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Sugawara Y, Iwasaki K, Suzuki Y, Hishimura R, Matsubara S, Matsuoka M, Onodera T, Kondo E, Iwasaki N. Bone Density Distribution Pattern in the Lateral Wall of the Femoral Intercondylar Notch: Implications for the Direct Insertion of the Femoral ACL Attachment. Orthop J Sports Med 2024; 12:23259671241236807. [PMID: 38571484 PMCID: PMC10986171 DOI: 10.1177/23259671241236807] [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: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 04/05/2024] Open
Abstract
Background The ideal position of the femoral bone tunnel in the anterior cruciate ligament (ACL) is controversial. The functional importance of the ACL fiber varies depending on where it is attached to the femur. Functionally important fibers can cause high mechanical stress on the bone, and the Wolff law predicts that bone mineral density will increase at high mechanical stress sites. Purpose/Hypothesis The purpose of this study was to use computed tomography imaging to determine the distribution pattern of bone density in the lateral intercondylar wall. It was hypothesized that the high-density area (HDA) of the lateral intercondylar wall would reflect the functional insertion of the ACL as reported in previous anatomic studies. Study Design Descriptive epidemiology study. Methods Data from 39 knees without ACL injuries were retrospectively collected. The HDA of the lateral intercondylar wall was defined as the region containing the top 10% of the radiodensity values. The shape of the HDA was approximated as an ellipse, and the quadrant method was used to determine the center of the ellipse. The association between the ratio of the minor axis to the major axis of the ellipse and background characteristics was investigated. Results According to the quadrant method, the center of the HDA ellipse was 33.6% in the deep-shallow direction and 23.4% in the high-low direction. The center of the ellipse was comparable to the anatomic center of the ACL footprint, as previously reported. The ratio of the minor axis to the major axis of the ellipse was 0.58 (95% CI, 0.54-0.62). There was a significant negative correlation between the ratio of the minor axis to the major axis of the HDA ellipse and the posterior tibial slope (r = -0.38, P = .02). Conclusion The center of the HDA ellipse was found to be similar to the anatomic center of the ACL footprint. Considering the mechanical stress responses in bone, the HDA of the lateral intercondylar wall has the potential to represent the ACL insertion, especially functional insertion.
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Affiliation(s)
- Yutaro Sugawara
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuki Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryosuke Hishimura
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinji Matsubara
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masatake Matsuoka
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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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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Shiwaku K, Kamiya T, Otsubo H, Suzuki T, Matsumura T, Teramoto A, Yamashita T. Less tunnel enlargement in triple-bundle versus double-bundle anterior cruciate ligament reconstruction: A randomized clinical trial. J Orthop Sci 2023; 28:1074-1081. [PMID: 36175252 DOI: 10.1016/j.jos.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/29/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND No study thus far has compared tunnel enlargement between double-bundle and triple-bundle anterior cruciate ligament reconstruction. We compared tibial tunnel enlargement and rate of tibial tunnel coalition between these two reconstructions, hypothesizing that tibial tunnel enlargement in triple-bundle reconstruction is less than that in double-bundle reconstruction, and that the tunnel coalition rate is equal between the two procedures. METHODS This prospective randomized clinical trial included 25 patients who underwent computed tomography 2 weeks and 1 year postoperatively. Eleven patients underwent double-bundle anterior cruciate ligament reconstruction and 14 underwent triple-bundle anterior cruciate ligament reconstruction. Tunnel positions and tunnel coalition at the tibial tunnel aperture were assessed using three-dimensional computed tomography. Tunnel enlargement rate was calculated by measuring the sagittal and axial widths of the tibial bone tunnel 10 mm from the tibial tunnel aperture. These parameters were then compared between the groups. RESULTS The changes in tunnel positions and tunnel coalitions between groups were not significantly different. On both sagittal and axial views, the tunnel enlargement rates of the medial and lateral sections of the anteromedial bundle in the triple-bundle group were significantly smaller than those in the double-bundle group (sagittal view, p = 0.02 and < 0.01, respectively; axial view, p = 0.02 and ≤ 0.05, respectively). The groups did not differ significantly in terms of posterolateral tunnel enlargement. CONCLUSION Tunnel widening in the medial and lateral sections of the anteromedial bundle-associated tibial tunnel in triple-bundle anterior cruciate ligament reconstruction was smaller than that of double-bundle reconstruction. The tunnel coalition rates between the two reconstructions were not significantly different.
