (P = 0.0165). Surgeons using a transtibial method positioned 75% proximal relative to the native location, with a mean 2.2 ± 3.0 mm proximal (P = 0.0042) and 0.2 ± 2.6 mm posterior (P = 0.8007). These two techniques showed a significant difference in magnitude in the distal-proximal axis (P = 0.0332). CONCLUSION The femoral footprint position differed between the native and reconstructed ACLs, suggesting that ACL reconstructions are not accurate. Rather, they are converging to a normative reference point that is neither anatomical nor isometric.
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Affiliation(s)
- Jack Legler
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.
| | - Carl Laverdiere
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Mathieu Boily
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | | | - Adam Hart
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
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Shi W, Zhang J, Meng Q, Chen N, Shen Q, Li S, Cao Z, Ao Y, Ma Y. The apex of the deep cartilage is a stable landmark to evaluate the femoral tunnel position in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:256-263. [PMID: 35962841 DOI: 10.1007/s00167-022-07090-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 07/25/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE To develop a simple and effective method for evaluating the femoral tunnel position using the apex of the deep cartilage (ADC) as the landmark. METHODS A total of 52 patients who underwent arthroscopic ACL reconstruction were recruited between June and September 2021. The femoral tunnel was placed on the central point of the anteromedial footprint with an accessory anteromedial and a high anterolateral portal. Then, the length from the ADC to the shallow cartilage margin (L1) and to the center of the femoral tunnel (l1), as well as the center to the low cartilage margin (H1, intraoperative height), was measured under arthroscopy and on postoperative CT scans (L2, l2 and H2). Moreover, intraoperative and postoperative cartilage ratios were equivalent to l1/L1 and l2/L2, respectively. Linear regression, Pearson correlation and Bland-Altman analysis were performed to evaluate the consistency between these two measurements of cartilage ratio (l/L) and height (H). RESULTS The mean age at the time of surgery was 28.7 years; 42 patients were male, and 17 patients were hurt in the left knee among 52 patients. The intraoperative cartilage ratio was 0.37 ± 0.04, and the height was 8.1 ± 1.1 mm with almost perfect inter-observer reproducibility. After the surgery, the cartilage ratio and height were measured as 0.39 ± 0.04 and 8.2 ± 1.3 mm on 3D-CT, respectively, with almost perfect intra- and inter-observer reproducibility. Significant positive correlations and linear regression were detected in the cartilage ratio (r = 0.844, p < 0.001), and height (r = 0.926, p < 0.001) intraoperatively and postoperatively. The Bland-Altman plot also showed excellent consistency between arthroscopy and 3D-CT. CONCLUSIONS The ADC is a good landmark in the assessment of femoral tunnel position, with excellent consistency between intraoperative arthroscopic measurements and postoperative 3D-CT. CLINICALTRIALS gov Identifier: NCT04937517. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Weili Shi
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China
| | - Jingwei Zhang
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China
| | - Qingyang Meng
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China
| | - Nayun Chen
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China
| | - Qixian Shen
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China
| | - Shucan Li
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China
| | - Zhuohan Cao
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China
| | - Yingfang Ao
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China.
| | - Yong Ma
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing, 100191, China.
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Graft position at the femoral condyle affects knee mobility after posterior cruciate ligament replacement. Knee 2022; 34:118-123. [PMID: 34883329 DOI: 10.1016/j.knee.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 11/02/2021] [Accepted: 11/19/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In some cases posterior cruciate ligament (PCL) tears require surgical reconstruction. As the femoral footprint of the ligament is quite large, an ideal graft fixation position on the medial notch wall has not yet been identified. The aim of this study was to compare three different graft fixation positions within the anatomical footprint of the PCL and test it for posterior tibial translation at different knee flexion angles. METHODS In six human knee specimens a drawer test was simulated on a material testing machine by applying load on the tibia. At three different knee flexion angles (0°, 45°, 90°) knee mobility was examined with respect to tibial posterior translation and stiffness for the following conditions: intact ligaments, detached PCL, three different graft fixation positions on the femoral condyle. RESULTS Replacement of the PCL within its femoral footprint restored knee stability in terms of tibial posterior translation. Low graft position showed comparable drawer displacements to the intact condition for all knee flexion angles (p > 0.344). A higher graft position excessively reduced the posterior translation (p < 0.047) and resulted in a restricted knee mobility and a stiffer joint. CONCLUSIONS Graft fixation positions on the femoral condyle play a crucial role in post-operative knee mobility and joint functionality after PCL replacement. Even though all graft fixation positions were placed within the femoral footprint of a native PCL, only the lower position on the medial notch wall showed comparable posterior tibial translation to an intact PCL.
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黄 碧, 邓 文, 李 韬, 李 棋. [Progress of different methods for femoral tunnel positioning in anterior cruciate ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:118-123. [PMID: 33448209 PMCID: PMC8171607 DOI: 10.7507/1002-1892.202005003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/31/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To systematically review the progress of different methods for femoral tunnel positioning in anterior cruciate ligament (ACL) reconstruction and provide a clinical reference for treatment of ACL rupture. METHODS The literature about the femoral tunnel positioning in ACL reconstruction was widely reviewed. The advantages and disadvantages and the clinical results of each method were summarized. RESULTS Currently in ACL reconstruction, methods for femoral tunnel positioning include transtibial technique (TT), anteromedial technique (AM), outside-in (OI), modified TT (mTT), and computer assisted surgery. There is no significant difference in the postoperative effectiveness between TT technique and AM technique. Compared with the TT technique, the OI technique has higher rotational stability of knee, but there is no significant difference in clinical results. The femoral tunnel located by mTT technique is closer to the anatomical placement than that of TT technique, but mTT technique is not effective for systematically anatomic femoral tunnel positioning, and further research is needed to prove its advantages. CONCLUSION Different femoral tunnel positioning methods have their own advantages and disadvantages, and there is no definite evidence that one is superior than the rest.
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Affiliation(s)
- 碧滢 黄
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 文宇 邓
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 韬 李
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 棋 李
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Management of Partial Tears of the Anterior Cruciate Ligament: A Review of the Anatomy, Diagnosis, and Treatment. J Am Acad Orthop Surg 2021; 29:60-70. [PMID: 33394613 DOI: 10.5435/jaaos-d-20-00242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Partial anterior cruciate ligament (ACL) tears comprise an estimated 10% to 27% of isolated ACL injuries. Partial ACL tears may be challenging to clinically diagnose. We reviewed relevant studies focusing on the anatomy, diagnosis, imaging, and treatment of a partial injury with the goal of providing guidance to clinicians. Although a comprehensive patient history, thorough clinical examination, and imaging studies are helpful in arriving at a diagnosis, the benchmark for diagnosis remains visualization and examination of the ACL at the time of knee arthroscopy. Currently, limited data exist about the long-term outcomes of nonsurgical treatment. Some studies demonstrate that younger, active patients have the risk of progressing to a complete ACL rupture with conservative treatment. The decision to proceed with surgery is based on careful history and physical examination findings that suggest either a "functional" or "nonfunctional" ACL. Surgical treatment consists of augmenting the intact bundle with a selective bundle reconstruction versus a traditional ACL reconstruction. Selective bundle reconstruction has limited data available but is an option. The best evidence supports traditional ACL reconstruction for the surgical management of patients with documented nonfunctional partial tears of the ACL.
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Nakamura K, Nakamura T, Horie M, Katagiri H, Otabe K, Nakagawa Y, Amemiya M, Sekiya I, Muneta T, Koga H. Anatomic femoral tunnel placement is difficult by the transtibial technique: comparison of three different femoral tunnel drilling techniques in double-bundle anterior cruciate ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 2020; 28:584-593. [PMID: 31612263 DOI: 10.1007/s00167-019-05740-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/30/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare the position and direction of femoral and tibial tunnels for both the anteromedial bundle (AMB) and posterolateral bundle (PLB) among three different femoral tunnel drilling techniques, transtibial (TT), transportal (TP), and outside-in (OI) techniques, in anatomic double-bundle ACL reconstruction to clarify advantages and disadvantages of each technique. METHODS One-hundred and thirty-nine patients underwent primary ACL reconstruction with an autologous semitendinosus tendon in our institution between 2014 and 2016. Thirteen patients were excluded according to the exclusion criteria. Of the 126 patients, 98 patients agreed to be included in this study. Patients were then randomized into three groups according to the femoral tunnel drilling technique; the TT, TP, and OI groups. Femoral and tibial tunnel angles and positions were measured using three-dimensional computed tomography. RESULTS Of patients who agreed to be included in this study, eight patients (seven in TT and one in OI) were excluded since the femoral tunnel could not be created at the intended position. Eighty-six patients (29 in TT, 29 in TP, and 28 in OI) were included for the analyses. Tunnel angles, as well as tunnel lengths, had significant differences among different techniques depending on each technique's characteristics. In terms of tunnel position, femoral tunnel positions of both the AMB and PLB in the TT group were significantly higher than those in the TP group (AMB: p = 0.003, PLB: p = 0.001), and the PLB tunnel position in the TP group had significantly smaller vaciance than that in the TT group (p = 0.004) and OI group (0.002). CONCLUSIONS The femoral tunnel positions created by the TT technique were significantly higher, with larger variance, than the TP technique in double-bundle ACL reconstruction, although the positions seemed to be within anatomical footprint. In addition, there were several cases in which femoral tunnels could not be created at the intended position by the TT technique. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Kaori Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masafumi Horie
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Koji Otabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masaki Amemiya
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takeshi Muneta
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Grassi A, Carulli C, Innocenti M, Mosca M, Zaffagnini S, Bait C. New Trends in Anterior Cruciate Ligament Reconstruction: A Systematic Review of National Surveys of the Last 5 Years. JOINTS 2018; 6:177-187. [PMID: 30582107 PMCID: PMC6301855 DOI: 10.1055/s-0038-1672157] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 08/10/2018] [Indexed: 12/29/2022]
Abstract
The purpose of this study was to analyze national surveys of orthopaedic surgeons on anterior cruciate ligament (ACL) reconstruction to determine their preferences related to the preferred graft, femoral tunnel positioning, fixation and tensioning methods, antibiotic and anti-thromboembolic prophylaxis, and use of tourniquet and drains. A systematic search of PubMed, Web of Science, and Cochrane Library was performed. Inclusion criteria were surveys of ACL reconstruction trends and preferences published in the past 5 years (2011–2016), involving members of national societies of orthopaedics. Information regarding survey modalities, population surveyed, graft choice both in the general or in the athletic population, surgical technique, fixation, use of antibiotic, tourniquet, drains, and anti-thromboembolic prophylaxis was extracted. Eight national surveys were included from Europe (three), North or Latin America (three), and Asia (two). Overall, 7,420 questionnaires were sent, and 1,495 participants completed the survey (response rate ranging from 16 to 76.6%). All surveys reported the hamstring tendon (HT) autograft as the preferred graft, ranging from 45 to 89% of the surveyed population, followed by bone-patellar tendon-bone (BPTB) graft (2–41%) and allograft (2–17%). Only two surveys focusing on graft choice in athletic population underlined how in high-demand sportive population the graft choices changes in favor of BPTB. Single-bundle reconstruction was the preferred surgical technique in the four surveys that investigated this issue. Five surveys were in favor of anteromedial (AM) portal and two in favor of trans-tibial technique. Suspension devices for femoral fixation were the preferred choice in all but one survey, while interference screws were the preferred method for tibial fixation. The two surveys that investigated graft tensioning were in favor of manual tensioning. The use of tourniquet, antibiotics, drains, and anti-thromboembolic prophylaxis were vaguely reported. A trend toward the preference of HT autograft was registered in all the surveys; however, sport participation has been highlighted as an important variable for increased use of BPTB. Single-bundle reconstruction with AM portal technique and suspension femoral fixation and screws fixation for the tibia seem the preferred solution. Other variables such as tensioning, antibiotic, anti-thromboembolic prophylaxis, tourniquet use, and drains were investigated scarcely among the surveys; therefore, no clear trends could be delineated. This is a Level V, systematic review of expert opinion study.
