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Lou J, Ma Q, Zhao X, Wu S, Gao H, Zhang W, Zhao B, Cai X. Comparison of the biomechanical properties of grafts in three anterior cruciate ligament reconstruction techniques based on three-dimensional finite element analysis. J Orthop Surg Res 2024; 19:322. [PMID: 38812053 PMCID: PMC11137914 DOI: 10.1186/s13018-024-04777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/02/2024] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVE To evaluate the biomechanical characteristics of grafts from three different anterior cruciate ligament (ACL) reconstructive surgeries and to determine which method is better at restoring knee joint stability. METHODS A 31-year-old female volunteer was enrolled in the study. According to the magnetic resonance imaging of her left knee, a three-dimensional model consisting of the distal femur, proximal tibia and fibula, ACL, posterior cruciate ligament, medial collateral ligament and lateral collateral ligament was established. Then, the ACL was removed from the original model to simulate the knee joint after ACL rupture. Based on the knee joint model without the ACL, single-bundle ACL reconstruction, double-bundle ACL reconstruction, and flat-tunnel ACL reconstruction were performed. The cross-sectional diameters of the grafts were equally set as 6 mm in the three groups. The bone tissues had a Young's modulus of 17 GPa and a Poisson's ratio of 0.36. The ligaments and grafts had a Young's modulus of 390 MPa and a Poisson's ratio of 0.4. Six probes were placed in an ACL or a graft to obtain the values of the equivalent stress, maximum principal stress, and maximum shear stress. After pulling the proximal tibia with a forward force of 134 N, the distance that the tibia moved and the stress distribution in the ACL or the graft, reflected by 30 mechanical values, were measured. RESULTS The anterior tibial translation values were similar among the three groups, with the double-bundle ACL reconstruction group performing the best, followed closely by the patellar tendon ACL reconstruction group. In terms of stress distribution, 13 out of 30 mechanical values indicated that the grafts reconstructed by flat bone tunnels had better performance than the grafts in the other groups, while 12 out of 30 showed comparable outcomes, and 5 out of 30 had worse outcomes. CONCLUSION Compared with traditional single-bundle and double-bundle ACL reconstructions, flat-tunnel ACL reconstruction has advantages in terms of stress dispersion. Additionally, flat-tunnel ACL reconstruction falls between traditional double-bundle and single-bundle ACL reconstructions in terms of restoring knee joint stability and is superior to single-bundle ACL reconstruction.
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Affiliation(s)
- Jiawnag Lou
- Hebei North University, 11-South Diamond Road, Gaoxin District, Zhangjiakou City, 075000, China.
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China.
- Beijing MEDERA Medical Group, Beijing, 102200, China.
| | - Qi Ma
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Xijiu Zhao
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Sha Wu
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Hong Gao
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Wei Zhang
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Baojing Zhao
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Xu Cai
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
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2
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Suruga M, Iriuchishima T, Yahagi Y, Iwama G, Horaguchi T, Aizawa S, Hirai S, Nakanishi K. Evaluation of the Angle Between the Long Axis of the Femoral Anterior Cruciate Ligament Footprint and Bony Morphology of the Knee: A Cadaveric Descriptive Study. Indian J Orthop 2024; 58:510-516. [PMID: 38694688 PMCID: PMC11058129 DOI: 10.1007/s43465-024-01131-5] [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: 08/04/2023] [Accepted: 03/02/2024] [Indexed: 05/04/2024]
Abstract
Purpose There have been numerous studies of the anterior cruciate ligament (ACL) anatomy, but few have focused on the long axis angle of the femoral ACL footprint. This study investigated the angle between the long axis of the femoral ACL footprint and the bony morphology of the knee. Methods This study is a cadaveric descriptive study. Thirty non-paired formalin-fixed knees of Japanese cadavers were used. Anteromedial (AM) and posterolateral (PL) bundles were identified according to the tension pattern differences during the complete range of motion of the knee. In the ACL femoral footprint, there is a fold between the mid-substance insertion site and fan-like extension fibers. After identifying AM and PL bundles of mid-substance fibers, the mid-substance and fan-like extension fibers were divided into those bundles and stained. We defined the line passing through the center of the AM and PL bundles as the long axis of the ACL. The center points of each of the four areas and the angle between the long axis of the ACL and the bony morphology of the knee were calculated using Image J software. Results The mean angle between the axis of the femoral shaft and the long axis of the ACL mid-substance insertion was 28.8 ± 12.2 degrees. The mean angle between the Blumensaat line and the long axis of the mid-substance was 54.2 ± 13.5 degrees. Conclusion The mean angle between the axis of the femoral shaft and the long axis of the femoral ACL footprint was approximately 29 degrees. There is a wide variation in the long axis of the femoral ACL footprint. To achieve better clinical results through a more anatomically accurate reconstruction, it can be beneficial to replicate the ACL femoral footprint along its native long axis.
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Affiliation(s)
- Makoto Suruga
- Department of Orthopaedic Surgery, Nihon University Hospital, 1-6, Kanda-Surugadai, Chiyoda-Ku, Tokyo, Japan
| | | | - Yoshiyuki Yahagi
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, Japan
| | - Genki Iwama
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, Japan
| | - Takashi Horaguchi
- B&J Clinic Ochanomizu, 2-1-47 Kanda Surugadai, Chiyoda-Ku, Tokyo, Japan
| | - Shin Aizawa
- Department of Functional Morphology, Nihon University School of Medicine, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, Japan
| | - Shuichi Hirai
- Department of Functional Morphology, Nihon University School of Medicine, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, Japan
| | - Kazuyoshi Nakanishi
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, Japan
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Kemler B, Coladonato C, Sonnier JH, Campbell MP, Darius D, Erickson BJ, Tjoumakaris FP, Freedman KB. Evaluation of Failed ACL Reconstruction: An Updated Review. Open Access J Sports Med 2024; 15:29-39. [PMID: 38586217 PMCID: PMC10998505 DOI: 10.2147/oajsm.s427332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.
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Affiliation(s)
- Bryson Kemler
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Michael P Campbell
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Danielle Darius
- Department of Education, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
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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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Desai T, Babu S S, S KY, Nedumparampil MM, George AJ, Sekaran P, Pilar A, Amaravathi RS. Periosteum-Augmented Soft-Tissue Graft for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2024; 13:102809. [PMID: 38312870 PMCID: PMC10837788 DOI: 10.1016/j.eats.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/26/2023] [Indexed: 02/06/2024] Open
Abstract
Soft-tissue grafts are an option for anterior cruciate ligament reconstruction. One of the major drawbacks of soft-tissue grafts is the delay in the osteointegration and ligamentization of the implanted graft. Enveloping the ends of the graft with periosteum sleeves can hasten the osteointegration process and help in quicker rehabilitation of the patient. This article describes a simple and unique way to augment the soft-tissue graft with periosteum for anterior cruciate ligament reconstruction.
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Affiliation(s)
- Tarun Desai
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Surendra Babu S
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Kaushik Y. S
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Mevin Mathew Nedumparampil
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | | | | | - Anoop Pilar
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Rajkumar S. Amaravathi
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
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Dai Y, Gao WJ, Li WC, Xiang XX, Wang WM. Research progress on preparation of lateral femoral tunnel and graft fixation in anterior cruciate ligament reconstruction. World J Clin Cases 2023; 11:8247-8255. [PMID: 38130627 PMCID: PMC10731198 DOI: 10.12998/wjcc.v11.i35.8247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/01/2023] [Accepted: 12/01/2023] [Indexed: 12/14/2023] Open
Abstract
Anterior cruciate ligament (ACL) injury is one of the most common types of sports injuries. People's need to participate in sports and desire for a high quality of life promotes the continuous development of ACL reconstruction technology. Arthroscopic ACL reconstruction has been recognized as an effective method for the treatment of ACL injuries. This review analyses and summarizes the advantages and limitations of each surgical procedure for arthroscopic ACL reconstruction reported in the relevant literature so as to promote the future development of more relevant techniques.
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Affiliation(s)
- Yue Dai
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Wen-Jie Gao
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Wen-Chuan Li
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Xian-Xiang Xiang
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Wei-Ming Wang
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
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7
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Iriuchishima T, Goto B. ACL Volume Measurement Using a Multi-truncated Pyramid Shape Simulation. Indian J Orthop 2023; 57:2082-2087. [PMID: 38009176 PMCID: PMC10673783 DOI: 10.1007/s43465-023-01025-y] [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: 04/09/2023] [Accepted: 10/12/2023] [Indexed: 11/28/2023]
Abstract
Purpose The purpose of this study was to measure anterior cruciate ligament (ACL) volume in a newly reported multi-truncated pyramid shape simulation using axial magnetic resonance imaging (MRI) for the detailed knowledge of the ACL anatomy. Methods Fifty subjects (27 female and 23 male, average age: 23 ± 7.8) visiting our clinic with knee pain and in whom MRI showed no structural injury were included in this study. Using the axial image of the MRI, four deferent levels of the cross-sectional area of the ACL were measured. ACL height was measured as the distance between the most proximal and distal slices of the MRI. ACL volume was calculated using a multi-truncated pyramid shape simulation. Femoral intercondylar notch height, area, and trans-epicondylar length (TEL) were also measured using MRI. Results The measured top, proximal 1/3, distal 1/3, and bottom of the ACL cross-sectional area were, 36.8 ± 10.7, 59.9 ± 15.4, 66.4 ± 20.8, and 107.3 ± 21.1mm2, respectively. ACL height was 26.3 ± 3.9 mm. Using these data, the calculated ACL volume was 1755 ± 874mm3. Significant correlations were observed between ACL volume and notch height, area, and TEL. Conclusion Similar ACL volume with previous reports was obtained in this simple and easy multi-truncated pyramid shape simulation from axial MRI evaluation. Significant correlation was observed between ACL volume and knee bony morphology. The ability of surgeons to measure ACL volume simply and effectively can be useful for the detailed ACL anatomical knowledge, and also for prediction and prevention of ACL injury.Level of evidence: IV, Case series.
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Affiliation(s)
| | - Bunsei Goto
- Department of Orthopedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
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Yahagi Y, Iriuchishima T, Iwama G, Suruga M, Horaguchi T, Aizawa S, Nakanishi K. Size Comparison of the Cadaveric Anterior Cruciate Ligament Midsubstance Cross-Sectional Area and the Cross-Sectional Area of Semitendinosus Double-Bundle Anterior Cruciate Ligament Reconstruction Autografts in Surgery. J Knee Surg 2023; 36:1247-1252. [PMID: 35944571 DOI: 10.1055/s-0042-1755377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to compare the cadaveric midsubstance cross-sectional anterior cruciate ligament (ACL) area and the cross-sectional semitendinosus (ST) double-bundle ACL autograft area in surgery. Thirty-nine nonpaired formalin-fixed cadaveric knees and 39 subjects undergoing ST double-bundle ACL reconstruction were included in this study. After soft tissue resection, cadaveric knees were flexed at 90 degrees, and the tangential line of the femoral posterior condyles was marked and sliced on the ACL midsubstance. The cross-sectional ACL area was measured using Image J software. In the patients undergoing ACL surgery, the harvested ST was cut and divided into anteromedial (AM) bundle and posterolateral (PL) bundle. Each graft edge diameter was measured by a sizing tube, and the cross-sectional graft area was calculated: (AM diameter/2)2 × 3.14 + (PL diameter/2)2 × 3.14. Statistical analysis was performed for the comparison of the cross-sectional area between the cadaveric ACL midsubstance and the ST double-bundle ACL autografts. The cadaveric midsubstance cross-sectional ACL area was 49.0 ± 16.3 mm2. The cross-sectional ST double-bundle autografts area was 52.8 ± 7.6 mm2. The ST double-bundle autograft area showed no significant difference when compared with the midsubstance cross-sectional ACL area. ST double-bundle autografts were shown to be capable of reproducing the midsubstance cross-sectional ACL area.