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Affiliation(s)
- Kousuke Shiwaku
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan; Sport Medical Center, Obihiro Kyokai Hospital, Obihiro, Japan
| | - Tomoaki Kamiya
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | | | | | | | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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Poutre AJ, Meyers AB. Imaging the pediatric anterior cruciate ligament: not little adults. Pediatr Radiol 2023; 53:1587-1599. [PMID: 36856757 DOI: 10.1007/s00247-023-05608-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/11/2023] [Accepted: 01/15/2023] [Indexed: 03/02/2023]
Abstract
An increased incidence of anterior cruciate ligament (ACL) injuries in children over the last few decades has led to a corresponding increase in ACL reconstruction procedures in children. In this review, we will illustrate unique features seen when imaging the ACL in children versus adults. After briefly reviewing relevant normal ACL anatomy, we will review imaging findings of congenital ACL dysplasia. This is followed by a discussion of imaging ACL avulsions. Lastly, we will review the different types of ACL reconstruction procedures performed in skeletally immature children and their post-operative appearances.
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Affiliation(s)
- Augustah J Poutre
- Department of Radiology, Brooke Army Medical Center, San Antonio, TX, USA
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 5031, Cincinnati, OH, 45229, USA
| | - Arthur B Meyers
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 5031, Cincinnati, OH, 45229, USA.
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Sconfienza LM, Albano D, Messina C, Gitto S, Mariani PP, Zappia M. Imaging of Anatomical Variants Around the Knee. Semin Musculoskelet Radiol 2023; 27:198-205. [PMID: 37011620 DOI: 10.1055/s-0043-1761955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Several anatomical variants have been described in the knee. These variants may involve intra- and extra-articular structures, such as menisci, ligaments, plicae, bony structures, muscles, and tendons. They have a variable prevalence, are generally asymptomatic, and are usually discovered incidentally in knee magnetic resonance imaging examinations. A thorough knowledge of these findings is essential to avoid overestimating and overinvestigating normal findings. This article reviews most anatomical variants around the knee, describing how to avoid misinterpretation.
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Affiliation(s)
| | | | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
| | - Salvatore Gitto
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
| | - Pier Paolo Mariani
- Villa Stuart Sport Clinic, FIFA Medical Centre of Excellence, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome Foro Italico, Rome, Italy
| | - Marcello Zappia
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
- Varelli Institute, Naples, Italy
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Cardona-Ramirez S, Cook JL, Stoker AM, Ma R. Small laboratory animal models of anterior cruciate ligament reconstruction. J Orthop Res 2022; 40:1967-1980. [PMID: 35689508 DOI: 10.1002/jor.25395] [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: 12/09/2021] [Revised: 04/19/2022] [Accepted: 06/08/2022] [Indexed: 02/04/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are common knee ligament injuries. While generally successful, ACL reconstruction that uses a tendon graft to stabilize the knee is still associated with a notable percentage of failures and long-term morbidities. Preclinical research that uses small laboratory species (i.e., mice, rats, and rabbits) to model ACL reconstruction are important to evaluate factors that can impact graft incorporation or posttraumatic osteoarthritis after ACL reconstruction. Small animal ACL reconstruction models are also used for proof-of-concept studies for the development of emerging biological strategies aimed at improving ACL reconstruction healing. The objective of this review is to provide an overview on the use of common small animal laboratory species to model ACL reconstruction. The review includes a discussion on comparative knee anatomy, technical considerations including types of tendon grafts employed amongst the small laboratory species (i.e., mice, rats, and rabbits), and common laboratory evaluative methods used to study healing and outcomes after ACL reconstruction in small laboratory animals. The review will also highlight common research questions addressed with small animal models of ACL reconstruction.