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Affiliation(s)
- Alberto Grassi
- II Clinica Ortopedica e Traumatologica, IRCSS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Carulli
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Matteo Innocenti
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Massimiliano Mosca
- II Clinica Ortopedica e Traumatologica, IRCSS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCSS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Corrado Bait
- Joint Surgery and Sport Medicine Unit, Istituto Clinico Villa Aprica, Como, Italy
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Prior Anterior Cruciate Ligament Reconstruction Effects on Future Total Knee Arthroplasty. J Arthroplasty 2018; 33:2821-2826. [PMID: 29731267 DOI: 10.1016/j.arth.2018.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/27/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The impact of prior anterior cruciate ligament (ACL) reconstruction on total knee arthroplasty (TKA) has rarely been studied. The objective of this study was to compare intraoperative characteristics in patients who underwent TKA with pre-existing hardware from prior ACL reconstruction with a matched cohort control group. METHODS A retrospective study of patients who had undergone primary TKA with pre-existing hardware from prior ACL reconstruction was performed from June 2012 through June 2017. These patients were 2-to-1 matched to the ACL group based on similar patient demographic and provider variables. Outcomes investigated included operative time, estimated blood loss (EBL), and postoperative complications. RESULTS One hundred one patients met the inclusion/exclusion criteria. The mean age was 54 ± 9 years, and the mean body mass index was 32.6 ± 6.5 kg/m2. The ACL group was divided into 4 subgroups: group 1, no pre-existing hardware removed (22 TKAs); group 2, pre-existing hardware removed from the femur only (8 TKAs); group 3, pre-existing hardware removed from the tibia only (45 TKAs); and group 4, pre-existing hardware removed from both the femur and tibia (26 TKAs). There was no statistical difference in EBL and postoperative complication between the ACL group and controls. Statistical differences were detected between 2 subgroups regarding mean operative time variables: ACL group 3 (74 ± 23 minutes; control: 64 ± 21 minutes, P = .020) and group 4 (79 ± 24 minutes; control: 65 ± 19 minutes, P = .010). CONCLUSION Hardware retained, especially on the tibia, from prior ACL reconstruction has a major impact on TKA surgical procedure operative time but not on EBL and/or complications.
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Forsythe B, Lansdown D, Zuke WA, Verma NN, Cole BJ, Bach BR, Inoue N. Dynamic 3-Dimensional Mapping of Isometric Anterior Cruciate Ligament Attachment Sites on the Tibia and Femur: Is Anatomic Also Isometric? Arthroscopy 2018; 34:2466-2475. [PMID: 30077270 DOI: 10.1016/j.arthro.2018.03.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 03/21/2018] [Accepted: 03/26/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to (1) map the length changes of the medial wall of the lateral femoral condyle (MWLFC) with respect to various points about the tibial anterior cruciate ligament (ACL) footprint to determine the area that demonstrates the least amount of length change through full range of motion and (2) to identify a range of flexion that would be favorable for graft tensioning. METHODS Six fresh-frozen cadaveric knees were obtained from screened individuals with no prior history of arthritis, cancer, surgery, or any ligamentous knee injury. For each knee, 3-dimensional computed tomography point-cloud models were obtained in succession from 0° to 135°. A point grid was placed on the MWLFC and the tibia. Intra-articular length was calculated for each point on the femur to the tibia at all flexion angles and grouped to represent areas for bone tunnels. Normalized length changes were compared. RESULTS Areas anterior/distal on the MWLFC increased with increasing flexion, and areas proximal/posterior decreased with increasing flexion. The area about the intersection of the lateral intercondylar ridge and the bifurcate ridge was most isometric throughout flexion as no significant change in ligament length was found throughout flexion. The normalized length changes from the central position of the tibia showed no significant difference compared with the anterior or posterior tibial position. CONCLUSIONS No area of the MWLFC is truly isometric through flexion. Femoral tunnel placement slightly anterior to the center of the anteromedial and posterolateral bundles was most isometric. Minimal length change occurs between 10° and 40°, which reflects the range where graft tensioning was most often performed. The results of this study provide further support for an anatomic ACL reconstruction. CLINICAL RELEVANCE: The femoral tunnel location for ACL reconstruction with the least amount of length change through range of motion should encompass the direct fibers of the ACL.
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Affiliation(s)
- Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A..
| | - Drew Lansdown
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - William A Zuke
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Bernard R Bach
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nozomu Inoue
- Rush University Medical Center, Chicago, Illinois, U.S.A
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Mochizuki Y, Kaneko T, Kawahara K, Toyoda S, Kono N, Hada M, Ikegami H, Musha Y. The quadrant method measuring four points is as a reliable and accurate as the quadrant method in the evaluation after anatomical double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:2389-2394. [PMID: 29159674 DOI: 10.1007/s00167-017-4797-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/08/2017] [Indexed: 01/19/2023]
Abstract
PURPOSE The quadrant method was described by Bernard et al. and it has been widely used for postoperative evaluation of anterior cruciate ligament (ACL) reconstruction. The purpose of this research is to further develop the quadrant method measuring four points, which we named four-point quadrant method, and to compare with the quadrant method. METHODS Three-dimensional computed tomography (3D-CT) analyses were performed in 25 patients who underwent double-bundle ACL reconstruction using the outside-in technique. The four points in this study's quadrant method were defined as point1-highest, point2-deepest, point3-lowest, and point4-shallowest, in femoral tunnel position. Value of depth and height in each point was measured. Antero-medial (AM) tunnel is (depth1, height2) and postero-lateral (PL) tunnel is (depth3, height4) in this four-point quadrant method. The 3D-CT images were evaluated independently by 2 orthopaedic surgeons. A second measurement was performed by both observers after a 4-week interval. Intra- and inter-observer reliability was calculated by means of intra-class correlation coefficient (ICC). Also, the accuracy of the method was evaluated against the quadrant method. RESULTS Intra-observer reliability was almost perfect for both AM and PL tunnel (ICC > 0.81). Inter-observer reliability of AM tunnel was substantial (ICC > 0.61) and that of PL tunnel was almost perfect (ICC > 0.81). The AM tunnel position was 0.13% deep, 0.58% high and PL tunnel position was 0.01% shallow, 0.13% low compared to quadrant method. CONCLUSIONS The four-point quadrant method was found to have high intra- and inter-observer reliability and accuracy. This method can evaluate the tunnel position regardless of the shape and morphology of the bone tunnel aperture for use of comparison and can provide measurement that can be compared with various reconstruction methods. The four-point quadrant method of this study is considered to have clinical relevance in that it is a detailed and accurate tool for evaluating femoral tunnel position after ACL reconstruction. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Yuta Mochizuki
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan.
| | - Takao Kaneko
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Keisuke Kawahara
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Shinya Toyoda
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Norihiko Kono
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Masaru Hada
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Hiroyasu Ikegami
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Yoshiro Musha
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
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Gali JC, Camargo DB, Oliveira FAMD, Pereira RHN, Silva PACD. Anatomia descritiva da inserção femoral do ligamento cruzado anterior. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Gali JC, Camargo DB, Oliveira FAMD, Pereira RHN, Silva PACD. Descriptive anatomy of the anterior cruciate ligament femoral insertion. Rev Bras Ortop 2018; 53:421-426. [PMID: 30027073 PMCID: PMC6051963 DOI: 10.1016/j.rboe.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/02/2017] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the morphology of the anterior cruciate ligament (ACL) femoral insertion in order to describe its anatomical features and insertion site location, with the aim of verifying if the ACL femoral insertion has individual characteristics and to provide information for appropriate femoral tunnel placement on anatomic ACL reconstruction. Methods Sixteen knees obtained from amputations were studied. The ACL femoral bundles and insertion shape were observed macroscopically, and the ligaments insertion length and thickness were measured with a digital caliper. The distances between the limits of the ligament to the articular cartilage, and the measurement of the area of insertion were checked using ImageJ software. Results The ACL femoral insertion site was eccentric, closer to the deep condyle cartilage. In ten knees (62.5%), the ACL femoral insertion was oval; the mean length of the insertion was 16.4 mm, varying from 11.3 to 19.3 mm, the mean thickness varied from 7.85 to 11.23 mm, and the mean area of the insertion was 99.7 mm2, varying from 80.9 a 117.2 mm2. The mean distances between the limits of the ligament to the superficial, deep, and inferior articular cartilage were 9.77 ± 1.21, 2.60 ± 1.20, and 1.86 ± 1.15 mm, respectively. Conclusion There was a 30% to 40% difference between the minimum and maximum results of measurements of ACL femoral insertion length, thickness, and area demonstrating an important individual variation. The insertion site was eccentric, closer to the deep cartilage of the lateral femoral condyle.