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Affiliation(s)
- Yoshiyuki Yahagi
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Takanori Iriuchishima
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
| | - Genki Iwama
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Makoto Suruga
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Takashi Horaguchi
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Shin Aizawa
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuyoshi Nakanishi
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
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Fox MA, Zsidai B, Dadoo S, Greiner JJ, Musahl V. Anatomic Anterior Cruciate Ligament Reconstruction. Arthroscopy 2023; 39:1968-1970. [PMID: 37543381 DOI: 10.1016/j.arthro.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/06/2023] [Indexed: 08/07/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) techniques have substantially evolved over the past several decades, driven by evidence that nonanatomic techniques increase the risk for instability, loss of motion, surgical failure, and posttraumatic osteoarthritis. Early techniques used transtibial femoral tunnel drilling, although improved understanding of the anatomy and biomechanics has led to independent femoral tunnel. Anatomic ACLR requires careful consideration of the native ACL dimensions and orientation. Although there is significant variation between patients, understanding of anatomic patterns allows for reliable identification of the ACL footprints and appropriate tunnel positioning, particularly in chronic injuries where the remanent ACL stump is degraded or absent. The femoral tunnel should be placed low and posterior on the lateral femoral condyle using the lateral intercondylar and bifurcate ridges as landmarks. The center of the tibial footprint can be determined by referencing the medial tibial spine and posterior border of anterior horn of lateral meniscus. Measurement of the dimensions of the native ACL and intercondylar notch is also critical for determining graft size and minimizing the risk of impingement, with a goal of reconstructing 50% to 80% of the tibial footprint area. Clinical outcome studies have demonstrated superior anteroposterior and rotatory knee stability with low surgical revision rates (reported between 3% and 5%). By adhering to the principles of anatomic ACLR, surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function. The aim of this infographic is to highlight essential features of anatomic ACLR techniques, which a focus on the native anatomy and surgical planning to achieve an anatomic ACLR.
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Affiliation(s)
- Michael A Fox
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A..
| | - Bálint Zsidai
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.; Department of Orthopedic Surgery, University of Gothenberg, Gothenburg, Sweden
| | - Sahil Dadoo
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Justin J Greiner
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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10
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Zaffagnini S, Lucidi GA, Macchiarola L, Agostinone P, Neri MP, Marcacci M, Grassi A. The 25-year experience of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: the story so far. J Exp Orthop 2023; 10:36. [PMID: 37005946 PMCID: PMC10067780 DOI: 10.1186/s40634-023-00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023] Open
Abstract
This article presents with an evidence based approach, the kinematical rationale, biological evidence and the long term results of the "Over-The-Top" anterior cruciate ligament reconstruction with lateral plasty technique. This surgery was developed more than 25 years ago at the Rizzoli Institute by professor Marcacci and Zaffagnini and it is still widely performed in many orthopedic center worldwide.
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Affiliation(s)
- Stefano Zaffagnini
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Gian Andrea Lucidi
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Luca Macchiarola
- Ortopedia E Traumatologia, IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Piero Agostinone
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy.
| | - Maria Pia Neri
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Maurilio Marcacci
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Clinical and Research Center, Milan, Italy
| | - Alberto Grassi
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
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11
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Farshidfar SS, Cadman J, Neri T, Parker D, Appleyard R, Dabirrahmani D. Towards a validated musculoskeletal knee model to estimate tibiofemoral kinematics and ligament strains: comparison of different anterolateral augmentation procedures combined with isolated ACL reconstructions. Biomed Eng Online 2023; 22:31. [PMID: 36973768 PMCID: PMC10044816 DOI: 10.1186/s12938-023-01094-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Isolated ACL reconstructions (ACLR) demonstrate limitations in restoring native knee kinematics. This study investigates the knee mechanics of ACLR plus various anterolateral augmentations using a patient-specific musculoskeletal knee model. MATERIALS AND METHODS A patient-specific knee model was developed in OpenSim using contact surfaces and ligament details derived from MRI and CT data. The contact geometry and ligament parameters were varied until the predicted knee angles for intact and ACL-sectioned models were validated against cadaveric test data for that same specimen. Musculoskeletal models of the ACLR combined with various anterolateral augmentations were then simulated. Knee angles were compared between these reconstruction models to determine which technique best matched the intact kinematics. Also, ligament strains calculated by the validated knee model were compared to those of the OpenSim model driven by experimental data. The accuracy of the results was assessed by calculating the normalised RMS error (NRMSE); an NRMSE < 30% was considered acceptable. RESULTS All rotations and translations predicted by the knee model were acceptable when compared to the cadaveric data (NRMSE < 30%), except for the anterior/posterior translation (NRMSE > 60%). Similar errors were observed between ACL strain results (NRMSE > 60%). Other ligament comparisons were acceptable. All ACLR plus anterolateral augmentation models restored kinematics toward the intact state, with ACLR plus anterolateral ligament reconstruction (ACLR + ALLR) achieving the best match and the greatest strain reduction in ACL, PCL, MCL, and DMCL. CONCLUSION The intact and ACL-sectioned models were validated against cadaveric experimental results for all rotations. It is acknowledged that the validation criteria are very lenient; further refinement is required for improved validation. The results indicate that anterolateral augmentation moves the kinematics closer to the intact knee state; combined ACLR and ALLR provide the best outcome for this specimen.
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Affiliation(s)
- Sara Sadat Farshidfar
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Joseph Cadman
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Thomas Neri
- Sydney Orthopaedic Research Institute, Sydney, Australia
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint Etienne, France
- EA 7424-Inter-University Laboratory of Human Movement Science, University Lyon-University Jean Monnet Saint Etienne, Saint Etienne, France
| | - David Parker
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | - Richard Appleyard
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Danè Dabirrahmani
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
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12
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Borque KA, Laughlin MS, Pinheiro VH, Jones M, Williams A. Rebranding the 'anatomic' ACL reconstruction: Current concepts. J ISAKOS 2023; 8:23-28. [PMID: 36435433 DOI: 10.1016/j.jisako.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022]
Abstract
The anterior cruciate ligament (ACL) is a complex ribbon-like structure, which is approximately 3.5 times larger at the tibial and femoral insertions than at the midpoint. Accordingly, it is impossible to recreate with a single cylindrical graft. However, this has not stopped surgeons from using the term "anatomic" to describe multiple ACL reconstruction techniques inserting at a number of different locations within the original ACL footprint, causing confusion. The term "anatomic" should be discarded and replaced by an anatomic description of the tunnel placements on the tibia and femur. Current ACL reconstruction techniques cite anatomical studies that identified "direct and indirect fibres" of the ACL. The "direct fibres" bear 85-95% of the load and provide the main resistance to both anterior tibial translation and internal rotation/pivot shift. On the femur, these fibres insert in a line just posterior to the intercondylar ridge and comprise the portion of the ACL that surgeons should strive to restore. Placement of the graft just posterior to the intercondylar ridge creates a line of placement options from the anteromedial bundle to the "central" position and finally to the posterolateral bundle position. The authors prefer placing the femoral tunnel in the isometric anteromedial position and addressing a high-grade pivot shift at the IT-band with a lateral extra-articular tenodesis. As with the femoral tunnel, the native ACL footprint on the tibia is much larger than the ACL graft and thus can be placed in multiple "anatomic" locations. The authors prefer placement of the tibial tunnel in the anterior most position of the native footprint that does not cause impingement in the femoral notch. Additional research is needed to determine the ideal tunnel positions on the femur and tibia and validating the technique with patient outcomes. However, this cannot be accomplished without describing tunnel placement with specific anatomical locations so other surgeons can replicate the technique.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Hospital, Houston, TX, 77479, USA.
| | | | | | - Mary Jones
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
| | - Andy Williams
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
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13
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Fox MA, Engler ID, Zsidai BT, Hughes JD, Musahl V. Anatomic anterior cruciate ligament reconstruction: Freddie Fu's paradigm. J ISAKOS 2023; 8:15-22. [PMID: 35988888 DOI: 10.1016/j.jisako.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/26/2022] [Accepted: 08/03/2022] [Indexed: 11/25/2022]
Abstract
Anterior cruciate ligament (ACL) reconstruction techniques have evolved over the past four decades. There is evidence that non-anatomic reconstruction techniques, such as traditional transtibial drilling, fail to recreate the native anatomy of the ACL, which can lead to increased rotatory knee instability, revision risk, and post-traumatic osteoarthritis. Anatomic ACL reconstruction has emerged as the gold standard, with the goal of restoring the patient's native anatomy and knee kinematics. This review will summarise the relevant anatomy, modern anatomic ACL reconstruction techniques, and literature supporting anatomic ACL reconstruction as the new paradigm. LEVEL OF EVIDENCE: Level V, review article.
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Affiliation(s)
- Michael A Fox
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
| | - Ian D Engler
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Balint T Zsidai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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14
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Feng H, Wang N, Xie D, Yang Z, Zeng C, Lei G, Li H, Wang Y. Anteromedial Portal Technique, but Not Outside-in Technique, Is Superior to Standard Transtibial Technique in Knee Stability and Functional Recovery After Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis. Arthroscopy 2022; 39:1515-1525. [PMID: 36577618 DOI: 10.1016/j.arthro.2022.11.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE To compare the postoperative outcomes of 4 different femoral drilling techniques in anterior cruciate ligament reconstruction. METHODS Three databases were searched for randomized controlled trials comparing any 2 or more of the following femoral drilling techniques in anterior cruciate ligament reconstruction: standard transtibial (sTT), anteromedial portal (AMP), outside-in (OI), or modified transtibial (mTT) technique. A Bayesian network meta-analysis was performed to assess postoperative stability and functional recovery in terms of the side-to-side difference (measured by arthrometry), Lachman test, pivot-shift test, International Knee Documentation Committee subjective and objective scores, Lysholm score, and Tegner score. The Fisher exact probability test and χ2 test were used to compare the incidences of infection and graft rupture, respectively. RESULTS We included 20 randomized controlled trials involving 1,515 patients. The AMP technique showed a lower side-to-side difference (standardized mean difference, -0.33; 95% credible interval [CrI], -0.53 to -0.12), higher negative rate on the pivot-shift test (odds ratio, 2.19; 95% CrI, 1.38 to 3.44), and higher International Knee Documentation Committee objective score (odds ratio, 3.13; 95% CrI, 1.42 to 7.82) than the sTT technique. However, knee stability and functional outcomes did not differ significantly between the OI and sTT techniques. Safety outcomes of the mTT technique were unavailable. The incidence of graft rupture was 5.20% for the OI technique, 2.27% for the AMP technique, and 1.51% for the sTT technique. The OI technique had a significantly higher incidence of graft rupture than the sTT technique (χ2 = 4.421, P = .035). No significant difference in the incidence of infection was found between the sTT, AMP, and OI techniques (P = .281). CONCLUSIONS The AMP technique, but not the OI technique, was superior to the sTT technique in knee stability and functional recovery. The OI technique had a higher incidence of graft rupture than the sTT technique. There was no significant difference between the AMP and OI techniques or between the mTT technique and any other femoral drilling technique. LEVEL OF EVIDENCE Level II, meta-analysis of Level I and II studies.
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Affiliation(s)
- Haoran Feng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Ning Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Dongxing Xie
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Zidan Yang
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center for Osteoarthritis, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center for Osteoarthritis, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Hui Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center for Osteoarthritis, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
| | - Yilun Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center for Osteoarthritis, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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15
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Shi Q, Wang H, He K, Tao M, Cheng CK. Comparison of the morphology of the anterior cruciate ligament and related bony structures between pigs and humans. Front Vet Sci 2022; 9:1045785. [PMID: 36467640 PMCID: PMC9716283 DOI: 10.3389/fvets.2022.1045785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/03/2022] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Pigs are widely used for clinical research on the anterior cruciate ligament (ACL) because of the similarity of the knee structure to the human knee. But evidence to support the suitability of using porcine samples to guide clinical practices is limited. This study aims to explore the qualitative and quantitative morphological features of the porcine knee and ACL, and to compare these with data on humans reported in literature. METHODS Nineteen porcine knees were used for this study. The bone structures were measured on coronal X-ray images. The length of the ACL was measured using a caliper. The ACL bone insertion sites were marked and measured on a digital photograph. The lengths of the long and short axis of the ACL isthmus were measured on the X-ray microscopy reconstructed images. The outcomes were compared with previously reported data on humans using an abstract independent-samples T test. RESULTS Qualitative observation indicated a similar location, orientation and general morphology of the porcine ACL to human ACLs. The major difference was the location of the ACL tibial insertion with respect to the anterior horn of the lateral meniscus (AHLM). The porcine ACL was split into AM and PL bundles by the AHLM, while the AHLM was adjacent to the anterolateral border of the ACL tibial insertion in human knees. The quantitative comparison showed no significant difference between the human and porcine ACL in terms of the length of the ACL, the width of the femoral condyle and tibial plateau, and the tibial interspinal width. However, the CSA, the lengths of the long and short axis of the ACL isthmus, and the femoral and tibial insertion areas of the porcine ACL were all significantly larger than the reported features in human knees. CONCLUSION The location, orientation and basic morphology of the porcine ACL and knee are similar to humans. However, the two-bundle structure is more distinct in a porcine ACL, and the dimensions of the porcine ACL are generally larger. This study may provide useful information to researchers when assessing the feasibility and limitations of using porcine samples for research on the human ACL and knee.