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Affiliation(s)
- Sebastian Cardona-Ramirez
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Aaron M Stoker
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Richard Ma
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
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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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Badawy CR, Jan K, Beck EC, Fleet N, Taylor J, Ford K, Waterman BR. Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e103-e113. [PMID: 35141542 PMCID: PMC8811493 DOI: 10.1016/j.asmr.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/09/2021] [Indexed: 12/16/2022] Open
Abstract
Despite advancements in our understanding of anterior cruciate ligament (ACL) injury prevention and nonsurgical management, ACL reconstruction continues to occur at an alarming rate. Among athletic patients, individuals participating in basketball, soccer, and football have the highest incidence of ACL injury, often requiring surgical intervention. To ensure the optimal treatment strategy for return to sport and prevention of secondary graft re-tear, it is important to tailor to the specific demands of the injured athlete and apply evidence-based best practices and rehabilitation principles. The purpose of this review is to provide readers with a brief background regarding ACL injuries, a focused review of clinical outcome studies after ACL reconstruction, and an updated framework with expert-guided recommendations for postoperative rehabilitation and return to sporting activity. Currently, there is no gold standard for rehabilitation after ACL reconstruction, highlighting the need for robust studies evaluating the best modalities for athlete rehabilitation, as well as determining the efficacy of new tools for improving therapy including blood flow restriction therapy and neuromuscular electrical stimulation. Based on clinical experience, a renewed focus on objective, criteria-based milestones may maximize the ability of return to preinjury levels of athletic function.
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Affiliation(s)
- Charles R Badawy
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Kyleen Jan
- University of Illinois College of Medicine, Chicago, Illinois, U.S.A
| | - Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Niles Fleet
- Department of Athletics, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Jeffrey Taylor
- Department of Physical Therapy, High Point University, High Point, North Carolina, U.S.A
| | - Kevin Ford
- Department of Physical Therapy, High Point University, High Point, North Carolina, U.S.A
| | - Brian R Waterman
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
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Uchida R, Shino K, Iuchi R, Tachibana Y, Yokoi H, Nakagawa S, Mae T. Anatomical Triple Bundle Anterior Cruciate Ligament Reconstructions With Hamstring Tendon Autografts: Tunnel Locations and 2-Year Clinical Outcomes. Arthroscopy 2021; 37:2891-2900. [PMID: 33887415 DOI: 10.1016/j.arthro.2021.03.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To anatomically clarify the location of the tunnel apertures created using the bony landmark strategy and to elucidate clinical outcomes after anatomic triple-bundle (ATB) anterior cruciate ligament (ACL) reconstruction. METHODS Thirty-two patients with unilateral ACL injury who had consented to undergo computed tomography (CT) at 3 weeks, as well as 2-year follow-up evaluation, were enrolled. At the time of surgery, remnant tissues were thoroughly cleared to create 2 femoral and 3 tibial tunnels inside the ACL attachment areas bordered by the bony landmarks. Two double-looped semitendinosus tendon autografts were prepared and fixed on the femur with two EndoButton-CLs and secured to the tibia with pullout sutures and plates with 10-20N of tension. The location of the tunnel aperture areas was assessed using 3-dimensional CT images, and 2-year postoperative clinical outcomes were evaluated. RESULTS The CT evaluation showed 100% of the femoral tunnel aperture area and at least 79% of the tibial tunnel aperture area were located inside the anatomic attachment areas. Thirty patients were available for clinical evaluation. The International Knee Documentation Committee subjective assessment showed all of the patients were classified as "normal" or "nearly normal." Lachman and pivot-shift tests were negative in 100% and 93%, respectively. The mean side-to-side difference of anterior laxity at the maximum manual force with a KT-1000 Knee Arthrometer was 0.7 ± 0.7 mm, ranging from 0 to 2 mm. CONCLUSION In ATB ACL reconstructions with hamstring tendon grafts, the tunnels can be created in proper locations using the arthroscopically-identifiable bony landmarks. Moreover, ATB ACL reconstruction with hamstring tendon grafts via the proper tunnels result in consistently satisfactory clinical outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ryohei Uchida
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka; Department of Orthopaedic Sports Medicine, Kansai Rosai Hospital, Hyogo.