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Affiliation(s)
- Julio Cesar Gali
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Danilo Bordini Camargo
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Felipe Azevedo Mendes de Oliveira
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Rafael Henrique Naves Pereira
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Phelipe Augusto Cintra da Silva
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
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Stress distribution is deviated around the aperture of the femoral tunnel in the anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:1145-1151. [PMID: 28401277 DOI: 10.1007/s00167-017-4543-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/04/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Final tunnel location in the anterior cruciate ligament (ACL) reconstruction is unpredictable due to tunnel widening and/or transposition. The mechanical stress around the tunnel aperture seems to be a major factor but is not fully investigated. The purpose of this study was to measure the stress from the ACL graft around the tunnel aperture when the ACL graft tension reaches its peak. METHODS Six cadaveric knees were used. Single-bundle ACL reconstruction was performed using a hamstrings graft. Both femoral and tibial tunnels were created at the centre of the original ACL footprint. A 7-mm-internal-diameter aluminium cylinder with pressure sensors was placed in the femoral tunnel. Hamstrings graft with a microtension sensor was inserted. After fixation, passive extension-flexion was performed while monitoring the tunnel aperture pressure and the graft tension simultaneously. The pressure on the femoral tunnel aperture when the ACL graft tension reach its peak was compared between four directions. RESULTS The ACL graft tension peaked (67 ± 49 N) at full extension (-5.8 ± 4.1°). Pressure at the femoral tunnel aperture was different between different directions (p < 0.01). Distal part had significantly larger pressure (1.7 ± 1.3 MPa) than the other directions (p < 0.01). Second largest pressure was carried in the anterior part (0.6 ± 0.5 MPa), followed by proximal and posterior parts (0.4 ± 0.3, 0.2 ± 0.2 MPa respectively). CONCLUSION The stress distribution at the femoral tunnel aperture is not equal in different directions, while the distal part dominantly bears the stress from the ACL graft. Surgeons should pay close attention to the distal edge of the femoral tunnel which should be inside the anatomic ACL footprint eventually.
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DeFrate LE. Effects of ACL graft placement on in vivo knee function and cartilage thickness distributions. J Orthop Res 2017; 35:1160-1170. [PMID: 28213953 PMCID: PMC5466493 DOI: 10.1002/jor.23541] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/23/2017] [Indexed: 02/04/2023]
Abstract
Injuries to the anterior cruciate ligament (ACL) frequently lead to early-onset osteoarthritis. Despite advancement in surgical techniques, ACL reconstruction has a limited ability to prevent these degenerative changes. While previous studies have investigated knee function after ACL reconstruction, in vivo investigations of the effects of graft placement on in vivo joint function and cartilage health are limited. This review presents a series of studies that used novel imaging and 3D modeling techniques to determine the in vivo placement of the ACL graft on the femur using two different ACL reconstruction techniques. These techniques resulted in two distinct graft placement groups: one where the ACL was placed anatomically near the center of the native ACL footprint and another where the graft was placed anteroproximally on the femur, centered outside the ACL footprint. We quantified the effects of graft placement on graft deformation during in vivo loading and how these variables affected knee motion. Finally, we quantified whether femoral placement of the graft affected cartilage thickness. Our results demonstrate that achieving anatomic graft placement on the femur is critical to restoring native ACL function and normal knee kinematics. Knees with grafts that more closely restored normal ACL function, and thus knee motion, experienced less focal cartilage thinning than did those that experienced abnormal knee motion. These results suggest that achieving anatomic graft placement is a critical factor in restoring normal knee motion and potentially slowing the development of degenerative changes after ACL reconstruction. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1160-1170, 2017.
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Affiliation(s)
- Louis E. DeFrate
- Department of Orthopaedic Surgery, Mechanical Engineering and Materials Science, and Biomedical Engineering, Duke University, Durham, NC USA
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Smith CR, Vignos MF, Lenhart RL, Kaiser J, Thelen DG. The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement. J Biomech Eng 2016; 138:021017. [PMID: 26769446 DOI: 10.1115/1.4032464] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Indexed: 11/08/2022]
Abstract
The study objective was to investigate the influence of coronal plane alignment and ligament properties on total knee replacement (TKR) contact loads during walking. We created a subject-specific knee model of an 83-year-old male who had an instrumented TKR. The knee model was incorporated into a lower extremity musculoskeletal model and included deformable contact, ligamentous structures, and six degrees-of-freedom (DOF) tibiofemoral and patellofemoral joints. A novel numerical optimization technique was used to simultaneously predict muscle forces, secondary knee kinematics, ligament forces, and joint contact pressures from standard gait analysis data collected on the subject. The nominal knee model predictions of medial, lateral, and total contact forces during gait agreed well with TKR measures, with root-mean-square (rms) errors of 0.23, 0.22, and 0.33 body weight (BW), respectively. Coronal plane component alignment did not affect total knee contact loads, but did alter the medial-lateral load distribution, with 4 deg varus and 4 deg valgus rotations in component alignment inducing +17% and -23% changes in the first peak medial tibiofemoral contact forces, respectively. A Monte Carlo analysis showed that uncertainties in ligament stiffness and reference strains induce ±0.2 BW uncertainty in tibiofemoral force estimates over the gait cycle. Ligament properties had substantial influence on the TKR load distributions, with the medial collateral ligament and iliotibial band (ITB) properties having the largest effects on medial and lateral compartment loading, respectively. The computational framework provides a viable approach for virtually designing TKR components, considering parametric uncertainty and predicting the effects of joint alignment and soft tissue balancing procedures on TKR function during movement.
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Reconstruction of the anterior cruciate ligament by means of an anteromedial portal and femoral fixation using Rigidfix. Rev Bras Ortop 2015; 49:619-24. [PMID: 26229871 PMCID: PMC4487468 DOI: 10.1016/j.rboe.2014.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 10/15/2013] [Indexed: 01/15/2023] Open
Abstract
Objective To evaluate a series of patients who underwent surgery for reconstruction of the anterior cruciate ligament with flexor tendons, by means of the anteromedial transportal technique using Rigidfix for femoral fixation, and to analyze the positioning of the pins by means of tomography. Methods Thirty-two patients were included in the study. The clinical evaluation was done using the Lysholm, subjective IKDC and Rolimeter. All of them underwent computed tomography with 3D reconstruction in order to evaluate the entry point and positioning of the Rigidfix pins in relation to the joint cartilage of the lateral condyle of the femur. Results The mean Lysholm score obtained was 87.81 and the subjective IKDC was 83.72. Among the 32 patients evaluated, 43% returned to activities that were considered to be very vigorous, 9% vigorous, 37.5% moderate and 12.5% light. In 16 patients (50%), the distal entry point of the Rigidfix pin was located outside of the cartilage (extracartilage); in seven (21.87%), the distal pin injured the joint cartilage (intracartilage); and in nine (28.12%), it was at the border of the lateral condyle of the femur. Conclusion The patients who underwent ACL reconstruction by means of the anteromedial transportal using the Rigidfix system presented satisfactory clinical results over the length of follow-up evaluated. However, the risk of lesions of the joint cartilage from the distal Rigidfix pin needs to be taken into consideration when the technique via an anteromedial portal is used. Further studies with larger numbers of patients and longer follow-up times should be conducted for better evaluation.
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Lu W, Zhu W, Peng L, Fen W, Li H, Ou Y, Liu H, Wang D, Zeng Y. Femoral footprint variation of the posterolateral bundle of the anterior cruciate ligament and double-bundle reconstruction. Knee 2015; 22:169-73. [PMID: 25825366 DOI: 10.1016/j.knee.2014.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 07/27/2014] [Accepted: 10/30/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The study is aimed to observe the range of variation of the ACL PLB femoral footprint and investigate countermeasures for accurate femoral bone tunnel placement during double-bundle ACL reconstruction. METHODS The femoral insertions of the anteromedial bundle (AMB) and PLB of the ACL were dissected in 30 male cadaveric knees. The ACL footprint on the lateral intercondylar wall (LIW) was observed, and the shape of the LIW, the resident ridge, the angle between the ACL long axis and femoral axis (AA), and the vertical distance from the center of the PLB to the lowest cartilage border of the LIW (PD) were measured. RESULTS The area most populated by the ACL fibers was directly under the resident ridge. AA = 18.7°±15.25° with variation from -18° to 56°, and PD=7.02±1.47 mm with variation from 3.75 to 11.08 mm. Both discrete values were very large in both groups of data. There were two kinds of LIW: trapezoidal (8 knees) and triangular (21 knees). Both AA and PD values exhibited significant differences between the two types of LIWs (P=0.00). CONCLUSION AA and PD vary among individuals. The insertions and centers of the PLB cannot be exactly anatomically determined with one size. For double-bundle ACL reconstruction, an individualized intraoperative footprint observation for fresh cases with footprint remnants, or resident ridge and anteromedial bundle-interval identification for old ACL tears, can be reasonable methods for posterolateral tunnel orientation. CLINICAL RELEVANCE Clinical relevance is observe the range of variation of the PLB femoral footprint for clinical double-bundle ACL reconstruction.
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Affiliation(s)
- Wei Lu
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China
| | - Weimin Zhu
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China
| | - Liangquan Peng
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China
| | - Wenzhe Fen
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China
| | - Hao Li
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China
| | - Yangkan Ou
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China
| | - Haifeng Liu
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China
| | - Daping Wang
- Department of Sports Medical, The First Affiliated Hospital of Shenzhen University (Shenzhen Second People Hospital), Shenzhen 518000, PR China.
| | - Yanjun Zeng
- Biomechanics and Medical Information Institute, Beijing University of Technology, Beijing 100022, PR China.