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16
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Kinoshita T, Hashimoto Y, Iida K, Nakamura H. ACL Graft Matching: Cadaveric Comparison of Microscopic Anatomy of Quadriceps and Patellar Tendon Grafts and the Femoral ACL Insertion Site. Am J Sports Med 2022; 50:2953-2960. [PMID: 35914183 DOI: 10.1177/03635465221110895] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal graft choice between the bone-patellar tendon-bone (BPTB) and the quadriceps tendon remains controversial. Studies evaluating the microscopic anatomy of the quadriceps tendon-patellar bone (QTB) and BPTB grafts for anterior cruciate ligament (ACL) reconstruction are currently lacking. HYPOTHESIS The relationship between post-ACL reconstruction graft bending angle (GBA) and the angle corresponding to the GBA (cGBA) would indicate that the BPTB can bend more than the QTB at the femoral tunnel aperture. STUDY DESIGN Controlled laboratory study. METHODS Twenty paired human cadaveric knees fixed at <10° of knee joint flexion (mean age, 82.5 years) underwent histological sectioning and staining with Masson trichrome and toluidine blue. The femoral ACL insertion, QTB graft, and BPTB graft were microscopically analyzed. The width of the direct insertion, thickness of the uncalcified fibrocartilage and calcified fibrocartilage, ligament attachment angle, and cGBA for each group were measured. Eighteen patients who underwent ACL reconstruction with QTB or BPTB autograft were included for the evaluation of GBA using computed tomography images at 1 week postoperatively. RESULTS The mean insertion widths of the femoral ACL, QTB, and BPTB were 7.81, 9.07, and 6.54 mm, respectively. The QTB was 16% wider than the ACL, while the BPTB was 16% narrower than the ACL. The mean insertion thicknesses of the femoral ACL, QTB, and BPTB were 0.53, 0.94, and 0.38 mm, respectively. The QTB was 77% thicker than the ACL (P < .001), while the BPTB was 28% thinner than the ACL (P = .017). The mean ligament attachment angles of the femoral ACL, QTB, and BPTB were 20.3°, 30.2°, and 33.3°, respectively, and the QTB and the BPTB were 49% and 64% larger, respectively, than the ACL. The mean cGBAs of the femoral ACL, QTB, and BPTB were 33.9°, 35.1°, and 12.3°, respectively. The BPTB was 64% smaller than the ACL, while there was no significant difference between the QTB and the ACL. The mean GBA was 57.7°. CONCLUSION The insertion width and thickness were significantly greater and smaller in the QTB and BPTB grafts, respectively, than in the ACL. The relationship between GBA after ACL reconstruction and cGBA in knee extension indicates that at the femoral tunnel aperture, the BPTB can bend more than the QTB. CLINICAL RELEVANCE QTB graft may allow more anatomic ACL reconstruction to be performed.
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Affiliation(s)
- Takuya Kinoshita
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ken Iida
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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17
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Iriuchishima T, Goto B. Tibial Spine Location Influences Tibial Tunnel Placement in Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction. J Knee Surg 2022; 35:294-298. [PMID: 32643780 DOI: 10.1055/s-0040-1713736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to assess the influence of tibial spine location on tibial tunnel placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT). A total of 39 patients undergoing anatomical single-bundle ACL reconstruction were included in this study (30 females and 9 males; average age: 29 ± 15.2 years). In anatomical single-bundle ACL reconstruction, the tibial and femoral tunnels were created close to the anteromedial bundle insertion site using a transportal technique. Using postoperative 3D-CT, accurate axial views of the tibia plateau were evaluated. By assuming the medial and anterior borders of the tibia plateau as 0% and the lateral and posterior borders as 100%, the location of the medial and lateral tibial spine, and the center of the tibial tunnel were calculated. Statistical analysis was performed to assess the correlation between tibial spine location and tibial tunnel placement. The medial tibial spine was located at 54.7 ± 4.5% from the anterior border and 41.3 ± 3% from the medial border. The lateral tibial spine was located at 58.7 ± 5.1% from the anterior border and 55.3 ± 2.8% from the medial border. The ACL tibial tunnel was located at 34.8 ± 7.7% from the anterior border and 48.2 ± 3.4% from the medial border. Mediolateral tunnel placement was significantly correlated with medial and lateral tibial spine location. However, for anteroposterior tunnel placement, no significant correlation was found. A significant correlation was observed between mediolateral ACL tibial tunnel placement and medial and lateral tibial spine location. For clinical relevance, tibial ACL tunnel placement might be unintentionally influenced by tibial spine location. Confirmation of the ACL footprint is required to create accurate anatomical tunnels during surgery. This is a Level III; case-control study.
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Affiliation(s)
| | - Bunsei Goto
- Department of Orthopedic Surgery, Kamimoku Spa Hospital, Gunma, Japan
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18
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Yoon KH, Kim YS, Park JY, Kim SG, Lee JH, Choi SH, Kim SJ. Ideal Combination of Anatomic Tibial and Femoral Tunnel Positions for Single-Bundle ACL Reconstruction. Orthop J Sports Med 2022; 10:23259671211069960. [PMID: 35071661 PMCID: PMC8777344 DOI: 10.1177/23259671211069960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/07/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Anatomic anterior cruciate ligament reconstruction (ACLR) is preferred over
nonanatomic ACLR. However, there is no consensus on which point the tunnels
should be positioned among the broad anatomic footprints. Purpose/Hypothesis: To identify the ideal combination of tibial and femoral tunnel positions
according to the femoral and tibial footprints of the anteromedial (AM) and
posterolateral (PL) anterior cruciate ligament bundles. It was hypothesized
that patients with anteromedially positioned tunnels would have better
clinical scores, knee joint stability, and graft signal intensity on
follow-up magnetic resonance imaging (MRI) than those with posterolaterally
positioned tunnels. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 119 patients who underwent isolated single-bundle ACLR with a
hamstring autograft from July 2013 to September 2018 were retrospectively
investigated. Included were patients with clinical scores and knee joint
stability test results at 2-year follow-up and postoperative 3-dimensional
computed tomography and 1-year postoperative MRI findings. The cohort was
divided into 4 groups, named according to the bundle positions in the tibial
and femoral tunnels: AM-AM (n = 33), AM-PL (n = 26), PL-AM (n = 29), and
PL-PL (n = 31). Results: There were no statistically significant differences among the 4 groups in
preoperative demographic data or postoperative clinical scores (Lysholm,
Tegner, and International Knee Documentation Committee subjective scores);
knee joint stability (anterior drawer, Lachman, and pivot-shift tests and
Telos stress radiographic measurement of the side-to-side difference in
anterior tibial translation); graft signal intensity on follow-up MRI; or
graft failure. Conclusion: No significant differences in clinical scores, knee joint stability, or graft
signal intensity on follow-up MRI were identified between the patients with
anteromedially and posterolaterally positioned tunnels.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Yoon-Seok Kim
- Department of Orthopaedic Surgery, Armed Forces Hongcheon Hospital, Hongcheon, Republic of Korea
| | - Jae-Young Park
- Department of Orthopaedic Surgery, Uijeongbu Eulji Medical Center, School of Medicine, Eulji University, Uijeongbu-si, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopaedic Surgery, National Medical Center, Seoul, Republic of Korea
| | - Jong-Hwan Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sun Hwan Choi
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sang Jin Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
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19
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Musahl V, Nazzal EM, Lucidi GA, Serrano R, Hughes JD, Margheritini F, Zaffagnini S, Fu FH, Karlsson J. Current trends in the anterior cruciate ligament part 1: biology and biomechanics. Knee Surg Sports Traumatol Arthrosc 2022; 30:20-33. [PMID: 34927221 DOI: 10.1007/s00167-021-06826-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022]
Abstract
A trend within the orthopedic community is rejection of the belief that "one size fits all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.Level of evidenceV.
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Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.
| | - Gian Andrea Lucidi
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.,IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rafael Serrano
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jon Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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20
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Iriuchishima T, Goto B, Fu FH. The radiographic tibial spine area is correlated with the occurrence of ACL injury. Knee Surg Sports Traumatol Arthrosc 2022; 30:78-83. [PMID: 33688977 DOI: 10.1007/s00167-021-06523-w] [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: 01/07/2021] [Accepted: 02/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to reveal the possible influence of the tibial spine area on the occurrence of ACL injury. METHODS Thirty-nine subjects undergoing anatomical ACL reconstruction (30 female, 9 male: average age 29 ± 15.2) and 37 subjects with intact ACL (21 female, 16 male: average age 29 ± 12.5) were included in this study. In the anterior-posterior (A-P) and lateral knee radiograph, the tibial spine area was measured using a PACS system. In axial knee MRI exhibiting the longest femoral epicondylar length, the intercondylar notch area was measured. Tibial spine area, tibial spine area/body height, and tibial spine area/notch area were compared between the ACL tear and intact groups. RESULTS The A-P tibial spine area of the ACL tear and intact groups was 178 ± 34 and 220.7 ± 58mm2, respectively. The lateral tibial spine area of the ACL tear and intact groups was 145.7 ± 36.9 and 178.9 ± 41.7mm2, respectively. The tibial spine area was significantly larger in the ACL intact group when compared with the ACL tear group (A-P: p = 0.02, lateral: p = 0.03). This trend was unchanged even when the tibial spine area was normalized by body height (A-P: p = 0.01, lateral: p = 0.02). The tibial spine area/notch area of the ACL tear and intact groups showed no significant difference. CONCLUSION The A-P and lateral tibial spine area was significantly smaller in the ACL tear group when compared with the ACL intact group. Although the sample size was limited, a small tibial spine might be a cause of knee instability, which may result in ACL injury. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Bunsei Goto
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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21
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Mishra S, Mylarappa A, Satapathy D, Samal S. Morphometric Analysis of Anatomy of Anterior Cruciate Ligament of Knee and its Attachments - a Cadaveric Study in Indian Population. Malays Orthop J 2021; 15:8-14. [PMID: 34966489 PMCID: PMC8667243 DOI: 10.5704/moj.2111.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction: The Anterior Cruciate Ligament tends to stabilise the knee in various range of extension and flexion. Precise study of anatomy, attachments and position of bundles is important for successful ACL reconstruction. In our study, we attempt to assess general anatomy of ACL, determine and compare its morphometric data pertaining to length and width and its tibio-femoral foot prints in different gender and secondarily determine changes in the same during ACL dynamics witnessed during knee flexion changes. Materials and methods: A total of 19 knees from 10 cadavers were used in the research with mean age of 61±7 years. After dissecting the skin, muscles, patellar and articular capsule were removed and bundle attachments were studied. Thereafter the relative length, width and stiffness of ACL bundles at 0, 90, 140 (maximum) angles of knee flexion were measured along with maximum horizontal and vertical bundle footprints at tibio-femoral attachments were recorded. Results: Mean length and width of insertion of anteromedial (AM) bundle on the tibial surface was 8.8mm and 9.0mm in males and 8.1mm and 8.8mm in females. Furthermore, that of PL bundle was 9.1mm and 7.8mm in males and 8.9mm and 7.1mm in females. Conclusion: The anteromedial (AM) bundle and posterolateral (PL) bundle of ACL were found to be most relaxed at full extension and were most taut at maximum flexion of 140°. AM bundle underwent greater stretching and change of length in comparison to the PL bundle, indicating that it is comparatively a more dominant bundle.
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Affiliation(s)
- S Mishra
- Department of Orthopaedics, Siksha O Anusandhan University Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - A Mylarappa
- Department of Orthopaedics, Siksha O Anusandhan University Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - D Satapathy
- Department of Orthopaedics, Siksha O Anusandhan University Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - S Samal
- Department of Orthopaedics, Siksha O Anusandhan University Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
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Iriuchishima T, Goto B. Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction. J Knee Surg 2021; 34:1531-1538. [PMID: 32480416 DOI: 10.1055/s-0040-1710521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms "anterior cruciate ligament reconstruction," "anatomic or anatomical," and "single bundle." Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow-deep direction (32.3%) and in a high-low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.