| | - Konsei Shino
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Ryo Iuchi
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Yuta Tachibana
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Hiroyuki Yokoi
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Shigeto Nakagawa
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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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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Otani T, Kobayashi Y, Tanaka M. Computational study of kinematics of the anterior cruciate ligament double-bundle structure during passive knee flexion–extension. Med Eng Phys 2020; 83:56-63. [DOI: 10.1016/j.medengphy.2020.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 05/28/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
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Englander ZA, Wittstein J, Goode AP, Garrett WE, DeFrate LE. Reconsidering Reciprocal Length Patterns of the Anteromedial and Posterolateral Bundles of the Anterior Cruciate Ligament During In Vivo Gait. Am J Sports Med 2020; 48:1893-1899. [PMID: 32515986 PMCID: PMC7693121 DOI: 10.1177/0363546520924168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Some cadaveric studies have indicated that the anterior cruciate ligament (ACL) consists of anteromedial and posterolateral bundles that display reciprocal function with regard to knee flexion. However, several in vivo imaging studies have suggested that these bundles elongate in parallel with regard to flexion. Furthermore, the most appropriate description of the functional anatomy of the ACL is still debated, with the ACL being described as consisting of 2 or 3 bundles or as a continuum of fibers. HYPOTHESIS As long as their origination and termination locations are defined within the ACL attachment site footprints, ACL bundles elongate in parallel with knee extension during gait. STUDY DESIGN Descriptive laboratory study. METHODS High-speed biplanar radiographs of the right knee joint were obtained during gait in 6 healthy male participants (mean ± SD: body mass index, 25.5 ± 1.2 kg/m2; age, 29.2 ± 3.8 years) with no history of lower extremity injury or surgery. Three-dimensional models of the right femur, tibia, and ACL attachment sites were created from magnetic resonance images. The bone models were registered to the biplanar radiographs, thereby reproducing the in vivo positions of the knee joint. For each knee position, the distances between the centroids of the ACL attachment sites were used to represent ACL length. The lengths of 1000 virtual bundles were measured for each participant by randomly sampling locations on the attachment site surfaces and measuring the distances between each pair of locations. Spearman rho rank correlations were performed between the virtual bundle lengths and ACL length. RESULTS The virtual bundle lengths were highly correlated with the length of the ACL, defined as the distance between the centroids of the attachment sites (rho = 0.91 ± 0.1, across participants; P < 5 × 10-5). The lengths of the bundles that originated and terminated in the anterior and medial aspects of the ACL were positively correlated (rho = 0.81 ± 0.1; P < 5 × 10-5) with the lengths of the bundles that originated and terminated in the posterior and lateral aspects of the ACL. CONCLUSION As long as their origination and termination points are specified within the footprint of the attachment sites, ACL bundles elongate in parallel as the knee is extended. CLINICAL RELEVANCE These data elucidate ACL functional anatomy and may help guide ACL reconstruction techniques.
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Affiliation(s)
- Zoë A. Englander
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Jocelyn Wittstein
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Adam P. Goode
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - William E. Garrett
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Louis E. DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
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Ohori T, Mae T, Shino K, Tachibana Y, Yoshikawa H, Nakata K. Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft. Part 2: Factors related to the tibial tunnel enlargement. J Orthop Sci 2020; 25:279-284. [PMID: 31080043 DOI: 10.1016/j.jos.2019.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/28/2019] [Accepted: 03/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Factors related to tunnel enlargement after anterior cruciate ligament (ACL) reconstruction should be evaluated by multivariate analysis, because the phenomenon has multifactorial characteristics. The purpose of this study was to elucidate the factors related to the tibial tunnel enlargement rate after anatomic ACL reconstruction with a bone-patellar tendon-bone (BTB) graft using multivariate analysis. METHODS Eighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture. The CSA was measured at 3 weeks and 1 year after surgery, and the tunnel enlargement rate at the aperture was calculated. Multiple linear regression analysis was performed to detect the significantly related factors to the tibial tunnel enlargement rate at the aperture among potential factors consisting of preoperative demographic factors and predisposing factors with the tibial tunnel. RESULTS The tibial tunnel enlargement rate at the aperture was 21.9 ± 14.1% (mean ± standard deviation). Multiple linear regression analysis detected the tendon length inside the tunnel as a significantly independent factor related to the tibial tunnel enlargement rate at the aperture (standardized β = 0.726, P = 0.008). There was no significant relationship between the tibial tunnel enlargement rate at the aperture and postoperative side-to-side difference (SSD) of the anterior knee laxity or Tegner activity level scale under single linear regression analysis. CONCLUSION The greater tendon length inside the tunnel was independently related to the higher tibial tunnel enlargement rate at the aperture 1-year after anatomic ACL reconstruction with a BTB graft under multiple linear regression analysis.