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A modified quadrant method for describing the femoral tunnel aperture positions in ACL reconstruction using two-view plain radiographs. Knee Surg Sports Traumatol Arthrosc 2015; 23:981-5. [PMID: 24288076 DOI: 10.1007/s00167-013-2781-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 11/16/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE A modified quadrant method was developed for description of femoral tunnel aperture positions on the sagittal plane after double-bundle anterior cruciate ligament (ACL) reconstruction, which can be measured by using two-view radiographs. The purpose of the study is to provide a new measurement method and to evaluate the reproducibility and accuracy of the method. METHODS Forty-one patients who had undergone a double-bundle ACL reconstruction were investigated. Two-view plain radiographs, a 45-degree-flexion posterior-anterior standing (Rosenberg) and a lateral view, were taken at 1 year postoperatively, and the femoral tunnel positions were measured. Intra- and inter-observer reproducibility was calculated by means of intra-class correlation coefficient (ICC). Also, the accuracy of the method was evaluated by comparing the measurement from three-dimensional computed tomography (3D-CT). RESULTS Intra-observer reproducibility was excellent (ICC > 0.9). Inter-observer reproducibility of antero-medial (AM) tunnel position was almost perfect (ICC > 0.8) and that of postero-lateral (PL) tunnel was substantial (ICC > 0.7). The accuracy of the method was assessed by comparing the measurement from 3D-CT and was found to be almost perfect (ICC > 0.8). With the modified quadrant method, the average height of AM and PL tunnels were 17.8 and 44.4 %, respectively, and the depth of AM and PL tunnels were 25.5 and 36.7 %, respectively. CONCLUSIONS A modified quadrant method was found to have acceptable reproducibility and accuracy. The method is useful for describing the femoral tunnel aperture positions in ACL reconstruction because of its easiness and simplicity. By using this method, it is possible to analyse the femoral tunnel position even in the cases without CT analysis. LEVEL OF EVIDENCE IV.
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Celiktas M, Kose O, Sarpel Y, Gulsen M. Can we use intraoperative femoral tunnel length measurement as a clue for proper femoral tunnel placement on coronal plane during ACL reconstruction? Arch Orthop Trauma Surg 2015; 135:523-8. [PMID: 25701457 DOI: 10.1007/s00402-015-2173-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Successful anterior cruciate ligament (ACL) reconstruction is dependent on correct placement of both tibial and femoral tunnels. The purpose of this study is to investigate whether we can use intraoperative femoral tunnel length measurement to estimate the correct femoral tunnel placement on coronal plane. METHODS This prospective study comprised 164 consecutive patients who underwent ACL reconstruction surgery. Transtibial or anteromedial portal technique is used for drilling the femoral tunnels. The length of the femoral tunnel was measured during the operation. The femoral tunnel coronal plane angle was calculated on the postoperative tunnel radiographs. A statistical comparison was made of the lengths of the tunnel, the techniques used drilling and the femoral tunnel angles. RESULTS The far anteromedial portal was used in 81 (49%) cases and the transtibial technique in 83 (51%) cases. The mean femoral tunnel length was 42 ± 6.4 mm and the mean femoral tunnel coronal angle was 41.1° ± 11.6. The tunnel angle in the transtibial technique was determined as significantly low compared to the far anteromedial portal technique (32.6°:49.8°) and the tunnel length was significantly longer (45.8:38.1 mm) (p < 0.001). In the statistical analysis, it was found that a patient with a tunnel length of 41 mm and above had a 92.1% likelihood of femoral tunnel angle below 45°. CONCLUSION Femoral tunnel length can be used as a clue for intraoperative evaluation of the femoral tunnel position. If the femoral tunnel length is greater than 41 mm, the coronal plane orientation of the femoral tunnel will be improper and not at a desired position.
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Affiliation(s)
- Mustafa Celiktas
- Department of Orthopedics and Traumatology, Private Ortopedia Hospital, Adana, Turkey
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Amano H, Toritsuka Y, Uchida R, Mae T, Ohzono K, Shino K. Outcome of anatomical double-bundle ACL reconstruction using hamstring tendons via an outside-in approach. Knee Surg Sports Traumatol Arthrosc 2015; 23:1222-30. [PMID: 24667940 DOI: 10.1007/s00167-014-2950-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the clinical outcome of anatomical double-bundle anterior cruciate ligament (ACL) reconstruction using multistranded hamstring tendons via an outside-in approach. METHODS One hundred and twenty-one patients (mean age 28 ± 10 years) who underwent ACL reconstruction were examined. Using an outside-in femoral drill guide, an upper femoral tunnel for the anteromedial (AM) graft was created just below the superior articular cartilage margin of the medial wall of the lateral condyle through a small incision. A lower femoral tunnel for the posterolateral (PL) graft was drilled in the centre of the inferior-posterior half of the attachment area behind the resident's ridge in the same manner. Two tibial tunnels were created at the centre of the AM and PL bundle footprints of a normal ACL. Patients were evaluated at 24 months postoperatively. RESULTS According to the IKDC form, 52 knees (43 %) were graded as normal, 64 (53 %) as nearly normal, 1 (1 %) as abnormal and 4 (3 %) as graft rupture due to re-injury. Loss of knee extension of <5° was observed in one patient (1 %). Among 111 patients who were directly evaluated, none showed loss of flexion of <5°. Lachman sign was negative in 103 patients (93 %), while the pivot shift test result was negative or equivalent to that of the contralateral healthy knee in 103 patients (93 %). The mean side-to-side difference in anterior laxity at manual maximum force with the KT-2000 arthrometer(®) was 0.9 ± 1.1 mm, and 94 % of patients showed a range between -1 and +2 mm. CONCLUSION The anatomical double-bundle outside-in ACL reconstruction provided a satisfactory short-term outcome. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Hiroshi Amano
- Department of Orthopaedics, Osaka Rosai Hospital, 1179-3, Nagasonecho, Kitaku, Sakai, Osaka, 591-8025, Japan
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Kobayashi H, Akamatsu Y, Kumagai K, Kusayama Y, Aratake M, Saito T. Is the surgical epicondylar axis the center of rotation in the osteoarthritic knee? J Arthroplasty 2015; 30:479-83. [PMID: 25466167 DOI: 10.1016/j.arth.2014.10.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/16/2014] [Accepted: 10/20/2014] [Indexed: 02/01/2023] Open
Abstract
The relationship between the surgical epicondylar axis (SEA) and the rotational axis of the distal femur remains unclear. We investigated the relationship between the SEA and the distal femur and whether the SEA can be used as the rotational axis of the knee. Angular and linear measurements of 70 femora at 0°, 30°, 60°, 90°, and 120° of flexion were recorded. Results showed that the SEA was a logical and appropriate parameter as a principal axis for knee flexion at least between 0° and 60° of flexion. The study has important implications for the design and positioning of femoral components in total knee arthroplasty.
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Affiliation(s)
- Hideo Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University School of Medicine
| | - Yasushi Akamatsu
- Department of Orthopaedic Surgery, Yokohama City University School of Medicine
| | - Ken Kumagai
- Department of Orthopaedic Surgery, Yokohama City University School of Medicine
| | - Yoshihiro Kusayama
- Department of Orthopaedic Surgery, Yokohama City University School of Medicine
| | - Masato Aratake
- Department of Orthopaedic Surgery, Yokohama City University School of Medicine
| | - Tomoyuki Saito
- Department of Orthopaedic Surgery, Yokohama City University School of Medicine
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Bolia A, Winkels P, Böttcher P. Radiographic location of the femoral footprint of the cranial cruciate ligament in dogs. TIERARZTLICHE PRAXIS. AUSGABE K, KLEINTIERE/HEIMTIERE 2015; 43:23-30. [PMID: 25609136 DOI: 10.15654/tpk-140357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 07/28/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe the radiographic location of the center of the femoral footprint of the cranial cruciate ligament (CrCL) in dogs. MATERIAL AND METHODS Using femora from 49 adult, orthopedically sound dogs (bodyweight≥20 kg), a radiopaque marker was placed on the cranial border of the femoral footprint of the CrCL. Computed tomography and threedimensional (3D) reconstruction of each femur was performed subsequently, followed by manual segmentation of the footprint on the 3D models and calculation of its center. Finally, virtual digital radiographs in two planes were produced and the location of the calculated center of the CrCL was expressed using three different methods (4x4 box grid method and percentage position for the medio-lateral projection; o'clock position for the disto-proximal projection). RESULTS In the medio-lateral radiographs the center of the femoral footprint was consistently located in the second rectangle from the top of the most caudal column of the 4x4 grid. The mean percentage caudo-cranial and proximo-distal location was 20.2% (±2.2) and 33.8% (±3.7), respectively. In the disto-proximal radiograph, the o'clock position of the CrCL center was between 2 and 3 o'clock in 97.6% of cases. CONCLUSION The radiographic location of the center of the femoral footprint can be consistently predicted in medio-lateral and disto-proximal stifle radiographs of dogs over 20 kg. CLINICAL SIGNIFICANCE The reported data can be used to plan and verify the placement of the femoral tunnel opening for intra-articular anatomic CrCL repair.