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Affiliation(s)
| | - Bunsei Goto
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
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Mediavilla I, Aramberri M, Tiso G, Margalet E, MargAbat F. "Y" Graft Double Bundle Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2021; 10:e2135-e2141. [PMID: 34504753 PMCID: PMC8417341 DOI: 10.1016/j.eats.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/18/2021] [Indexed: 02/03/2023] Open
Abstract
UNLABELLED Single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been a standard procedure. However, residual rotary instability in approximately 20% of the cases (irrespective of the graft choice and the surgical technique) forces the surgeon to improve the biomechanical quality of the reconstruction. In parallel, adjustable suspensory fixation (ASF) devices have arisen. Biomechanics has defined (both anatomical and functional) the anteromedial (AM) and posterolateral (PL) bundles that work synergistically. In the unsymmetrical "anatomic" SB ACL reconstruction, the distribution of the ACL graft fibers (for AM or PL behavior) is not under the control of the surgeon. Furthermore, different sizes of the original footprints (depending on height) suggest the need to customize the graft footprint. This customization is only possible if distances are measured during surgical procedures. We present an inside-out technique for DB ACL reconstruction ("all-inside" also possible). Semitendinosus is folded to obtain a Y-shaped trifurcate configuration graft, distributing their bundles in two different areas. Used as measuring instruments, we used the "offset" guides as measuring instruments, allowing the surgeon to know the distance between the centers of the AM and PL tunnels. It may be carried out by means of common "offset" guides and any marketed ASF devices, while generating customized footprints. CLASSIFICATION I: knee; II: ACL.
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Affiliation(s)
- Iñaki Mediavilla
- University Hospital of Basurto, Bilbao, Spain,Address correspondence to Iñaki Mediavilla, M.D., Ph.D., University Hospital of Basurto, Montevideo Avenue, 18 48013 Bilbao, Spain.
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Hirtler L, Kainberger F, Röhrich S. The intercondylar fossa-A narrative review. Clin Anat 2021; 35:2-14. [PMID: 34374453 PMCID: PMC9291140 DOI: 10.1002/ca.23773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/22/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022]
Abstract
The intercondylar fossa (“intercondylar notch,” IN) is a groove at the distal end of the femur, housing important stabilizing structures: cruciate ligaments and meniscofemoral ligaments. As the risk for injury to these structures correlates with changes to the IN, exact knowledge of its morphology, possible physiological and pathological changes and different approaches for evaluating it are important. The divergent ways of assessing the IN and the corresponding measurement methods have led to various descriptions of its possible shapes. Ridges at the medial and lateral wall are considered clinically important because they can help with orientation during arthroscopy, whereas ridges at the osteochondral border could affect the risk of ligament injury. Changes related to aging and sex differences have been documented, further emphasizing the importance of individual assessment of the knee joint. Overall, it is of the utmost importance to remember the interactions between the osseous housing and the structures within.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Franz Kainberger
- Department of Radiology and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sebastian Röhrich
- Department of Radiology and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
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Editorial Commentary: Outcomes After Anterior Cruciate Ligament Reconstruction Are Defined by Individual Anatomy, Including Both Soft Tissue and Bone Morphology: It's All Important. Arthroscopy 2021; 37:2542-2544. [PMID: 34353559 DOI: 10.1016/j.arthro.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/10/2021] [Indexed: 02/02/2023]
Abstract
Well-designed studies add to our understanding of the anatomy, biology, biomechanics, and outcomes of the anterior cruciate ligament (ACL) following injury. Despite improvements in ACL treatment, we are still unable to exactly restore the individually unique function of the native ACL due to the complexity of knee physiology. The ACL is a dynamic structure with a rich neurovascular supply, distinct bundles, and 3-dimensional architecture that function in synergy with the bony morphology to facilitate healthy knee kinematics. Furthermore, the ACL exhibits a wide range of natural, anatomic variation. Since anatomic ACL reconstruction has been defined as functional restoration of the ACL to its native dimensions and collagen orientation, in addition to restoring the native footprint, it is important to restore the native size of the ACL, as the size of the tibial insertion site can vary by a factor of 3 from patient to patient. Moreover, variations in ACL soft tissue reflect differences in bony morphology. Bony morphology influences the static and dynamic biomechanics of the knee. Several bony morphologic factors influence the outcomes following ACL reconstruction, including posterior tibial slope, femoral condylar offset ratio, and notch shape. Morphologic differences that reflect pathologic states, such as the lateral notch sign and posterolateral plateau fracture, have been shown to be associated with greater grade instability. To respect the unique nature of each patient during surgical treatment, it is necessary to perform an individualized, anatomic, and value-based ACL reconstruction.
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Iriuchishima T, Goto B, Fu FH. Truncated-pyramid shape simulation for the measurement of femoral intercondylar notch volume can detect the volume difference between ACL-injured and intact subjects. Knee Surg Sports Traumatol Arthrosc 2021; 29:1709-1713. [PMID: 32761277 DOI: 10.1007/s00167-020-06204-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/31/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to measure the femoral intercondylar notch volume using a truncated-pyramid shape simulation and compare this volume between anterior cruciate ligament (ACL) injured and intact subjects. METHODS Forty-seven subjects diagnosed with ACL tear by MRI (22 male and 25 female: median age 26: range 15-49), and 41 subjects in which knee MRI was performed and no ACL injury detected (20 males and 21 females: median age 27: range 16-49), were included in this study. Using three-dimensional computed tomography (3D-CT), the axial femoral intercondylar notch area was measured in the slice containing the most proximal (S1) and most distal (S2) level of Blumensaat's line. Femoral condyle height (h) was measured using a sagittal view of knees in 3D-CT. The truncated-pyramid shape simulation was calculated as: Volume = [Formula: see text]. Statistical analysis was performed to compare S1, S2, notch height, and notch volume between the ACL-injured and intact groups. RESULTS The measured S1, S2, and the notch height of the ACL-injured and intact groups were 201 ± 64 and 214 ± 50mm2, 370 ± 91 and 461 ± 94mm2, and 31 ± 3 and 30 ± 4mm, respectively. The calculated femoral intercondylar notch volume of the ACL-injured and intact groups was 8.6 ± 2.2 and 9.9 ± 2.6cm3, respectively. The ACL intact group showed significantly larger S2 and notch volume when compared with the ACL-injured group. CONCLUSION For clinical relevance, notch volume and most distal axial notch area parameters were significantly larger in ACL intact subjects. The truncated-pyramid shape simulation is an easy and cost-effective method to evaluate intercondylar notch volume. In knees with small femoral intercondylar notch volume, attention is needed to prevent ACL injury. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Takanori Iriuchishima
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Kamimoku, Minakami, Japan.
| | - Bunsei Goto
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Kamimoku, Minakami, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Zhang J, Ma Y, Pang C, Wang H, Jiang Y, Ao Y. No differences in clinical outcomes and graft healing between anteromedial and central femoral tunnel placement after single bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:1734-1741. [PMID: 32772135 DOI: 10.1007/s00167-020-06206-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical outcomes and graft healing after anterior cruciate ligament (ACL) reconstruction with anteromedial and central femoral tunnel placement. METHODS During 2016 and 2018, 110 consecutive patients underwent single bundle ACL reconstruction; 85 patients met the inclusion criteria, and each patient underwent 3D-CT within 1 week and MRI 1.5 years after the operation. The central point of the femoral tunnel and signal/noise quotient (SNQ) of three regions of interest (ROI) in the intra-articular graft were measured to analyse the tunnel position and graft healing extent. Clinical assessments, including functional scores, KT-2000 arthrometer measurements and pivot-shift tests, were evaluated at the 2-year follow-up. Patients were divided into two groups depending on the femoral tunnel position: the anteromedial position group (Group A) and the centre position group (Group B). RESULTS Seventy-one patients were available for the 2-year follow-up and MRI examination: 34 patients in Group A and 35 patients in Group B, and 2 patients were excluded for an eccentric tunnel position. No graft failure occurred, and compared with the preoperative assessment outcomes, the outcomes of both groups improved at the final follow-up. Group A was significantly better than Group B regarding the KT-2000 arthrometer measurements (P = 0.031). No significant differences were observed in terms of functional scores, pivot-shift test results, or the SNQ between groups. CONCLUSIONS No differences in clinical outcomes or graft healing were found between AM and central femoral tunnel placements in single bundle ACL reconstruction. Therefore, satisfactory clinical outcomes, knee stability and graft healing can be obtained for both femoral tunnel placements. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jiahao Zhang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yong Ma
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Chaonan Pang
- Department of Radiology, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Haijun Wang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yanfang Jiang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yingfang Ao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
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Zee MJM, Sulaihem RA, Diercks RL, van den Akker-Scheek I. Intra-and interobserver reliability of determining the femoral footprint of the torn anterior cruciate ligament on MRI scans. BMC Musculoskelet Disord 2021; 22:493. [PMID: 34049511 PMCID: PMC8164263 DOI: 10.1186/s12891-021-04376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Re-injury rates following reconstruction of the anterior cruciate ligament (ACL) are significant; in more than 20% of patients a rupture of the graft occurs. One of the main reasons for graft failure is malposition of the femoral tunnel. The femoral origin of the torn ACL can be hard to visualize during arthroscopy, plus many individual variation in femoral origin anatomy exists, which may lead to this malpositioning. To develop a patient specific guide that may resolve this problem, a preoperative MRI is needed to identify the patient specific femoral origin of the ACL. The issue here is that there may be a difference in the reliability of identification of the femoral footprint of the ACL on MRI between different observers with different backgrounds and level of experience. The purpose of this study was to determine the intra- and interobserver reliability of identifying the femoral footprint of the torn ACL on MRI and to compare this between orthopedic surgeons, residents in orthopedic surgery and MSK radiologists. METHODS MR images of the knee joint were collected retrospectively from 20 subjects with a confirmed rupture of the ACL. The 2D (coronal, sagittal, transversal) proton-density (PD) images were selected for the segmentation procedure to create 3D models of the femurs. The center of the femoral footprint of the ACL on 20 MRI scans, with visual feedback on 3D models (as reference) was determined twice by eight observers. The intra- and interobserver reliability of determining the center of the femoral footprint on MRI was evaluated. Intraclass correlation coefficients (ICCs) were calculated for the X, Y and Z coordinates separately and for a 3D coordinate. RESULTS The mean 3D distance between the first and second assessment (intraobserver reliability) was 3.82 mm. The mean 3D distance between observers (interobserver reliability) was 8.67 mm. ICCs were excellent (> 0.95), except for those between the assessments of the two MSK radiologists of the Y and Z coordinates (0.890 and 0.800 respectively). Orthopedic surgeons outscored the residents and radiologists in terms of intra- and interobserver agreement. CONCLUSION Excellent intraobserver reliability was demonstrated (< 4 mm). However the results of the interobserver reliability manifested remarkably less agreement between observers (> 8 mm). An orthopedic background seems to increase both intra- and interobserver reliability. Preoperative planning of the femoral tunnel position in ACL reconstruction remains a surgical decision. Experienced orthopedic surgeons should be consulted when planning for patient specific instrumentation in ACL reconstruction.