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Affiliation(s)
- Tomoki Ohori
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Konsei Shino
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Yuta Tachibana
- Department of Sports Orthopaedics, Osaka Rosai Hospital, 1179-3, Nagasone-cho, Kita-ku, Sakai, Osaka, 591-8025, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
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Sánchez-Alepuz E, Miranda I, Miranda FJ. Functional evaluation of patients with anterior cruciate ligament injury. A transversal analytical study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020. [DOI: 10.1016/j.recote.2020.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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15
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Getzmann JM, Bohnert L, Roos JE, Agten CA. Anomalous insertion of the medial meniscus into a triple bundle anterior cruciate ligament: A rare combination of two anatomical variants. Eur J Radiol Open 2020; 7:100220. [PMID: 32099871 PMCID: PMC7030987 DOI: 10.1016/j.ejro.2020.100220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/30/2020] [Indexed: 11/25/2022] Open
Abstract
The anomalous insertion of the medial meniscus into a triple bundle anterior cruciate ligament is a rare variant. The coexistence of these anomalies might be a risk factor for developing tears of the medial meniscus. Excision of the anomalous insertion of the medial meniscus is a possible form of treatment when conservative therapy fails.
Rare anatomical variants in the human knee joint include the anomalous insertion of the medial meniscus (AIMM) into the anterior cruciate ligament (ACL) or the presence of a triple bundle ACL. The functional implications of those anomalies have not yet been fully elucidated and might be important in reconstructive surgery of the damaged knee. We report the case of a 35-year-old female patient with an AIMM into a triple bundle ACL associated with tears of the medial meniscus in both of her knees. Arthroscopic partial meniscectomy was performed on one side, and conservative treatment with physiotherapy was chosen for the other side with good clinical outcomes.
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Affiliation(s)
- Jonas M Getzmann
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Spitalstrasse, CH-6000, Lucerne 16, Switzerland
| | - Laurent Bohnert
- Department of Orthopedic Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16a, CH-6210, Sursee, Switzerland
| | - Justus E Roos
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Spitalstrasse, CH-6000, Lucerne 16, Switzerland
| | - Christoph A Agten
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Spitalstrasse, CH-6000, Lucerne 16, Switzerland
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16
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Sánchez-Alepuz E, Miranda I, Miranda FJ. Functional evaluation of patients with anterior cruciate ligament injury. A transversal analytical study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 64:99-107. [PMID: 31780400 DOI: 10.1016/j.recot.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 05/29/2019] [Accepted: 10/06/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate, by means of biomechanical analysis, functional alterations of gait and balance of patients with anterior cruciate ligament (ACL) injury. MATERIAL AND METHODS Transversal analytical study on 64 people, 27 health subjects and 37 patients with ACL injury. Biomechanical analysis of gait in all individuals was performed by means of four tests: 1) kinematic test, to characterize gait pattern; 2) kinetic test, to characterize forces against the floor, duration of treads, symmetry of both legs, and the reproducibility of the gait; 3) pivot-shift test, to analyze the rotational stability of the knee on the sagittal axis; and 4) equilibrium test. RESULTS alterations in kinematic and kinetic analysis were found in both the injured knee and the healthy knee compared to the control group. In the pivot-shift gait test there is a tendency to increase the forces on the three axes, both in the support leg and in the exit leg in patients with ACL injury, in comparison with healthy subjects. CONCLUSION ACL injury-induced changes in gait pattern, changes in forces against the floor, duration of treads, symmetry of both legs, and the reproducibility of gait and changes in rotational stability of the knee on the sagittal axis.