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Affiliation(s)
- A Bolia
- Amalia Bolia, Klinik für Kleintiere der Universität Leipzig, An den Tierkliniken 23, 04103 Leipzig, Germany,
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Reconstrução do ligamento cruzado anterior pelo portal anteromedial e fixação femoral com Rigidfix. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Quantitative topographic anatomy of the femoral ACL footprint: a micro-CT analysis. Med Biol Eng Comput 2014; 52:985-995. [DOI: 10.1007/s11517-014-1196-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 09/17/2014] [Indexed: 01/28/2023]
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Taketomi S, Inui H, Nakamura K, Hirota J, Sanada T, Masuda H, Takeda H, Tanaka S, Nakagawa T. Clinical outcome of anatomic double-bundle ACL reconstruction and 3D CT model-based validation of femoral socket aperture position. Knee Surg Sports Traumatol Arthrosc 2014; 22:2194-201. [PMID: 24085109 DOI: 10.1007/s00167-013-2663-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 08/31/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical results of anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in which anatomic position of femoral socket apertures was validated using three-dimensional (3D) computed tomography (CT) modelling. METHODS Anatomic DB ACL reconstructions with hamstring autografts were performed in 34 patients. Two femoral sockets were created through a far anteromedial (AM) portal behind the lateral intercondylar ridge with the assistance of intraoperative 3D fluoroscopic navigation. Femoral tunnel aperture positioning was investigated postoperatively using 3D CT images in all patients. Clinical results were also evaluated subjectively and objectively at least up to 2 years. RESULTS Measurement of the AM and the posterolateral (PL) femoral socket locations on the 3D CT images using the quadrant method showed that the centre of the AM socket aperture was located at a depth of 21.0 ± 4.1% and a height of 30.5 ± 9.3% and that of the PL socket aperture was located at a depth of 31.3 ± 5.8% and a height of 57.2 ± 7.7%. The femoral socket locations were considered as anatomic in accordance with previous cadaveric studies examining the positions of ACL femoral insertion site. Subjectively, the mean Lysholm score was 96.9 ± 4.0 points. According to IKDC final objective scores, 26 knees (76%) were objectively graded as normal, 8 (24%) as nearly normal, and 0 (0%) as abnormal or severely abnormal. Postoperative side-to-side anterior translation measured with a KT-2000 arthrometer averaged 0.7 ± 1.2 mm. CONCLUSIONS DB ACL reconstructions in which femoral socket apertures were validated anatomically using 3D CT provided satisfactory short-term results. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan,
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Zauleck MK, Gabriel S, Fischmeister MF, Hirtler L. Origin of the anterior cruciate ligament and the surrounding osseous landmarks of the femur. Clin Anat 2014; 27:1103-10. [DOI: 10.1002/ca.22440] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/28/2014] [Accepted: 06/30/2014] [Indexed: 01/26/2023]
Affiliation(s)
| | | | | | - Lena Hirtler
- Department for Systematic Anatomy; Center for Anatomy and Cell Biology, Medical University of Vienna; Vienna Austria
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Taketomi S, Inui H, Sanada T, Yamagami R, Tanaka S, Nakagawa T. Eccentric femoral tunnel widening in anatomic anterior cruciate ligament reconstruction. Arthroscopy 2014; 30:701-9. [PMID: 24680319 DOI: 10.1016/j.arthro.2014.02.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 02/06/2014] [Accepted: 02/06/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to retrospectively evaluate femoral tunnel widening (TW) and migration of the femoral tunnel aperture after anatomic anterior cruciate ligament (ACL) reconstructions with hamstring grafts and bone-patellar tendon-bone (BPTB) grafts. METHODS Of the 105 consecutive patients who underwent ACL reconstruction, the 52 patients who underwent isolated ACL reconstruction and in whom tunnel measurement could be obtained by computed tomography were included in this study. In 26 patients, double-bundle reconstruction (DBR) of the ACL using hamstring tendons was performed. These patients were compared with 26 patients in whom rectangular tunnel ACL reconstruction using BPTB grafts (BPTBR) was performed. Femoral tunnel aperture positioning and TW were investigated postoperatively using 3-dimensional computed tomographic images, which were performed a week and a year after surgery in all patients. RESULTS In DBR, the average diameter of the anteromedial (AM) femoral tunnel increased by 34.0% in the horizontal direction and 28.2% in the vertical direction, whereas that of the posterolateral (PL) femoral tunnel increased by 58.2% and 73.4%, respectively, at 1 year after surgery compared with 1 week after surgery. The percentage TW value of the PL tunnel was significantly greater than that of the AM tunnel. In BPTBR, the average diameter increased by 22.0% and 17.1%, respectively. The percentage TW value of the PL tunnel in DBR was significantly greater than that of the femoral tunnel in BPTBR. Each tunnel aperture migrated distally ("shallow") in the horizontal direction and high in the vertical direction. AM and PL tunnel apertures in DBR migrated in the vertical direction significantly more than they did in BPTBR. No significant differences between the 2 groups were found in clinical outcomes. CONCLUSIONS The femoral PL tunnel aperture in DBR showed significantly more widening than did the AM tunnel aperture in DBR and the femoral tunnel aperture in BPTBR. Also, greater migration of the femoral tunnel aperture in the vertical direction because of TW was observed in DBR than in BPTBR. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo.
| | - Hiroshi Inui
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo
| | - Takaki Sanada
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo
| | - Ryota Yamagami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo
| | - Takumi Nakagawa
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
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Anatomic ACL reconstruction produces greater graft length change during knee range-of-motion than transtibial technique. Knee Surg Sports Traumatol Arthrosc 2014; 22:1190-5. [PMID: 24077671 DOI: 10.1007/s00167-013-2694-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 09/16/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Because distance between the knee ACL femoral and tibial footprint centrums changes during knee range-of-motion, surgeons must understand the effect of ACL socket position on graft length, in order to avoid graft rupture which may occur when tensioning and fixation is performed at the incorrect knee flexion angle. The purpose of this study is to evaluate change in intra-articular length of a reconstructed ACL during knee range-of-motion comparing anatomic versus transtibial techniques. METHODS After power analysis, seven matched pair cadaveric knees were tested. The ACL was debrided, and femoral and tibial footprint centrums for anatomic versus transtibial techniques were identified and marked. Asuture anchor was placed at the femoral centrum and a custom, cannulated suture-centring device at the tibial centrum, and excursion of the suture, representing length change of an ACL graft during knee range-of-motion, was measured in millimeters and recorded using a digital transducer. RESULTS Mean increase in length as the knee was ranged 120°–0° (full extension) was 4.5 mm (±2.0 mm) for transtibial versus 6.7 mm (±0.9 mm) for anatomic ACL technique. A significant difference in length change occurs during knee range-of-motion both within groups and between the two groups. CONCLUSIONS Change in length of the ACL intra-articular distance during knee range-of-motion is greater for anatomic socket position compared to transtibial position. Surgeons performing anatomic single-bundle ACL reconstruction may tension and fix grafts with the knee in full extension to minimize risk of graft stretch or rupture or knee capture during full extension. This technique may also result in knee anterior–posterior laxity in knee flexion.
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Shaerf DA, Pastides PS, Sarraf KM, Willis-Owen CA. Anterior cruciate ligament reconstruction best practice: A review of graft choice. World J Orthop 2014; 5:23-29. [PMID: 24649411 PMCID: PMC3952691 DOI: 10.5312/wjo.v5.i1.23] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/05/2013] [Accepted: 10/20/2013] [Indexed: 02/06/2023] Open
Abstract
There is much literature about differing grafts used in anterior cruciate ligament (ACL) reconstruction. Much of this is of poor quality and of a low evidence base. We review and summarise the literature looking at the four main classes of grafts used in ACL reconstruction; bone-patella tendon-bone, hamstrings, allograft and synthetic grafts. Each graft has the evidence for its use reviewed and then compared, where possible, to the others. We conclude that although there is no clear “best” graft, there are clear differences between the differing graft choices. Surgeon’s need to be aware of the evidence behind these differences, in order to have appropriate discussions with their patients, so as to come to an informed choice of graft type to best suit each individual patient and their requirements.
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Comparison of isometric and anatomical graft placement in synthetic ACL reconstructions: A pilot study. Comput Biol Med 2013; 43:2287-96. [DOI: 10.1016/j.compbiomed.2013.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/29/2013] [Accepted: 10/08/2013] [Indexed: 01/14/2023]
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Torabi M, Fu F, Luo J, Costello J. Clinical relevance and imaging features of isolated single bundle anterior cruciate tear and single bundle augmentation. Clin Imaging 2013; 37:830-5. [PMID: 23845258 DOI: 10.1016/j.clinimag.2013.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 05/02/2013] [Indexed: 11/30/2022]
Abstract
The anterior cruciate ligament (ACL) consists of two anatomic and functional bundles, the anteromedial and posterolateral bundle. Depending on the mechanism of injury, there are different injury patterns, demonstrating a wide spectrum of partial ACL tears. Single bundle partial ACL tears can be treated with augmentation. Theoretically, sparing the intact parts of the ACL may increase vascularization and proprioception and may result in better stability and improved clinical outcome for the patient. In this article, we review the anatomy and function of ACL bundles and demonstrate cases of single bundle ACL tear with subsequent augmentation.
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Affiliation(s)
- Maha Torabi
- Department of Radiology, University of Pittsburgh Medical Center (Presbyterian South Tower), Pittsburgh, PA 15213, USA.
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Symptomatische Partialrupturen des vorderen Kreuzbands. ARTHROSKOPIE 2013. [DOI: 10.1007/s00142-012-0717-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Arliani GG, Astur DC, Moraes ER, Kaleka CC, Jalikjian W, Golano P, Cohen M. Three dimensional anatomy of the anterior cruciate ligament: a new approach in anatomical orthopedic studies and a literature review. Open Access J Sports Med 2012; 3:183-8. [PMID: 24198601 PMCID: PMC3781913 DOI: 10.2147/oajsm.s37203] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The anterior cruciate ligament (ACL) is an important structure in the knee. The ACL does not heal following lesions, and surgical reconstruction is the standard treatment among athletes. Some steps of ACL reconstruction remain controversial. It is important to fully understand the anatomy of the ACL to accurately reproduce its anatomy during surgical reconstructions. The purpose of this study was to evaluate the use of anaglyphic images that produce 3D images to better visualize the anatomy of the ACL, and to highlight the anatomical features of this ligament as reported in the literature. METHODS We included ten knees in this study. After dissection of the knee structures, pictures were acquired using a camera with Nikon D40, AF-S Nikkor 18-55 mm (1:3.5-5.6 G2 ED), and Micro Nikkor 105 mm (1:2.8) lenses. The pair of images was processed using Callipyan 3D Anabuilder software, which transforms the two images into one anaglyphic image. RESULTS During the dissection of the knees, nine pictures were acquired and transformed into anaglyphic images. CONCLUSION This study, demonstrated that the use of 3D images is a useful tool that can improve the knowledge of the anatomy of the knee, while also facilitating knee reconstruction surgery.