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Affiliation(s)
- M J M Zee
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700RB, Groningen, The Netherlands.
| | - R A Sulaihem
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700RB, Groningen, The Netherlands
| | - R L Diercks
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700RB, Groningen, The Netherlands
| | - I van den Akker-Scheek
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700RB, Groningen, The Netherlands
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Büyükdoğan K, Laidlaw MS, Fox MA, Kew ME, Miller MD. Effect of Tibial Tunnel Placement Using the Lateral Meniscus as a Landmark on Clinical Outcomes of Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2021; 49:1451-1459. [PMID: 33830836 DOI: 10.1177/0363546521999672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It remains unclear if use of the lateral meniscus anterior horn (LMAH) as a landmark will produce consistent tunnel positions in the anteroposterior (AP) distance across the tibial plateau. PURPOSE To evaluate the AP location of anterior cruciate ligament (ACL) reconstruction tibial tunnels utilizing the LMAH as an intra-articular landmark and to examine how tunnel placement affects knee stability and clinical outcomes. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective review was conducted of 98 patients who underwent primary ACL reconstruction with quadrupled hamstring tendon autografts between March 2013 and June 2017. Patients with unilateral ACL injuries and a minimum follow-up of 2 years were included in the study. All guide pins for the tibial tunnel were placed using the posterior border of the LMAH as an intra-articular landmark. Guide pins were evaluated with the Bernard-Hertel grid in the femur and the Stäubli-Rauschning method in the tibia. Patients were divided by the radiographic location of the articular entry point of the guide pin with relation to the anterior 40% of the tibial plateau. Outcomes were evaluated by the Marx Activity Scale and International Knee Documentation Committee (IKDC) form. Anterior knee laxity was evaluated using a KT-1000 arthrometer and graded with the objective portion of the IKDC form. Rotational stability was evaluated using the pivot-shift test. RESULTS A total of 60 patients were available for follow-up at a mean 28.6 months. The overall percentage of AP placement of the tibial tunnel was 39.3% ± 3.8% (mean ± SD; range, 31%-47%). Side-to-side difference of anterior knee laxity was significantly lower in the anterior group than the posterior group (1.2 ± 1.1 mm vs 2.5 ± 1.3 mm; P < .001; r = 0.51). The percentage of AP placement of the tibial tunnel demonstrated a positive medium correlation with side-to-side difference of anterior knee laxity as measured by a KT-1000 arthrometer (r = 0.430; P < .001). The anterior group reported significantly better distribution of IKDC grading as compared with the posterior group (26 grade A and 6 grade B vs 15 grade A and 13 grade B; P = .043; V = 0.297). The pivot-shift test results and outcome scores showed no significant differences between the groups. CONCLUSION Using the posterior border of the LMAH as an intraoperative landmark yields a wide range of tibial tunnel locations along the tibial plateau, with anterior placement of the tibial tunnel leading toward improved anterior knee stability.
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Affiliation(s)
- Kadir Büyükdoğan
- Department of Orthopedic Surgery, Koc University Hospital, Zeytinburnu/Istanbul, Turkey
| | - Michael S Laidlaw
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael A Fox
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Montreuil J, Saleh J, Cresson T, De Guise JA, Lavoie F. Tibial Tunnel Placement in ACL Reconstruction Using a Novel Grid and Biplanar Stereoradiographic Imaging. Orthop J Sports Med 2021; 9:2325967121989369. [PMID: 34250158 PMCID: PMC8239338 DOI: 10.1177/2325967121989369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Nonanatomic graft placement is a frequent cause of anterior cruciate ligament
reconstruction (ACLR) failure, and it can be attributed to either tibial or
femoral tunnel malposition. To describe tibial tunnel placement in ACLR, we
used EOS, a low-dose biplanar stereoradiographic imaging modality, to create
a comprehensive grid that combines anteroposterior (AP) and mediolateral
(ML) coordinates. Purpose: To (1) validate the automated grid generated from EOS imaging and (2) compare
the results with optimal tibial tunnel placement. Study Design: Descriptive laboratory study. Methods: Using EOS, 3-dimensional models were created of the knees of 37 patients who
had undergone ACLR. From the most medial, lateral, anterior, and posterior
points on the tibial plateau of the EOS 3-dimensional model for each
patient, an automated and personalized grid was generated from 2 independent
observers’ series of reconstructions. To validate this grid, each observer
also manually measured the ML and AP distances, the medial proximal tibial
angle (MPTA), and the tibial slope for each patient. The ideal tibial tunnel
placement, as described in the literature, was compared with the actual
tibial tunnel grid coordinates of each patient. Results: The automated grid metrics for observer 1 gave a mean (95% CI) AP depth of
54.7 mm (53.4-55.9), ML width of 75.0 mm (73.3-76.6), MPTA of 84.9°
(83.7-86.0), and slope of 7.2° (5.4-9.0). The differences with corresponding
manual measurements were means (95% CIs) of 2.4 mm (1.4-3.4 mm), 0.5 mm
(–1.3 to 2.2 mm), 1.2° (–0.4° to 2.9°), and –0.4° (–2.1° to 1.2°),
respectively. The correlation between automated and manual measurements was
r = 0.78 for the AP depth, r = 0.68
for the ML width, r = 0.18 for the MPTA, and
r = 0.44 for the slope. The center of the actual tibial
aperture on the plateau was a mean of 5.5 mm (95% CI, 4.8-6.1 mm) away from
the referenced anatomic position, with a tendency toward more medial
placement. Conclusion: The automated grid created using biplanar stereoradiographic imaging provided
a novel, precise, and reproducible description of the tibial tunnel
placement in ACLR. Clinical Relevance: This technique can be used during preoperative planning, intraoperative
guidance, and postoperative evaluation of tibial tunnel placement in
ACLR.
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Affiliation(s)
- Julien Montreuil
- Laboratoire de recherche en Imagerie et Orthopédie de l'ETS, Montréal, Québec, Canada.,McGill Division of Orthopaedic Surgery, Montreal General Hospital, Montréal, Québec, Canada
| | - Joseph Saleh
- Faculté de Médecine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Thierry Cresson
- Laboratoire de recherche en Imagerie et Orthopédie de l'ETS, Montréal, Québec, Canada
| | - Jacques A De Guise
- Laboratoire de recherche en Imagerie et Orthopédie de l'ETS, Montréal, Québec, Canada
| | - Frédéric Lavoie
- Service de chirurgie orthopédique, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Gupta R, Singhal A, Kapoor A, Mehta R, Masih GD. Femoral tunnel length has no correlation with graft rupture: A retrospective cohort study. Knee 2021; 29:405-410. [PMID: 33714927 DOI: 10.1016/j.knee.2021.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 09/19/2020] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Literature is controversial on femoral tunnel length as a risk factor for graft injury if the graft length in the tunnel is kept constant at ≥15 mm. METHODS A total of 1079 sportspersons, meeting our inclusion criteria, were assessed for graft rupture. Patients with femoral tunnel length (FTL) ≤30 mm were labeled as Group 1, while those with FTL > 30 mm were labeled as Group 2. Both groups were compared for potential risk factors for graft injury keeping graft length in the tunnel at ≥15 mm and statistical analysis was performed to study whether the femoral tunnel length acted as an additional risk factor. RESULTS Of 1079 sportspersons, 37 suffered from graft rupture. Patients with FTL > 30 mm were included in Group 1(n = 22) and patients with FTL ≤ 30 mm (n = 15) were included in Group 2. Both groups were comparable for risk factors for ACL injury: age (P = 0.37), gender (P = 0.53), mode of re-injury (P = 0.38), graft diameter (P = 0.71), level of sports activity (P = not significant), duration from injury to index surgery (P = 0.74), duration from index surgery to re-injury (P = 0.52), timing of return to sports after index surgery (P = 0.30), duration of sporting activity before second injury (P = 0.31), Tegner's level (P = not siginificant), Notch width index (P = 0.12) posterior slope (P = 0.77) and height (P = 0.41). CONCLUSION Because the graft length in the tunnel was kept at optimum and the risk factors for ACL injury were comparable in both groups at a follow up period, we suggest that femoral tunnel length is not a risk factor for graft failure.
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Affiliation(s)
- Ravi Gupta
- Government Medical College Hospital, Chandigarh, India
| | - Akash Singhal
- Government Medical College Hospital, Chandigarh, India.
| | - Anil Kapoor
- Government Medical College Hospital, Chandigarh, India
| | - Rohil Mehta
- Government Medical College Hospital, Chandigarh, India
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The morphology of the tibial footprint of the anterior cruciate ligament changes with ageing from oval/elliptical to C-shaped. Knee Surg Sports Traumatol Arthrosc 2021; 29:922-930. [PMID: 32385559 DOI: 10.1007/s00167-020-06049-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/30/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To further the current understanding of the modifications of the morphology of the ACL tibial footprint in healthy knees during the ageing process. The hypothesis is that there are differences in the morphology of the ACL tibial footprint between the cadavers of the young and elderly due to a degenerative physiological process that occurs over time. METHODS The tibial footprint of the ACL was dissected in 64 knee specimens of known gender and age. They were divided into four groups by age and gender, setting 50 years of age as the cut-off point. Three observers analyzed the tibial footprint dissections and the shape was described and classified. RESULTS The knees from the cadavers of males older than 50 years of age presented a "C" morphology in 85% of the cases. In the group of males aged less than 50 years, an oval/elliptical morphology was found in 85.7% of the cases. In the group of women over 50 years-old, the "C" morphology was observed in 82.3% of the cases. In women under the age of 50, the oval/elliptical morphology was found in 84.6% of the cases. A significant difference was observed between the prevalence rates of the morphologies of the younger and older groups (p < 0.001 for both genders). However, no differences were observed between males and females of the same age group (n.s.). CONCLUSIONS The morphology of the tibial footprint of the ACL presents significant variations with ageing. It can go from an oval/elliptical shape to a "C" shaped morphology. The results of this work make for an advance in the individualization of ACL reconstruction based on the age and the specific morphology of the tibial footprint.
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Takeuchi S, Rothrauff BB, Taguchi M, Kanto R, Onishi K, Fu FH. In situ cross-sectional area of the quadriceps tendon using preoperative magnetic resonance imaging significantly correlates with the intraoperative diameter of the quadriceps tendon autograft. Knee Surg Sports Traumatol Arthrosc 2021; 29:742-749. [PMID: 32333056 DOI: 10.1007/s00167-020-05993-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/07/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Preoperative assessment to determine the sizes of potential autografts is necessary for individualized anterior cruciate ligament reconstruction (ACLR). However, no study has investigated the prediction of the intraoperative diameter of the quadriceps tendon (QT) autograft based upon preoperative imaging. This study investigated the correlation between the intraoperative diameter of a QT autograft and in situ thickness or cross-sectional area (CSA) measured using preoperative MRI. METHODS Thirty-one knees of 31 patients (mean age 20.9 ± 5.0 years) who underwent individualized anatomic ACLR using all soft tissue QT autograft were included retrospectively. At 15 mm proximal to the superior pole of the patella, the maximum QT thickness was assessed in the sagittal plane and the CSA was assessed at the central 10 mm of the QT in the axial plane. The angle between the axial plane and a line perpendicular to the QT longitudinal axis was used to calculate an adjusted CSA using a cosine function. Intraoperatively, each QT autograft was harvested with 10 mm width and the diameter was measured using a graft sizing device. RESULTS Intra- and inter-observer reliabilities of all measurements using preoperative MRI were excellent (intra-class correlation coefficient, 0.833-0.970). Significant correlations were observed between the thickness, CSA, or adjusted CSA, and the intraoperative diameter (R = 0.434, 0.607, and 0.540, respectively; P < 0.05). CONCLUSIONS The CSA correlated most strongly with the QT autograft diameter. For individualized anatomic ACLR, measuring in situ CSA can be useful for preoperative planning of appropriate graft choices prior to surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Satoshi Takeuchi
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Medical Building, Suite 1011, 3941 Fifth Avenue, Pittsburgh, PA, 15203, USA
| | - Benjamin B Rothrauff
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Medical Building, Suite 1011, 3941 Fifth Avenue, Pittsburgh, PA, 15203, USA
| | - Masashi Taguchi
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Medical Building, Suite 1011, 3941 Fifth Avenue, Pittsburgh, PA, 15203, USA
| | - Ryo Kanto
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Medical Building, Suite 1011, 3941 Fifth Avenue, Pittsburgh, PA, 15203, USA
| | - Kentaro Onishi
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Medical Building, Suite 1011, 3941 Fifth Avenue, Pittsburgh, PA, 15203, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Medical Building, Suite 1011, 3941 Fifth Avenue, Pittsburgh, PA, 15203, USA.