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Affiliation(s)
- E Sánchez-Alepuz
- Servicio de Cirugía Ortopédica y Traumatología de Unión de Mutuas, Valencia, España; Servicio de Cirugía Ortopédica y Traumatología, Hospital IMED Valencia, Burjassot, Valencia, España
| | - I Miranda
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - F J Miranda
- Departamento de Fisiología, Universitat de València, Valencia, España
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Suzuki D, Otsubo H, Adachi T, Suzuki T, Nagoya S, Yamashita T, Shino K. Functional Adaptation of the Fibrocartilage and Bony Trabeculae at the Attachment Sites of the Anterior Cruciate Ligament. Clin Anat 2019; 33:988-996. [PMID: 31749212 DOI: 10.1002/ca.23520] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/04/2019] [Accepted: 11/08/2019] [Indexed: 11/07/2022]
Abstract
The direct insertion of an enthesis is composed of uncalcified fibrocartilage (FC) and calcified FC, believed to function as buffers for multidirectional forces applied to the ligament. This study was performed to investigate the relationship between the FC thickness and bony trabecular orientation of the anterior cruciate ligament (ACL) on both the femoral and tibial sides. Six cadavers were examined (age at death: 73-92 years). Both femoral and tibial insertions of the ACL were harvested and used to make 0.5 mm interval semi-serial sections. Microdigital images were taken and used to measure the maximum thickness of both the uncalcified FC and Calcified FC. Two-dimensional discrete Fourier analysis was also performed to determine the orientation angle and orientation intensity of bony trabeculae directly under the FC. The mean thicknesses of the uncalcified FC at the femoral and tibial insertions were 0.98 mm and 0.49 mm, respectively. The mean thicknesses of the calcified FC were 0.47 mm and 0.38 mm, respectively. There was a significant difference in the uncalcified FC thickness, but not in the calcified FC thickness. The bony trabeculae showed a prominent orientation parallel to the ACL fiber on both sides, but it was more intense on the tibial side than on the femoral side. The trabecular orientation was prominent in the proximal-posterior part of the femoral side and in the anteromedial part of the tibial side, suggesting that mechanical stress is greater in these parts. The dominant bony trabecular angle was 69.0° on the femoral side and 59.8° on the tibial side when the tidemark was set at 0°. These findings suggest that the femoral side receives multidirectional stresses, while relatively unidirectional stress is loaded on the tibial side. Furthermore, stress is considered to be greater in the proximal-posterior part of the femoral insertion and in the anteromedial part of the tibial insertion. At the time of ACL reconstruction, attention should be paid to assign a robust portion of the graft to the posterior part of the femoral insertion and anteromedial part of the tibial insertion. Clin. Anat., 33:988-996, 2020. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Daisuke Suzuki
- Department of Health Sciences, Hokkaido Chitose College of Rehabilitation, 2-10 Satomi, Chitose, Japan.,Department of Musculoskeletal Biomechanics and Surgical Development, Sapporo Medical University, South 1 West 17, Chuo-ku, Sapporo, Japan
| | - Hidenori Otsubo
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, Japan
| | - Taiji Adachi
- Department of Biosystems Science, Institute for Frontier Life and Medical Sciences, Kyoto University, 53 Shougoin-Kawaharacho, Sakyo-ku, Kyoto, Japan
| | - Tomoyuki Suzuki
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, Japan
| | - Satoshi Nagoya
- Department of Musculoskeletal Biomechanics and Surgical Development, Sapporo Medical University, South 1 West 17, Chuo-ku, Sapporo, Japan
| | - Toshihiko Yamashita
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, Japan
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Japan
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Tachibana Y, Mae T, Shino K, Matsuo T, Sugamoto K, Yoshikawa H, Nakata K. Sequential analysis of three-dimensional tibiofemoral relationship through anatomic anterior cruciate ligament reconstruction with gravity-assisted radiographic technique in prone position. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2019; 18:11-17. [PMID: 31641617 PMCID: PMC6796590 DOI: 10.1016/j.asmart.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/10/2019] [Accepted: 08/28/2019] [Indexed: 12/02/2022]
Abstract
Background/objectives It is important to restore the tibiofemoral relationship as well as the anterior knee laxity for more successful anterior cruciate ligament (ACL) reconstruction, since a residual abnormality in the tibiofemoral relationship would lead an abnormal stress on the articular cartilages/menisci and consequently increase the risk of osteoarthritis in the future. This study aimed to sequentially clarify the three-dimensional tibiofemoral relationship before and after anatomic anterior cruciate ligament (ACL) reconstruction under an anterior tibial load with a gravity-assisted radiographic technique in the prone position. Methods Fifteen patients with unilateral ACL injury participated in the study. Anatomic triple-bundle ACL reconstruction was performed using semitendinosus tendon autografts. During the computed tomography scans that were performed preoperatively, and those performed at 3 weeks and at 6 months postoperatively, the