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Affiliation(s)
- Gustavo Gonçalves Arliani
- Centro de Traumatologia do Esporte (CETE), Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo SP, Brazil (DOT-UNIFESP/EPM)
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Sullivan JP, Matava MJ, Flanigan DC, Gao Y, Britton CL, Amendola A, Wolf BR. Reliability of tunnel measurements and the quadrant method using fluoroscopic radiographs after anterior cruciate ligament reconstruction. Am J Sports Med 2012; 40:2236-41. [PMID: 22962289 DOI: 10.1177/0363546512458086] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction tunnel placement is often evaluated by radiographs. This study examines the interobserver reliability of various radiographic measurements of ACL tunnels. HYPOTHESIS When ideal radiographic views are obtained, the interobserver reliability of the measurements among experienced surgeons would be good to excellent. STUDY DESIGN Descriptive laboratory study. METHODS Tunnels for single-bundle ACL reconstruction were drilled and filled with metal interference screws or a tibial reamer on 73 cadaveric knees. Ideal fluoroscopic radiographs were obtained. Three independent reviewers performed 18 measurements including a modification of the grid method. For the grid method analysis, reviewers fit a 16 × 12 grid to the lateral knee radiograph, and the center of the femoral tunnel was marked. Interobserver reliability of the measurements was performed using intraclass correlation coefficients (ICCs). A precision grouping analysis was performed for the grid measurements to calculate the mean radius and standard deviation grouping distances. RESULTS The ICCs were excellent (>.75) for the tibial tunnel angles and tunnel measurements, the clock face measurement, and the Aglietti et al and Jonsson et al measurements. The ICCs were good (.4-.75) for an estimation of graft impingement, Harner et al measurements, and notch height. The mean radius for grid measurements was 0.6 ± 0.4 units (range, 0-2.36 units), with each unit being 1 box in the 16 × 12 grid. When a circle was constructed with a 1.3-unit radius, 95% of the 3 surgeons' measurements would be included in the area of that circle. CONCLUSION Reliability of ACL tunnel measurements was good to excellent under ideal circumstances for the majority of measurements. The modified grid method demonstrated very acceptable reliability. CLINICAL RELEVANCE Measurements with good to excellent reliability can be used to evaluate ACL tunnel placement when ideal radiographic views are obtained.
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Affiliation(s)
- Jaron P Sullivan
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Intraoperative correlation analysis between tunnel position and translational and rotational stability in single- and double-bundle anterior cruciate ligament reconstruction. Arthroscopy 2012; 28:1424-36. [PMID: 22717211 DOI: 10.1016/j.arthro.2012.03.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 03/25/2012] [Accepted: 03/26/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the relation between the tunnel positions and the kinematic improvement of the knee joint after single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstructions. METHODS The study included 42 patients who underwent either SB (n = 21) or DB (n = 21) ACL reconstruction using hamstring tendon autograft. Anterior tibial translation and rotational laxity were measured by a navigation system before and after graft fixation. Three-dimensional computed tomography measurement was conducted for evaluation of tunnel placements. Regression analysis was carried out to determine the association between the postoperative kinematic change and the tunnel position. RESULTS The average tunnel location was mostly different between the SB and posterolateral bundle (PLB) tunnels, as well as between the anteromedial bundle (AMB) and PLB tunnels of DB ACL reconstructions, whereas the SB and AMB tunnels were similar in the tibial mediolateral and femoral deep-shallow positions. A regression curve showed that the PLB femoral tunnel position was correlated with rotation whereas both the SB and AMB femoral tunnel locations were mostly correlated with anterior tibial translation. CONCLUSIONS The PLB tunnel location in DB ACL reconstruction had a considerable effect on rotational laxity, whereas the SB and AMB tunnel locations mostly influenced anterior tibial translation. LEVEL OF EVIDENCE Level III, case-control study.
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Markatos K, Kaseta MK, Lallos SN, Korres DS, Efstathopoulos N. The anatomy of the ACL and its importance in ACL reconstruction. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:747-52. [PMID: 23412211 DOI: 10.1007/s00590-012-1079-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 09/09/2012] [Indexed: 12/18/2022]
Abstract
The anterior cruciate ligament (ACL) anatomy is very significant if a reconstruction is attempted after its rupture. An anatomic study should have to address, its biomechanical properties, its kinematics, its position and anatomic correlation and its functional properties. In this review, an attempt is made to summarize the most recent and authoritative tendencies as far as the anatomy of the ACL, and its surgical application in its reconstruction are concerned. Also, it is significant to take into account the anatomy as far as the rehabilitation protocol is concerned. Separate placement in the femoral side is known to give better results from transtibial approach. The medial tibial eminence and the intermeniscal ligament may be used as landmarks to guide the correct tunnel placement in anatomic ACL reconstruction. The anatomic centrum of the ACL femoral footprint is 43 % of the proximal-to-distal length of lateral, femoral intercondylar notch wall and femoral socket radius plus 2.5 mm anterior to the posterior articular margin. Some important factors affecting the surgical outcome of ACL reconstruction include graft selection, tunnel placement, initial graft tension, graft fixation, graft tunnel motion and healing. The rehabilitation protocol should come in phases in order to increase range of motion, muscle strength and leg balance, it should protect the graft and weightbearing should come in stages. The cornerstones of such a protocol remain bracing, controlling edema, pain and range of motion. This should be useful and valuable information in achieving full range of motion and stability of the knee postoperatively. In the end, all these advancements will contribute to better patient outcome. Recommendations point toward further experimental work with in vivo and in vitro studies, in order to assist in the development of new surgical procedures that could possibly replicate more closely the natural ACL anatomy and prevent future knee pathology.
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Affiliation(s)
- K Markatos
- Second Department of Orthopaedic Surgery, University of Athens, Medical School, Athens, Greece,
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Ramme AJ, Wolf BR, Warme BA, Shivanna KH, Willey MC, Britton CL, Magnotta VA, Grosland NM. Surgically oriented measurements for three-dimensional characterization of tunnel placement in anterior cruciate ligament reconstruction. ACTA ACUST UNITED AC 2012; 17:221-31. [DOI: 10.3109/10929088.2012.707230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Warme BA, Ramme AJ, Willey MC, Britton CL, Flint JH, Amendola AS, Wolf BR. Reliability of early postoperative radiographic assessment of tunnel placement after anterior cruciate ligament reconstruction. Arthroscopy 2012; 28:942-51. [PMID: 22381687 DOI: 10.1016/j.arthro.2011.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 12/07/2011] [Accepted: 12/08/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the interobserver and intraobserver reliability of radiographic assessment of tunnel placement in anterior cruciate ligament reconstruction. METHODS Seven sports fellowship-trained orthopaedic surgeons in the Multicenter Orthopaedic Outcomes Network (MOON) group participated in the study. We prospectively enrolled 54 consecutive patients after primary anterior cruciate ligament reconstruction. Postoperative plain radiographs were obtained including a full-extension anteroposterior view of the knee, a lateral view of the knee in full extension, and a notch view at 45° of flexion (Rosenberg view). Three blinded reviewers performed 8 different radiographic measurements including those of Harner and Aglietti/Jonsson. Intraclass correlation coefficients were used to determine reliability of the measurements. Intrarater reliability was assessed by repeated measurements of a subset of 20 patient images from 1 institution, and inter-rater reliability was assessed by use of all 54 sets of films from a total of 4 institutions. RESULTS Intraobserver reliability for femoral measures ranged from none to substantial, with notch height having the worst results. Intraobserver reliability was moderate to almost perfect for tibial measures. Interobserver reliability ranged from slight to moderate for femoral measures. The Harner method for determining tunnel depth was more reliable than the Aglietti/Jonsson method. Interobserver reliability for tibial measures ranged from fair to substantial. The presence of metal interference screws did not improve reliability of measurements. CONCLUSIONS Postoperative radiographs are easily obtained, but our results show that radiographic measurements are of quite variable reliability, with most of the results falling into the fair to moderate categories.
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Affiliation(s)
- Bryan A Warme
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 2701 Prairie Meadow Dr, Iowa City, IA 52242, USA
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Larson AI, Bullock DP, Pevny T. Comparison of 4 femoral tunnel drilling techniques in anterior cruciate ligament reconstruction. Arthroscopy 2012; 28:972-9. [PMID: 22409948 DOI: 10.1016/j.arthro.2011.12.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 11/07/2011] [Accepted: 12/12/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine which femoral tunnel drilling technique most closely reproduces the anatomic femoral footprint and has acceptable tunnel length and tunnel orientation. METHODS We divided 20 cadaveric knees into 4 equal groups. Arthroscopically, the anatomic femoral footprint was marked with an awl as the tunnel starting point. In group 1 the femoral tunnel was drilled through a tibial tunnel. In groups 2 and 3 the femoral tunnel was drilled through the anteromedial arthroscopy portal, with a rigid drill and flexible drill, respectively. In group 4 the femoral tunnel was drilled with the outside-in technique over a pin positioned with an arthroscopic femoral guide. Measurements of the tunnel length, aperture, and placement were taken from 3-dimensional computed tomography scans. RESULTS Tunnel length for groups 1, 2, 3, and 4 averaged 42.08 mm, 37.73 mm, 28.92 mm, and 31.96 mm (P = .039). The mean coronal angle of the tunnels as measured from the line tangent to the posterior femoral condyles was 63.30°, 61.22°, 51.77°, and 45.00° (P = .007), and the mean distance from the inferior articular surface to the edge of the tunnel was 5.60 mm, 4.36 mm, 2.42 mm, and -0.63 mm (P = .008) for groups 1, 2, 3, and 4, respectively. There was no statistical difference in footprint length, width, area, or distance from the posterior articular margin. CONCLUSION Drilling by the transtibial technique produces the most vertical and longest tunnels. Independent drilling techniques produce the most anatomic tunnels but at the expense of tunnel length. CLINICAL RELEVANCE When the orthopaedic surgeon is performing ACL reconstruction, it is critical to achieve anatomic placement of the graft, as well as maintain appropriate tunnel length.