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Wu B, Liang D, Yang L, Li S, Qiu Z, Qin Q, Liang X, Liu H, Ouyang K, Xiong J, Wang D, Lu W, Zhong M, Li Y, Li H, Feng W, Chen K, Peng L, Zhu W. Interbundle Impingement Pressure in Individualized and Nonindividualized Double-Bundle Anterior Cruciate Ligament Reconstruction: A Cadaveric Study. Orthop J Sports Med 2021; 9:2325967120958487. [PMID: 33614806 PMCID: PMC7869155 DOI: 10.1177/2325967120958487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Graft impingement is one of the main concerns in double-bundle anterior
cruciate ligament reconstruction (DB-ACLR). Impingement between the
anteromedial (AM) and posterolateral (PL) bundles has been postulated to
cause graft deterioration or rerupture, but this has not been thoroughly
investigated, and the interbundle impingement pressure (IIP) has not been
well researched. Purpose: To determine the IIP between the AM and PL bundles in the native anterior
cruciate ligament (ACL) and in DB-ACLR with individualized and
nonindividualized double-tunnel placement. Study Design: Controlled laboratory study. Methods: A total of 30 fresh-frozen, nonpaired, human cadaveric knees were randomly
divided into 3 groups of 10 knees: native intact ACL (NI group), DB-ACLR
tunnel placement using the preserved remnant procedure (individualized
reconstruction) (PR group), and DB-ACLR tunnel placement using the bony
landmark procedure (nonindividualized reconstruction) (BL group). Pressure
sensors were inserted between the AM and PL bundles. The knee was moved
passively from full extension to full flexion, and the IIP between the 2 ACL
bundles was measured every 15°. Similarly, the impingement pressure was
measured between the ACL and intercondylar roof and between the ACL and
posterior cruciate ligament (PCL). Results: No significant differences were found in the maximum, mean, or minimum
ACL-roof and ACL-PCL impingement pressures among the 3 groups. The IIP
significantly increased when the knee joint was flexed >120° in all 3
groups (P < .001). Compared with the other 2 groups, the
BL group had significantly higher maximum and mean IIP throughout the range
of knee movement (P < .001) and from maximum extension
to 120° of flexion (P < .001). The BL group also had
significantly higher minimum IIP than the other 2 groups when knee flexion
was >120° (P < .001). No significant differences were
seen in maximum, minimum, or mean IIP between the NI and PR groups. Conclusion: The PR procedure (individualized DB-ACLR) was more consistent with the
interbundle biomechanical conditions of the native ACL, whereas the BL
procedure (nonindividualized DB-ACLR) had higher maximum and mean IIP. The
IIP was higher than the ACL–intercondylar roof or ACL-PCL pressures, and it
increased significantly when knee flexion was >120°. Clinical Relevance: These data suggest that surgeons can perform individualized DB-ACLR using
preserved remnants for tunnel placement as impingement-free DB-ACLR.
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Affiliation(s)
- Bing Wu
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Daqiang Liang
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Lei Yang
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Sheng Li
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Zhihe Qiu
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Qihuang Qin
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Xinzhi Liang
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Haifeng Liu
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Kan Ouyang
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Jianyi Xiong
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Daping Wang
- Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Wei Lu
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Mingjin Zhong
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China.,Investigation performed at the Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Ying Li
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China.,Investigation performed at the Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Hao Li
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China.,Investigation performed at the Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Wenzhe Feng
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China.,Investigation performed at the Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Kang Chen
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China.,Investigation performed at the Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Liangquan Peng
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China.,Investigation performed at the Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
| | - Weiming Zhu
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China.,Investigation performed at the Department of Sports Medicine, 1st Affiliated Hospital, Shenzhen University, Shenzhen, China
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Cremer P, Peltier A, Maubisson L, Neyret P, Lustig S, Servien E. Positioning of the Tibial Tunnel After Single-Bundle ACL Primary Reconstruction on 3D CT scans: A New Method. Arthrosc Sports Med Rehabil 2020; 2:e615-e622. [PMID: 33135002 PMCID: PMC7588642 DOI: 10.1016/j.asmr.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 07/16/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To assess intra-articular tunnel aperture positioning after primary anterior cruciate ligament (ACL) reconstruction with either the reference standard method or the intercondylar area method in a single center using 3-dimensional (3D) computed tomography (CT) scans and to evaluate the intra-articular position of the tibial tunnel relative to the ACL footprint. Methods 3D CT scans were performed after 120 single-bundle primary ACL reconstruction cases. The center of the tibial tunnel aperture and the center of the ACL footprint were referenced on axial views of the tibial plateau in the anteroposterior (AP) and mediolateral (ML) planes according to a centimetric grid system including the whole plateau (reference standard). This was compared with a grid system based on intercondylar area bony anatomy. The posterior aspect of intertubercular fossa, anterior aspect of the tibial plateau, medial intercondylar ridge, and crossing point between lateral intercondylar ridge and posterior margin were used as landmarks to define the grid. Results According to the reference standard method, the center of the tibial tunnel aperture was positioned 0.57 ± 2.62 mm more posterior and 0.67 ± 1.55 mm more medial than the center of the footprint. According to the intercondylar area method, the center of the tibial tunnel aperture was positioned 1.32 ± 2.74 mm more posterior and 0.66 ± 1.56 mm more medial than the center of the footprint. The position difference between the center of the tunnel aperture and the center of the footprint were statistically correlated for both grids, with r = –0.887, P < .001 for AP positioning and r = 0.615, P < .001 for ML positioning. Conclusion This intercondylar area method using arthroscopic landmarks can be used to assess tunnel placement on 3D CT scans after ACL reconstruction. Level of Evidence III, retrospective comparative study.
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Affiliation(s)
| | | | | | - Philippe Neyret
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
| | | | - Elvire Servien
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
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The occurrence of ACL injury influenced by the variance in width between the tibial spine and the femoral intercondylar notch. Knee Surg Sports Traumatol Arthrosc 2020; 28:3625-3630. [PMID: 32236676 DOI: 10.1007/s00167-020-05965-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/23/2020] [Indexed: 01/25/2023]
Abstract
PURPOSE The purpose of this study was to reveal the influence of the variance in width between the tibial spine and the femoral intercondylar notch on the occurrence of ACL injury. METHODS Thirty-nine subjects undergoing anatomical ACL reconstruction (30 female, 9 male; average age 29 ± 15.2) and 37 subjects with intact ACL (21 female, 16 male; average age 29 ± 12.5) were included in this study. In the anterior-posterior knee radiograph, tibial spine height, and the length between the top of the medial and lateral tibial spine (tibial spine width) were measured. In axial knee MRI exhibiting the longest femoral epicondylar length, intercondylar notch outlet length was measured and notch width index was calculated. Tibial spine width/notch outlet length, and tibial spine width/notch width index were compared between the ACL tear and intact groups. RESULTS Tibial spine width/notch outlet length of the ACL tear and intact groups was 0.6 ± 0.1 and 0.7 ± 0.1, respectively. Tibial spine width/notch width index of the ACL tear and intact groups was 0.4 ± 0.1, and 0.6 ± 0.1, respectively. Both parameters were significantly larger in the ACL intact group. CONCLUSION Both tibial spine width/notch outlet length and tibial spine width/notch width index were significantly smaller in the ACL tear group when compared with the ACL intact group. The occurrence of ACL injury influenced by the variance in width between the tibial spine and the femoral intercondylar notch. LEVEL OF EVIDENCE III.
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Morphology of the resident's ridge, and the cortical thickness in the lateral wall of the femoral intercondylar notch correlate with the morphological variations of the Blumensaat's line. Knee Surg Sports Traumatol Arthrosc 2020; 28:2668-2674. [PMID: 32157361 DOI: 10.1007/s00167-020-05932-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to reveal the morphological correlation between the lateral wall of femoral intercondylar notch and the Blumensaat's line. METHODS Forty-one non-paired human cadaveric knees were included in this study (23 female, 18 male: median age 83). Knees were resected, and 3 dimensional computed tomography (3D-CT) was performed. In the axial CT image, bony protrusion (resident's ridge) and cortical thickness in the lateral wall of the femoral intercondylar notch were detected. The length between the top of the ridge, or the most anterior, middle, and most posterior border of cortical thickness and posterior femoral condylar line was measured. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill types (small and large hill types). In the hill types, the length between the hilltop and the posterior border of the Blumensaat's line or the posterior border of the femoral condyle was evaluated. Statistical correlation was calculated between the top of the ridge location, cortical thickness location in the notch, and hilltop location. RESULTS There were 7 straight type knees and 34 hill type knees (9 small hill type knees and 25 large hill type knees). Only the hill types of knees were evaluated. The top of the ridge, anterior margin, middle, and posterior border of cortical thickness in the lateral wall of the femoral intercondylar notch existed at 61.8 ± 4.6%, 58.3 ± 12.3%, 42.1 ± 7.9%, and 25.5 ± 5.4% from the posterior condylar line, respectively. The hilltop existed at 24.9 ± 5.9% and 30.7 ± 5.0%, from the posterior border of the Blumensaat's line and from the posterior border of the femoral condyle, respectively. Significant correlation was observed between resident's ridge top, cortical thickness location and hilltop location. CONCLUSION In all cadaveric knees, cortical thickness was detected in the lateral wall of the femoral intercondylar notch. The resident's ridge and cortical thickness location had significant correlation with the hill location in the Blumensaat's line, indicating a continuation of the cortical bone from the posterior cortex of the femoral shaft via the hilltop of the Blumensaat's line to the cortical thickness in the lateral wall of the femoral intercondylar notch. For clinical relevance, hilltop location in the Blumensaat's line is a new bony landmark in anterior cruciate ligament surgery.
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Iriuchishima T, Suruga M, Yahagi Y, Iwama G, Aizawa S, Fu FH. The location of the femoral ACL footprint center is different depending on the Blumensaat's line morphology. Knee Surg Sports Traumatol Arthrosc 2020; 28:2453-2457. [PMID: 32514842 DOI: 10.1007/s00167-020-06087-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/02/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the difference in the center point of the femoral ACL footprint according to the morphological variations of the Blumensaat's line. METHODS Fifty-nine non-paired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. Digital images were evaluated using the Image J software. The periphery of the femoral ACL footprint was outlined and the center point was measured automatically. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill types (small and large hill types). The center of the femoral ACL footprint and hilltop placement were evaluated using the quadrant method. A quadrant grid was placed uniformly, irregardless of hill existence, and not including the articular cartilage. A correlation analysis was performed between the center point of the femoral ACL footprint and hilltop placement. RESULTS The straight type consisted of 19 knees, and the hill type 40 knees (small hill type 13 knees and large hill type 27 knees). The center of the femoral ACL footprint (shallow-deep/high-low) in the straight and hill type knees was 33.7/47.6%, and 37.2/50.3%, respectively. In the hill type, the ACL footprint center was significantly more shallow when compared to the straight type. Significant correlation was observed between the center point of the femoral ACL footprint and hilltop placement of the Blumensaat's line. CONCLUSION The center point of the femoral ACL footprint was significantly more shallow in the hill type knees when compared to the straight type. For clinical relevance, considering that the location of the femoral ACL footprint center is different depending on the Blumensaat's line morphology, to perform accurate ACL reconstruction, femoral ACL tunnel placement should be made based on Blumensaat's line morphological variations.
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Affiliation(s)
- Takanori Iriuchishima
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan. .,Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan.
| | - Makoto Suruga
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Yoshiyuki Yahagi
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Genki Iwama
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Shin Aizawa
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Laverdiere C, Harvey E, Schupbach J, Boily M, Burman M, Martineau PA. Effect of Teaching Session on Resident Ability to Identify Anatomic Landmarks and Anterior Cruciate Ligament Footprint: A Study Using 3-Dimensional Modeling. Orthop J Sports Med 2020; 8:2325967120905795. [PMID: 32201706 PMCID: PMC7068746 DOI: 10.1177/2325967120905795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 01/22/2023] Open
Abstract
Background: Femoral tunnel positioning in anterior cruciate ligament reconstruction
(ACLR) is an intricate procedure that requires highly specific surgical
skills. Purpose: To report the ability of residents to identify femoral landmarks and the
native ACL footprint before and after a structured formal teaching session
as a reflection of overall surgical skill training for orthopaedic surgery
residents in Canada. Study Design: Controlled laboratory study. Methods: A total of 13 senior orthopaedic residents were asked to identify a femoral
landmark and an ACL footprint on ten 3-dimensional (3D)–printed knee models
before and after a teaching session during the fall of 2018. The 3D models
were made based on actual patients with different anatomic morphologic
features. ImageJ software was used to quantify the measurements, which were
then analyzed through use of descriptive statistics. Results: Before and after the teaching session, residents attempted to identify a
specific anatomic location (bifurcate and intercondylar ridge intersection)
with a mean error per participant ranging from 5.00 to 10.95 mm and 4.79 to
12.13 mm in magnitude, respectively. Furthermore, before and after the
teaching session, residents identified the specific position to perform the
surgical procedure (ACL femoral footprint), with a mean error per
participant ranging from 4.58 to 8.80 mm and 3.87 to 11.07 mm in magnitude,
respectively. The teaching session resulted in no significant improvement in
identification of either the intersection of the bifurcate and intercondylar
ridges (P = .9343 in the proximal-distal axis and
P = .8133 in the anteroposterior axis) or the center of
the femoral footprint (P = .7761 in the proximal-distal
axis and P = .9742 in the anteroposterior axis). Conclusion: Although a formal teaching session was combined with a hands-on session that
entailed real surgical instrumentation and fresh cadaveric specimens, the
intervention seemed to have no direct impact on senior residents’
performance or their ability to demonstrate the material taught. This puts
into question the format and efficacy of present teaching methods. Also, it
is possible that the 3D spatial perception required to perform these skills
is not something that can be taught effectively through a teaching session
or at all. Further investigation is required regarding the effectiveness and
application of surgical skill laboratories and simulations on the
competencies of orthopaedic residents.