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Affiliation(s)
- Andrew I Larson
- Aspen Sports Medicine Foundation, Aspen, Colorado 81611, USA.
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Taketomi S, Inui H, Nakamura K, Hirota J, Takei S, Takeda H, Tanaka S, Nakagawa T. Three-dimensional fluoroscopic navigation guidance for femoral tunnel creation in revision anterior cruciate ligament reconstruction. Arthrosc Tech 2012; 1:e95-9. [PMID: 23766985 PMCID: PMC3678652 DOI: 10.1016/j.eats.2012.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 04/19/2012] [Indexed: 02/03/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction is accompanied by several technical challenges that must be addressed, such as a primary malpositioned bone tunnel, pre-existing hardware, or bone defects due to tunnel expansion. We describe a surgical technique used to create an anatomic femoral socket using a 3-dimensional (3D) fluoroscopy-based navigation system in technically demanding revision cases. After a reference frame is rigidly attached to the femur, an intraoperative image of the distal femur is obtained, which is transferred to a navigation system and reconstructed into a 3D image. A navigation computer helps the surgeon to visualize the whole image of the lateral wall of the femoral notch, even if the natural morphology of the intercondylar notch has been destroyed by the primary procedure. In addition, the surgeon can also confirm the position of the previous bone tunnel aperture, the previous exit of the femoral tunnel, and the presence of any pre-existing hardware on the navigation monitor. When a new femoral guidewire for the revision procedure is placed, the virtual femoral tunnel is overlaid on the reconstructed 3D image in real time. At our institution, 12 patients underwent 1-stage revision ACL procedures with the assistance of this computer navigation system, and the grafts were securely fixed in anatomically created tunnels in all cases. This technology can assist surgeons in creating anatomic femoral tunnels in technically challenging revision ACL reconstructions.
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Affiliation(s)
| | | | | | | | | | | | | | - Takumi Nakagawa
- Address correspondence to Takumi Nakagawa, M.D., Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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Han Y, Kurzencwyg D, Hart A, Powell T, Martineau PA. Measuring the anterior cruciate ligament's footprints by three-dimensional magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 2012; 20:986-95. [PMID: 21987362 DOI: 10.1007/s00167-011-1690-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 09/20/2011] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to compare 3D MR imaging and open cadaveric measurements of the ACL's footprints to see whether 3D MR imaging measurements are accurate enough to be used for preoperative templating in anatomic ACL reconstruction. METHODS Eight formalin-injected cadaveric knees were scanned by rapid acquisition isotropic 3D MR imaging. The femoral and tibial footprints were measured on MR imaging and compared with cadaveric dissection. Bland-Altman plots were used to assess the level of agreement. RESULTS The AM and PL bundles were clearly appreciated in each specimen by 3D MR imaging and cadaveric dissection. The average paired difference in the femoral and tibial footprint measurements was 2, 1, 2, and 2 mm for the femoral footprint length, femoral footprint width, tibial footprint length, and tibial footprint width, respectively. The individual paired measurements were all within the mean difference ± two standard deviations of the difference in the Bland-Altman plot showing strong agreement. CONCLUSION Measuring the ACL's footprint by 3D MR imaging or open cadaveric dissection has strong agreement and can be used interchangeably. 3D MR imaging has the potential to allow surgeons to: (1) tailor ACL reconstruction technique or graft choice based on ACL footprint size, (2) plan for selective bundle ACL reconstruction for partial tears, and (3) preoperatively template tunnel position according to the patient's individual anatomy.
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Affiliation(s)
- Yung Han
- Department of Orthopaedic Surgery, McGill University, Montreal, QC, Canada.
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Gnannt R, Chhabra A, Theodoropoulos JS, Hodler J, Andreisek G. MR imaging of the postoperative knee. J Magn Reson Imaging 2012; 34:1007-21. [PMID: 22002752 DOI: 10.1002/jmri.22672] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Advances in orthopedic and arthroscopic surgical procedures of the knee such as, knee replacement, ligamentous reconstruction as well as articular cartilage and meniscus repair techniques have resulted in a significant increase in the number of patients undergoing knee arthroscopy or open surgery. As a consequence postoperative MR imaging examinations increase. Comprehensive knowledge of the normal postoperative MR imaging appearances and abnormal findings in the knee associated with failure or complications of common orthopedic and arthroscopic surgical procedures currently undertaken is crucial. This article reviews the various normal and pathological postoperative MR imaging findings following anterior and posterior cruciate ligament, medial collateral ligament and posterolateral corner reconstruction, meniscus and articular cartilage surgery as well as total knee arthroplasty with emphasis on those surgical procedures which general radiologists will likely be faced in their daily clinical routine.
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Affiliation(s)
- Ralph Gnannt
- Department of Radiology, University Hospital Zurich, Zurich, Switzerland
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Dodds AL, Gupte CM, Neyret P, Williams AM, Amis AA. Extra-articular techniques in anterior cruciate ligament reconstruction: a literature review. ACTA ACUST UNITED AC 2012; 93:1440-8. [PMID: 22058292 DOI: 10.1302/0301-620x.93b11.27632] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.
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Affiliation(s)
- A L Dodds
- Imperial College NHS Trust/St Mary's and Charing Cross Hospitals, Praed Street, London W2 1NY, UK
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de Pádua VBC, Maldonado H, Vilela JCR, Provenza AR, Monteiro C, de Oliveira Neto HC. COMPARATIVE STUDY OF ACL RECONSTRUCTION WITH ANATOMICAL POSITIONING OF THE TUNNELS USING THE PATELLAR TENDON VERSUS HAMSTRING TENDON. Rev Bras Ortop 2012; 47:50-6. [PMID: 27027082 PMCID: PMC4799339 DOI: 10.1016/s2255-4971(15)30345-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 11/07/2011] [Indexed: 01/10/2023] Open
Abstract
Objective: To compare ACL reconstruction with anatomical positioning of the tunnels using the hamstring or patellar tendons. Methods: We prospectively evaluated 52 patients who underwent ACL reconstruction using the Chambat's technique, with anatomical positioning of the tunnels drilled outside in. They were divided into group A, with 27 patients, using the patellar tendon as a graft, and group B, with 25 patients, using the hamstring. Results: In group A 26 patients were very satisfied or satisfied and 1 unhappy, in group B. 25 patients were very satisfied or satisfied with the procedure (p = 0.990). According to the Lysholm scale, group A had a mean score of 96.11 and group B, 95.32 (p=0.594). In relation to preoperative IKDC, 100% of the patients in group A and 92% of those in group B were IKDC C or D (p = 0.221); in the assessment with a minimum of two-year follow-up, 96% of group A and 92% of group B were IKDC A or B (p = 0.256). The Lachman test, pivot shift, return to sports activities, and the comparative difference in anterior translation (RolimeterTM) also showed no statistically significant difference. In group A, 5 patients (18.5%) were unable to kneel on a hard surface, whereas no patient in group B had this complaint. Conclusion: The anterior cruciate ligament reconstruction presents similar results using the hamstring or patellar tendon with anatomical positioning of the tunnels. Drilling the femoral tunnel outside in is a reproducible and accurate option in the correct placement the femoral tunnel.
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Affiliation(s)
| | - Hilário Maldonado
- Titular Professor of Orthopedics and Traumatology, Marília Medical School (FAMEMA), Marília, SP, Brazil
| | | | - Alexandre Ribeira Provenza
- Third-year Residents in the Orthopedics Service, Santa Casa de Misericórdia de Marília, Marília, SP, Brazil
| | - Cleverson Monteiro
- Third-year Residents in the Orthopedics Service, Santa Casa de Misericórdia de Marília, Marília, SP, Brazil
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Meuffels DE, Potters JW, Koning AHJ, Brown Jr CH, Verhaar JAN, Reijman M. Visualization of postoperative anterior cruciate ligament reconstruction bone tunnels: reliability of standard radiographs, CT scans, and 3D virtual reality images. Acta Orthop 2011; 82:699-703. [PMID: 21999625 PMCID: PMC3247888 DOI: 10.3109/17453674.2011.623566] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Non-anatomic bone tunnel placement is the most common cause of a failed ACL reconstruction. Accurate and reproducible methods to visualize and document bone tunnel placement are therefore important. We evaluated the reliability of standard radiographs, CT scans, and a 3-dimensional (3D) virtual reality (VR) approach in visualizing and measuring ACL reconstruction bone tunnel placement. METHODS 50 consecutive patients who underwent single-bundle ACL reconstructions were evaluated postoperatively by standard radiographs, CT scans, and 3D VR images. Tibial and femoral tunnel positions were measured by 2 observers using the traditional methods of Amis, Aglietti, Hoser, Stäubli, and the method of Benereau for the VR approach. RESULTS The tunnel was visualized in 50-82% of the standard radiographs and in 100% of the CT scans and 3D VR images. Using the intraclass correlation coefficient (ICC), the inter- and intraobserver agreement was between 0.39 and 0.83 for the standard femoral and tibial radiographs. CT scans showed an ICC range of 0.49-0.76 for the inter- and intraobserver agreement. The agreement in 3D VR was almost perfect, with an ICC of 0.83 for the femur and 0.95 for the tibia. INTERPRETATION CT scans and 3D VR images are more reliable in assessing postoperative bone tunnel placement following ACL reconstruction than standard radiographs.
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Affiliation(s)
| | | | - Anton HJ Koning
- Department of Bioinformatics, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Charles H Brown Jr
- Abu Dhabi Knee and Sports Medicine Center, Abu Dhabi, United Arab Emirates
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Morphometric analysis and functional correlation of tibial and femoral footprints in anatomical and single bundle reconstructions of the anterior cruciate ligament of the knee. Orthop Traumatol Surg Res 2011; 97:S75-9. [PMID: 21903501 DOI: 10.1016/j.otsr.2011.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 05/27/2011] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The anterior cruciate ligament (ACL) is composed of an infinite number of fibers whose individual anatomical and biomechanical features have been well defined. Although numerous biomechanical studies have shown that reconstruction that is as anatomical as possible results in better control of rotational laxity, very few studies have investigated the surface area of tibial and femoral insertion sites in these reconstructions. The aim of this study was to compare the surface areas of tibial and femoral insertion sites in single and double bundle reconstructions and correlate these findings with the isometry profile obtained. Our hypothesis was that double bundle (DB) reconstruction results in better filling of the native ACL footprint thus increasing the biomechanical value of available graft tissue. PATIENTS AND METHODS Forty-six patients underwent computer navigated ACL using hamstring tendons: 23 underwent single bundle (SB) and 23 DB reconstruction. The Praxim navigation station equipped with ACL logics software made it possible to digitize insertion site footprints, register perioperative data for graft position as well as anteroposterior and rotational laxities and pivot shift. RESULTS There was a statistically significant difference between the two groups for tibial and femoral insertion site surface areas: 71 mm(2) ± 17 (SB) versus 99.9 mm(2) ± 30 (DB) for the tibia, 67 ± 11 mm(2) (SB) versus 96.9 mm(2) ± 28 (DB) for the femur. Isometry profiles showed that anisometry was favorable in all cases: 2.5 mm ± 2 for SB; 2.9 mm ± 2 for the anteromedial bundle (AMB) with DB and 9.6 mm ± 3.7 for the posterolateral bundle. When both groups were combined, there was a statistically significant correlation between the size of tibial insertion surface area and anteroposterior and rotational laxity. DISCUSSION This study confirms that better filling of native ACL footprint surface areas results in better control of anteroposterior laxity. LEVEL OF EVIDENCE Level IV.
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Leung KKM, Yu JK, Luo H, Ao YF, Wang JQ, Cui GQ, Hu YL, Gong X, Wang YJ, Zhang JY, Liu YL. The position of the posterolateral bundle femoral tunnel during arthroscopic double-bundle anterior cruciate ligament reconstruction: a cadaveric study. Arthroscopy 2011; 27:959-64. [PMID: 21693348 DOI: 10.1016/j.arthro.2011.02.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 02/11/2011] [Accepted: 02/14/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose was to find a simple guideline to help establish accurate positioning of the posterolateral bundle (PLB) femoral bone tunnel during double-bundle anterior cruciate ligament reconstruction by measuring the distance between the center of the PLB femoral footprint to the shallow and the deep articular cartilage borders of the lateral wall of the intercondylar notch. METHODS The femoral insertions of the anteromedial bundle and PLB of the anterior cruciate ligament were dissected in 22 male cadaveric knees, aged 25 to 45 years. By use of the intercondylar notch as the landmark, the distances between the center of the PLB femoral footprint and the shallow and the deep articular cartilage borders of the lateral wall of the intercondylar notch were measured with the knees flexed at 90°. The measured data (mean ± standard deviation) were evaluated and compared. RESULTS The center of the PLB was positioned 8.60 ± 1.52 mm and 8.65 ± 1.54 mm from the shallow and the deep cartilage borders of the lateral wall of the intercondylar notch, respectively (P = .95). The distance between the center of the PLB footprint to the low cartilage border of the lateral intercondylar wall was 5.05 ± 0.76 mm. CONCLUSIONS The findings suggest that the position of the center of the PLB femoral footprint is at the middle of the line joining the shallow and the deep borders of the femoral cartilage. CLINICAL RELEVANCE Surgeons can use our results as a guideline and use the PLB footprint remnant as a reference at the same time to locate the femoral PLB tunnel in a simple, easy, and repeatable way.
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Affiliation(s)
- Kevin Kar Ming Leung
- Institute of Sports Medicine, Peking University Third Hospital, Peking University, Beijing, China
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The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19:699-706. [PMID: 21222101 DOI: 10.1007/s00167-010-1376-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 12/15/2010] [Indexed: 01/13/2023]
Abstract
PURPOSE This article introduces guidelines for single- (SB) and double-bundle (DB) ACL reconstruction based on the concept of complete footprint restoration. The goal is to reconstruct a maximum of anterior cruciate ligament (ACL) insertion site area to regain a maximum of ACL function. The concept is based on the hypothesis that the restored biomechanical envelope of the knee is a function of reconstructed ACL insertion site area. METHODS Individual combinations of graft diameters and drill angles were calculated and matched for all individual insertion site lengths between 8 and 21 mm to maximize the percentage of anatomical footprint restoration. An "insertion site table" was developed to propose individual guidelines during ACL surgery for SB and DB ACL reconstruction based on the intraoperative measurement of the tibial insertion site length. RESULTS Our calculations support the use of SB in "small footprints" up to 13 mm, which may restore more than 95% of the native insertion site length. "Intermediate footprints" between 14 and 15 mm may be restored by both a SB or DB ACL reconstruction. For "larger footprints" of 16 mm or more, DB has the potential to replicate 97% or more of the insertion site length which cannot be achieved by a SB ACL reconstruction. CONCLUSIONS The concept of complete footprint restoration aims to reconstruct a maximum of ACL insertion site area to restore a maximum of functional envelope of the knee. Depending on the individual situation, different surgical approaches (SB/DB), graft diameters and drill angles may apply. An "insertion site table" was designed to give guidelines for SB and DB reconstruction during surgery. According to the new concept, DB ACL reconstruction is only considered as a surgical tool for large footprints and is not indicated for smaller ones.
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Ziegler CG, Pietrini SD, Westerhaus BD, Anderson CJ, Wijdicks CA, Johansen S, Engebretsen L, LaPrade RF. Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med 2011; 39:743-52. [PMID: 21173191 DOI: 10.1177/0363546510387511] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quantification of the overall anterior cruciate ligament (ACL) and anteromedial (AM) and posterolateral (PL) bundle centers in respect to arthroscopically pertinent bony and soft tissue landmarks has not been thoroughly assessed. HYPOTHESIS A standardized anatomical measurement method can quantitate the locations of the ACL and AM and PL bundle centers in reference to each other and anatomical landmarks. STUDY DESIGN Descriptive laboratory study. METHODS Quantification of the ACL and its bundle attachments was performed on 11 cadaveric knees using a radio frequency-tracking device. RESULTS The tibial ACL attachment center was 7.5 mm medial to the anterior horn of the lateral meniscus, 13.0 mm anterior to the retro-eminence ridge, and 10.5 mm posterior to the ACL ridge. The femoral ACL attachment center was 1.7 mm proximal to the bifurcate ridge and 6.1 mm posterior to the lateral intercondylar ridge. The tibial AM attachment center was 8.3 mm medial to the anteromedial aspect of the lateral meniscus anterior horn, 17.8 mm anterior to the retro-eminence ridge, and 5.6 mm posterior to the ACL ridge. The femoral AM attachment center was 4.8 mm proximal to the bifurcate ridge and 7.1 mm posterior to the lateral intercondylar ridge. The tibial PL bundle attachment center was 6.6 mm medial to the posteromedial aspect of the lateral meniscus anterior horn, 10.8 mm anteromedial to the root attachment of the lateral meniscus posterior horn, and 8.4 mm anterior to the retro-eminence ridge. The femoral PL bundle attachment center was 5.2 mm distal to the bifurcate ridge and 3.6 mm posterior to the lateral intercondylar ridge. CONCLUSION The authors developed a comprehensive compilation of measurements of arthroscopically pertinent bony and soft tissue landmarks that quantitate the ACL and its individual bundle attachment centers on the tibia and femur. CLINICAL RELEVANCE These clinically relevant arthroscopic landmarks may enhance single- and double-bundle ACL reconstructions through improved tunnel placement.
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Affiliation(s)
- Connor G Ziegler
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, USA
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Radiographic description of femoral tunnel placement expressed as intercondylar clock time in double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19:418-23. [PMID: 20734025 DOI: 10.1007/s00167-010-1243-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 07/28/2010] [Indexed: 01/12/2023]
Abstract
PURPOSE The purpose of this study was to propose an objective description of femoral tunnel position expressed as time of the intercondylar clock in ACL reconstruction using a simple radiograph for the sake of objective discussion and technical improvement. The reproducibility of the method was evaluated in double-bundle (DB) reconstructions. METHODS The first series of 54 knees in 54 patients who underwent primary "isometric" DB ACL reconstructions from 1995 to 2002 were randomly picked up. The second series of 48 knees in 48 patients with primary "anatomic" DB ACL reconstructions during 2007 were assessed as a recent femoral tunnel position with the same method. All DB reconstructions of ACL with the anteromedial (AM) and posterolateral (PL) bundles were performed with an arthroscopically assisted trans-tibial technique. The o'clock description of femoral tunnel placement was expressed using a weight-bearing posterior-anterior view at 45° of flexion (45° W/B PA view) of the knee. Assessment was undertaken with radiographs 1 year postoperatively. RESULTS The o'clock descriptions of femoral tunnel placement resulted in noon 40 min (standard deviation (SD): 10 min) for the AM bundle and one o'clock 40 min (SD: 20 min) for the PL bundle on average in the "isometric" reconstruction. In the "anatomic" reconstruction, the time descriptions of femoral tunnel placement were one o'clock 20 min (SD: 10 min) for the AM bundle and two o'clock 20 min (SD: 20 min) for the PL bundle on average. With the intra-examiner reproducibility assessment in the "anatomic" reconstruction, the differences between first and second assessments averaged 10 min (SD: 7 min) for femoral tunnel placement of the AM bundle and 12 min (SD: 9 min) of the PL bundle. Regarding the inter-examiner reproducibility, the differences between two examiners averaged 9 min (SD: 6 min) for femoral tunnel placement of the AM bundle and 14 min (SD: 9 min) of the PL bundle. CONCLUSION This simple radiographic assessment is reproducible and reliable for clinical use, and useful for the evaluation of ACL reconstructive procedures.
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