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Affiliation(s)
- Carl Laverdiere
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Eric Harvey
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Justin Schupbach
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Mathieu Boily
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Mark Burman
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
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Li F, Qin L, Gong X, Huang Z, Wang T, Liu Z, Sandiford S, Yang J, Zhu S, Liang X, Huang W, Hu N. The Chinese ACL injury population has a higher proportion of small ACL tibial insertion sizes than Western patients. Knee Surg Sports Traumatol Arthrosc 2020; 28:888-896. [PMID: 31111185 PMCID: PMC7035219 DOI: 10.1007/s00167-019-05541-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE The study purpose is to characterize the sizes of the anterior cruciate ligament (ACL) insertion site and intercondylar notch in Chinese patients undergoing ACL surgery. The findings will provide a reference for individualized clinical treatment of ACL rupture. METHODS For this study, 137 patients (102 males, 35 females) with an average age of 30.3 ± 9.5 years (range 14-52 years) undergoing ACL reconstruction were included. The tibial ACL insertion site length and width and the intercondylar notch width were measured on MRI and arthroscopically using a ruler. Descriptive statistics of the patients, the distribution of the measurements and the differences between males and females were calculated. RESULTS The ACL tibial insertion size and intercondylar notch width in Chinese patients with ACL injuries, as obtained by MRI and intra-operatively, exhibited significant individual variability. The tibial ACL insertion site had a mean length of 13.5 ± 2.1 mm and width of 10.9 ± 1.5 mm as measured on MRI and a mean length of 13.3 ± 2.1 mm and width of 11.0 ± 1.6 mm as measured intra-operatively. The mean intercondylar notch width was 15.2 ± 2.4 mm on MRI and the mean length was 15.0 ± 2.5 mm intra-operatively. The inter-rater reliability between MRI and intra-operative measurements confirmed that the two methods were consistent. In 65.7% of individuals, the ACL tibial insertion length was < 14 mm. CONCLUSION The distribution of tibial footprint size in Chinese patients is different from that in Western populations. There is a higher proportion of subjects with a tibial footprint size < 14 mm among Chinese patients with ACL injury. Therefore, great care should be taken when treating this population with the double-bundle technique or larger graft options. Level of evidence IV.
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Affiliation(s)
- Feilong Li
- Department of Orthopedics, The Dazu District People'S Hospital, Chongqing, 402360, China.,Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Leilei Qin
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xuan Gong
- Department of Outpatient, Chongqing General Hospital, Chongqing, 400013, China
| | - Zhenggu Huang
- Department of Orthopedics, The Dazu District People'S Hospital, Chongqing, 402360, China
| | - Ting Wang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ziming Liu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Steve Sandiford
- Department of Orthopedics, Queen Elizabeth Hospital, Bridgetown, Barbados
| | - Jianye Yang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Sizheng Zhu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xi Liang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ning Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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The Blumensaat's line morphology influences to the femoral tunnel position in anatomical ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:3638-3643. [PMID: 30915514 DOI: 10.1007/s00167-019-05492-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 03/18/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to reveal the influence of the morphological variations of the Blumensaat's line on femoral tunnel position in anatomical anterior cruciate ligament (ACL) reconstruction. METHODS Thirty-eight subjects undergoing anatomical single-bundle ACL reconstruction were included in this study (22 female, 16 male: median age 45: 15-63). Using a trans-portal technique, the femoral tunnel was targeted to reproduce the center of antero-medial bundle. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill types (small and large hill types). Femoral ACL tunnel position was evaluated using the quadrant method. When the quadrant method grid was applied, the baseline of the grid was matched to the anterior part of the Blumensaat's line, without considering the existence of a hill. Using pre-operative 3D-CT data, the axial and sagittal morphology of the knee was also compared, establlishing straight and hill types. RESULTS There were 12 straight type knees and 26 hill type knees (7 small hill type knees and 19 large hill type knees). The femoral tunnel position in straight type knees was 23.6 ± 3.7% in the shallow-deep direction, and 41.3 ± 8.2% in the high-low direction. In hill type knees, the tunnel position was 27 ± 4.7% in the shallow-deep direction, and 51 ± 10.1% in the high-low direction. The femoral tunnel was placed significantly more shallow and lower in hill type knees when compared with straight type knees. CONCLUSION Femoral ACL tunnel placement was significantly influenced by the morphological variations of the Blumensaat's line. As detecting morphological variation in arthroscopic surgery is difficult, surgeons should confirm such variations pre-operatively using radiograph or CT so as to avoid making extremely shallow and low tunnels in hill type knees. LEVEL OF EVIDENCE Case-controlled study, III.
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Nagai K, Gale T, Chiba D, Su F, Fu FH, Anderst W. The Complex Relationship Between In Vivo ACL Elongation and Knee Kinematics During Walking and Running. J Orthop Res 2019; 37:1920-1928. [PMID: 31042309 PMCID: PMC6719793 DOI: 10.1002/jor.24330] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/23/2019] [Indexed: 02/04/2023]
Abstract
In vivo anterior cruciate ligament (ACL) bundle (anteromedial bundle [AMB] and posterolateral bundle [PLB]) relative elongation during walking and running remain unknown. In this study, we aimed to investigate in vivo ACL relative elongation over the full gait cycle during walking and running. Ten healthy volunteers walked and ran at a self-selected pace on an instrumented treadmill while biplane radiographs of the knee were acquired at 100 Hz (walking) and 150 Hz (running). Tibiofemoral kinematics were determined using a validated model-based tracking process. The boundaries of ACL insertions were identified using high-resolution magnetic resonance imaging (MRI). The AMB and PLB centroid-to-centroid distances were calculated from the tracked bone motions, and these bundle lengths were normalized to their respective lengths on MRI to calculate relative elongation. Maximum AMB relative elongation during running (6.7 ± 2.1%) was significantly greater than walking (5.0 ± 1.7%, p = 0.043), whereas the maximum PLB relative elongation during running (1.1 ± 2.1%) was significantly smaller than walking (3.4 ± 2.3%, p = 0.014). During running, the maximum AMB relative elongation was significantly greater than the maximum PLB relative elongation (p < 0.001). ACL relative elongations were correlated with tibiofemoral six degree-of-freedom kinematics. The AMB and PLB demonstrate similar elongation patterns but different amounts of relative elongation during walking and running. The complex relationship observed between ACL relative elongation and knee kinematics indicates that ACL relative elongation is impacted by tibiofemoral kinematic parameters in addition to flexion/extension. These findings suggest that ACL strain is region-specific during walking and running. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1920-1928, 2019.
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Affiliation(s)
- Kanto Nagai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daisuke Chiba
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Favian Su
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H. Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kiapour AM, Ecklund K, Murray MM, Fleming BC, Freiberger C, Henderson R, Kramer D, Micheli L, Thurber L, Yen YM, Fleming BC. Changes in Cross-sectional Area and Signal Intensity of Healing Anterior Cruciate Ligaments and Grafts in the First 2 Years After Surgery. Am J Sports Med 2019; 47:1831-1843. [PMID: 31166701 PMCID: PMC6599545 DOI: 10.1177/0363546519850572] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The quality of a repaired anterior cruciate ligament (ACL) or reconstructed graft is typically quantified in clinical studies by evaluating knee, lower extremity, or patient performance. However, magnetic resonance imaging of the healing ACL or graft may provide a more direct measure of tissue quality (ie, signal intensity) and quantity (ie, cross-sectional area). HYPOTHESES (1) Average cross-sectional area or signal intensity of a healing ACL after bridge-enhanced ACL repair (BEAR) or a hamstring autograft (ACL reconstruction) will change postoperatively from 3 to 24 months. (2) The average cross-sectional area and signal intensity of the healing ligament or graft will correlate with anatomic features of the knee associated with ACL injury. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients with a complete midsubstance ACL tear who were treated with either BEAR (n = 10) or ACL reconstruction (n = 10) underwent magnetic resonance imaging at 3, 6, 12, and 24 months after surgery. Images were analyzed to determine the average cross-sectional area and signal intensity of the ACL or graft at each time point. ACL orientation, stump length, and bony anatomy were also assessed. RESULTS Mean cross-sectional area of the grafts was 48% to 98% larger than the contralateral intact ACLs at all time points (P < .01). The BEAR ACLs were 23% to 28% greater in cross-sectional area than the contralateral intact ACLs at 3 and 6 months (P < .02) but similar at 12 and 24 months. The BEAR ACLs were similar in sagittal orientation to the contralateral ACLs, while the grafts were 6.5° more vertical (P = .005). For the BEAR ACLs, a bigger notch correlated with a bigger cross-sectional area, while a shorter ACL femoral stump, steeper lateral tibial slope, and shallower medial tibial depth were associated with higher signal intensity (R2 > .40, P < .05). Performance of notchplasty resulted in an increased ACL cross-sectional area after the BEAR procedure (P = .007). No anatomic features were correlated with ACL graft size or signal intensity. CONCLUSION Hamstring autografts were larger in cross-sectional area and more vertically oriented than the native ACLs at 24 months after surgery. BEAR ACLs had a cross-sectional area, signal intensity, and sagittal orientation similar to the contralateral ACLs at 24 months. The early signal intensity and cross-sectional area of the repaired ACL may be affected by specific anatomic features, including lateral tibial slope and notch width-observations that deserve further study in a larger cohort of patients. REGISTRATION NCT02292004 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston MA 02115
| | - Kirsten Ecklund
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston MA 02115
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston MA 02115
| | | | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI 02818,School of Engineering, Brown University, Providence, RI 02818
| | - Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Laura Thurber
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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Iwama G, Iriuchishima T, Horaguchi T, Aizawa S. Measurement of the Whole and Midsubstance Femoral Insertion of the Anterior Cruciate Ligament: The Comparison with the Elliptically Calculated Femoral Anterior Cruciate Ligament Footprint Area. Indian J Orthop 2019; 53:727-731. [PMID: 31673173 PMCID: PMC6804389 DOI: 10.4103/ortho.ijortho_434_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to measure the detailed morphology of the femoral anterior cruciate ligament (ACL) footprint. The correlation and the comparison between the measured area and the area which mathematically calculated as elliptical were also evaluated. MATERIALS AND METHODS Thirty nine nonpaired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. The ACL was carefully dissected, and the periphery of the ACL insertion site was outlined on both the whole footprint and the midsubstance insertion. Lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area, length, and width of the femoral ACL footprint were measured with Image J software (National Institution of Health). Using the length and width of the femoral ACL footprint, the elliptical area was calculated as 0.25 π (length × width). Statistical analysis was performed to reveal the correlation and the comparison of the measured and elliptically calculated area. RESULTS The sizes of the whole and midsubstance femoral ACL footprints were 127.6 ± 41.7 mm2 and 61 ± 20.2 mm2, respectively. The sizes of the elliptically calculated whole and midsubstance femoral ACL footprints were 113.9 ± 4.5 mm2 and 58.4 ± 3 mm2, respectively. Significant difference was observed between the measured and the elliptically calculated area. In the midsubstance insertion, significant correlation was observed between the measured and the elliptically calculated area (Pearson's correlation coefficient = 0.603, P = 0.001). However, no correlation was observed in the whole ACL insertion area. CONCLUSION The morphology of the femoral ACL insertion resembles an elliptical shape. However, due to the wide variation in morphology, the femoral ACL insertion cannot be considered mathematically elliptical.
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Affiliation(s)
- Genki Iwama
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Takanori Iriuchishima
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan,Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Minakami, Japan
| | - Takashi Horaguchi
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan,Address for correspondence: Dr. Takanori Iriuchishima, Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Minakami, Japan. E-mail:
| | - Shin Aizawa
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
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Iriuchishima T, Goto B, Okano T, Ryu K, Fu FH. Femoral tunnel length in anatomical single-bundle ACL reconstruction is correlated with height, weight, and knee bony morphology. Knee Surg Sports Traumatol Arthrosc 2019; 27:93-99. [PMID: 29968189 DOI: 10.1007/s00167-018-5046-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to reveal the correlation between femoral tunnel length in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction and body size and/or knee morphology. METHODS Thirty-one subjects undergoing anatomical single-bundle ACL reconstruction were included in this study (20 female, 11 male; median age 46, 15-63). Pre-operative height, body weight, and body mass index (BMI) were measured. In pre-operative magnetic resonance imaging, the thickness of the quadriceps tendon and the whole anterior-posterior (AP) length of the knee were measured using the sagittal slice. Using post-operative three-dimensional computed tomography, accurate axial and lateral views of the femoral condyle were evaluated. The correlation of femoral tunnel length, which was measured intra-operatively, with the height, weight, BMI, quadriceps tendon thickness, AP length of the knee, trans-epicondylar length, the notch area (axial), length of Blumensaat's line, and the height and area of the lateral wall of the femoral intercondylar notch were statistically analyzed. Tunnel placement was also evaluated using a Quadrant method. RESULTS The average femoral tunnel length was 35.6 ± 4.4 mm. The average height, body weight, and BMI were 162.7 ± 7.2 cm, 61.9 ± 10 kg, and 23.4 ± 3.5, respectively. Femoral tunnel length was significantly correlated with height, body weight and the height and area of lateral wall of the femoral intercondylar notch, and the length of the Blumensaat's line. CONCLUSION For clinical relevance, the risk of creating a femoral tunnel of insufficient length in anatomical single-bundle ACL reconstruction exists in subjects with small body size. Surgeons should pay careful attention to prevent this from occurring. LEVEL OF EVIDENCE Case-controlled study, Level III.
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Affiliation(s)
- Takanori Iriuchishima
- Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Ishikura 198-2, Minakami, Japan.
| | - Bunsei Goto
- Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Ishikura 198-2, Minakami, Japan
| | - Tatsumasa Okano
- Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Ishikura 198-2, Minakami, Japan
| | - Keinosuke Ryu
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Iriuchishima T, Ryu K, Fu FH. Evaluation of age-related differences in anterior cruciate ligament size. Knee Surg Sports Traumatol Arthrosc 2019; 27:223-229. [PMID: 30539304 DOI: 10.1007/s00167-018-5336-1] [Citation(s) in RCA: 5] [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: 10/02/2018] [Accepted: 12/07/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE The purpose of this study was to reveal the relation between age and the morphological characteristics of the anterior cruciate ligament (ACL) using magnetic resonance imaging (MRI). METHODS Thirty-seven young subjects who were diagnosed with a meniscus injury without ACL tear using MRI (15 male and 22 female, median age 26, range 15-49), and 33 elderly subjects for whom knee MRI was performed before uni-compartmental knee arthroplasty (11 male and 22 female, median age 77, range 60-83), were included in this study. In the elderly group, healthy ACL gross morphology was confirmed macroscopically during surgery. In all knees, ACL was detected without any intensity alteration. In the MRI evaluation, using the axial slice revealing the greatest length between the medial and lateral epicondyle of the femur, axial ACL size was evaluated. Using the coronal plane image, the sagittal image was sliced parallel with the native ACL. In the sagittal image of the MRI, the largest area of the ACL was measured. Statistical analysis was performed to reveal the correlation between age and ACL size. Both axial and sagittal ACL areas were compared between the young and elderly groups. RESULTS Age and sagittal ACL area were significantly correlated (Pearson's coefficient correlation: - 0.353, P = 0.003). The sagittal ACL area was significantly larger in the young group when compared with the elderly group (P = 0.001). However, when the sagittal ACL area was normalized by the length of Blumensaat's line, no significant difference was observed. CONCLUSION For clinical relevance, sagittal ACL size was significantly larger in young subjects. The reason for this difference is likely the difference in knee size. When performing anatomical studies of the ACL using cadaveric knees of elderly specimens, there is the possibility that the ACL size will be underestimated. Considering that the ACL surgery is mainly performed for young subjects, cadavers of younger age should be used in such studies. LEVEL OF EVIDENCE Diagnostic study, Level III.
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Affiliation(s)
| | - Keinosuke Ryu
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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47
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Jorge PB, Escudeiro D, Severino NR, Santili C, de Paula Leite Cury R, Junior AD, Guglielmetti LGB. Positioning of the femoral tunnel in anterior cruciate ligament reconstruction: functional anatomical reconstruction. BMJ Open Sport Exerc Med 2018; 4:e000420. [PMID: 30305927 PMCID: PMC6173259 DOI: 10.1136/bmjsem-2018-000420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 01/14/2023] Open
Abstract
The aim of this study was to review and update the literature in regard to the anatomy of the femoral origin of the ACL, the concept of the double band and its respective mechanical functions, and the concept of direct and indirect fibres in the ACL insertion. These topics will be used to help determine which might be the best place to position the femoral tunnel and how this should be achieved, based on the idea of functional positioning, that is, where the most important ACL fibres in terms of knee stability are positioned. Low positioning of the femoral tunnel, reproducing more of the posterolateral band, and positioning the tunnel away from the lateral intercondylar ridge, that is, in the indirect fibres, would theoretically rebuild a ligament that is less effective in relation to knee stability. The techniques described to determine the femoral tunnel's centre point all involve some degree of subjectivity; the point is defined manually and depends on the surgeon's expertise. The centre of the ACL insertion in the femur should be used as a parameter. Once the centre of the ligament in its footprint is marked, the centre of the tunnel must be defined, drawing the marking toward the intercondylar ridge and anteromedial band. This will allow the femoral tunnel to occupy the region containing the most important original ACL fibres in terms of this ligament's function.
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Affiliation(s)
- Pedro Baches Jorge
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Diego Escudeiro
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Nilson Roberto Severino
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Cláudio Santili
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | | | - Aires Duarte Junior
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
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Asai S, Kim D, Hoshino Y, Moon CW, Maeyama A, Linde M, Smolinski P, Fu FH. Coronal tibial anteromedial tunnel location has minimal effect on knee biomechanics. Knee Surg Sports Traumatol Arthrosc 2018; 26:2960-2965. [PMID: 29450567 DOI: 10.1007/s00167-018-4844-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/24/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE Studies have found anatomic variation in the coronal position of the insertion site of anteromedial (AM) bundle of the anterior cruciate ligament (ACL) on the tibia, which can lead to questions about tunnel placement during ACL reconstruction. The purpose of this study was to determine how mediolateral placement of the tibial AM graft tunnel in double-bundle ACL reconstructions affects knee biomechanics. METHODS Two different types of double-bundle ACL reconstructions were performed. The AM tibial tunnel was placed at either the medial or lateral portion of tibial AM footprint. Nine cadaveric knees were tested with the robotic/universal force-moment sensor system with the use of (1) an 89.0-N anterior tibial load at full extension (FE), 30°, 60° and 90° of knee flexion and (2) a combined 7.0-Nm valgus torque and 5.0-Nm internal tibial rotation torque at FE, 15°, 30°and 45° of knee flexion. RESULTS Both medial (2.6 ± 1.2 mm) and lateral (1.6 ± 0.9 mm) double-bundle reconstructions reduced the anterior tibial translation (ATT) to less than the intact value (3.9 ± 0.7 mm) at FE. At all other flexion angles, there was no significant different in ATT between the intact knee and the reconstructions. At FE, the ATT for the medial AM reconstruction was different from that of the lateral AM construction and closer to the intact ACL value. CONCLUSION The coronal tibial placement of the AM tunnel had only a slight effect on knee biomechanics. In patients with differing AM bundle coronal positions, the AM tibial tunnel can be placed anatomically at the native insertion site.
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Affiliation(s)
- Shigehiro Asai
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Donghwi Kim
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Chan-Woong Moon
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Akira Maeyama
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Monica Linde
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA.,Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA. .,Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA.
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Aga C, Risberg MA, Fagerland MW, Johansen S, Trøan I, Heir S, Engebretsen L. No Difference in the KOOS Quality of Life Subscore Between Anatomic Double-Bundle and Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction of the Knee: A Prospective Randomized Controlled Trial With 2 Years' Follow-up. Am J Sports Med 2018; 46:2341-2354. [PMID: 30021073 DOI: 10.1177/0363546518782454] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The double-bundle reconstruction technique was developed to resemble the properties of the native anterior cruciate ligament (ACL) more closely than the conventional single-bundle technique. The clinical benefit of the operative procedure is controversial, and there is a need for studies with a focus on patient-reported outcomes (PROs). STUDY DESIGN Randomized controlled trial; Level of evidence, 1. HYPOTHESIS Anatomic double-bundle ACL reconstruction would be superior to anatomic single-bundle reconstruction regarding the change in the Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QoL) subscore from baseline to 2-year follow-up. METHODS According to sample size calculations, 120 patients aged 18 to 40 years with a primary ACL injury of their knee were randomized to the anatomic double-bundle or anatomic single-bundle reconstruction groups. Patients with posterior cruciate ligament, posterolateral corner, or lateral collateral ligament injuries or with established osteoarthritis were excluded. Patients with residual laxity from a coexistent medial collateral ligament injury were excluded. Data were registered at baseline, 1 year, and 2 years. In 24 patients, postoperative 3-dimensional computed tomography was performed to verify the positioning of the bundles. The outcome measures were the change in KOOS subscores and the International Knee Documentation Committee 2000 subjective score, pivot-shift test result, Lachman test finding, KT-1000 arthrometer measurement, activity level, return-to-sports rate, and osteoarthritic changes on radiographs. A linear mixed model was used for the analysis of all the PROs, including the primary outcome. RESULTS The change in the KOOS QoL subscore from baseline to 2-year follow-up was not different between the double- and single-bundle groups (mean change, 29.2 points vs 28.7 points, respectively; -0.5-point difference; 95% CI, -8.4 to 7.4 points; P = .91). Neither were there any differences between the 2 groups in the remaining PROs, knee laxity measurements, or activity levels of the patients. Radiological signs of osteoarthritis were found in 2 patients. Eleven patients had a graft rupture: 8 in the single-bundle group and 3 in the double-bundle group ( P = .16). Three-dimensional computed tomography of the knees verified the positioning of the anteromedial bundle, posterolateral bundle, and single-bundle grafts to be within acceptable limits. CONCLUSION There was no difference in the KOOS QoL subscore, the remaining PROs, knee laxity measurements, or activity levels comparing the double- and single-bundle ACL reconstruction techniques. The number of bundles does not seem to influence clinical and subjective outcomes, as long as the tunnels are adequately positioned. Registration: NCT01033188 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Cathrine Aga
- Department of Orthopedic Surgery, Martina Hansens Hospital, Bærum, Norway.,Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.,Oslo Sports Trauma Research Center, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - May Arna Risberg
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Morten Wang Fagerland
- Oslo Sports Trauma Research Center, Oslo, Norway.,Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Steinar Johansen
- Department of Orthopedic Surgery, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Ingrid Trøan
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Stig Heir
- Department of Orthopedic Surgery, Martina Hansens Hospital, Bærum, Norway.,Oslo Sports Trauma Research Center, Oslo, Norway
| | - Lars Engebretsen
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.,Oslo Sports Trauma Research Center, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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50
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Todor A. A new technique in double‑bundle anterior cruciate ligament reconstruction with implant‑free tibial fixation: letter to the editor. Knee Surg Sports Traumatol Arthrosc 2018; 26:2542-2543. [PMID: 28321476 DOI: 10.1007/s00167-017-4455-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 01/25/2017] [Indexed: 02/14/2023]
Affiliation(s)
- Adrian Todor
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedcis, "Iuliu Hatieganu" University of Medicine and Pharmacy, 47 Traian Mosoiu street, Cluj Napoca, 400132, Cluj, Romania.
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