patients lay in the prone position with the knee flexed at 15°, wherein the calf weight could exert an anterior drawer force on the tibia due to gravity. Three-dimensional the tibial position relative to the femur were evaluated for each time point, followed by calculation of side-to-side differences in the parameters between the ACL-deficient/ACL-reconstructed knees and the contralateral intact knees. Seven healthy volunteers were enrolled in the control group and the side-to-side differences (right minus left) in these parameters were calculated. Results The tibia in the ACL-deficient knee was located anteriorly by 3.5 ± 1.1 mm and rotated internally by 2.4° ± 2.3°; these values were significantly larger than the corresponding values of −0.2 ± 1.5 mm and 0.1° ± 2.2° in the control group. However, at 3 weeks postoperatively, the tibia in the ACL-reconstructed knee was over-constrained as compared to that in the control group; it was located posteriorly by 2.5 ± 1.4 mm and rotated externally by 3.4° ± 3.4°. At 6 months postoperatively, no significant difference was observed in the tibial displacements/rotations between the patient and control groups. The side-to-side difference in the anterior knee laxity at the manual maximum anterior load was 0.1 ± 1.2 mm at 6 months postoperatively, with a significant improvement over the preoperative value of 7.4 ± 2.5 mm. Conclusions Anatomic ACL reconstruction could restore not only the normal anterior knee laxity, but also the normal tibiofemoral relationship even under an anterior tibial load. Tibiofemoral relationship was analyzed before and after anatomic ACL reconstruction. Tibial anterior shift and internal rotation was observed in ACL-injuried knees. Anatomic ACL reconstruction could restore the normal tibiofemoral relationship.
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Affiliation(s)
- Yuta Tachibana
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita-city, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita-city, Osaka, 565-0871, Japan
| | - Konsei Shino
- Sports Orthopaedic Center, Osaka Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Tomohiko Matsuo
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita-city, Osaka, 565-0871, Japan
| | - Kazuomi Sugamoto
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita-city, Osaka, 565-0871, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita-city, Osaka, 565-0871, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita-city, Osaka, 565-0871, Japan
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Englander ZA, Garrett WE, Spritzer CE, DeFrate LE. In vivo attachment site to attachment site length and strain of the ACL and its bundles during the full gait cycle measured by MRI and high-speed biplanar radiography. J Biomech 2019; 98:109443. [PMID: 31679755 DOI: 10.1016/j.jbiomech.2019.109443] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to measure in vivo attachment site to attachment site lengths and strains of the anterior cruciate ligament (ACL) and its bundles throughout a full cycle of treadmill gait. To obtain these measurements, models of the femur, tibia, and associated ACL attachment sites were created from magnetic resonance (MR) images in 10 healthy subjects. ACL attachment sites were subdivided into anteromedial (AM) and posterolateral (PL) bundles. High-speed biplanar radiographs were obtained as subjects ambulated at 1 m/s. The bone models were registered to the radiographs, thereby reproducing the in vivo positions of the bones and ACL attachment sites throughout gait. The lengths of the ACL and both bundles were estimated as straight line distances between attachment sites for each knee position. Increased attachment to attachment ACL length and strain were observed during midstance (length = 28.5 ± 2.6 mm, strain = 5 ± 4%, mean ± standard deviation), and heel strike (length = 30.5 ± 3.0 mm, strain = 12 ± 5%) when the knee was positioned at low flexion angles. Significant inverse correlations were observed between mean attachment to attachment ACL lengths and flexion (rho = -0.87, p < 0.001), as well as both bundle lengths and flexion (rho = -0.86, p < 0.001 and rho = -0.82, p < 0.001, respectively). AM and PL bundle attachment to attachment lengths were highly correlated throughout treadmill gait (rho = 0.90, p < 0.001). These data can provide valuable information to inform design criteria for ACL grafts used in reconstructive surgery, and may be useful in the design of rehabilitation and injury prevention protocols.
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Affiliation(s)
- Zoë A Englander
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | | | | | - Louis E DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, USA.
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Ohori T, Mae T, Shino K, Tachibana Y, Yoshikawa H, Nakata K. Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft. Part 1: Morphological change in the tibial tunnel. J Orthop Sci 2019; 24:861-866. [PMID: 30709787 DOI: 10.1016/j.jos.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/07/2019] [Accepted: 01/15/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Three-dimensional (3D) computed tomography (CT) is reliable and accurate imaging modality for evaluating tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to evaluate the tibial tunnel enlargement including the morphological change after anatomic ACL reconstruction with a bone-patellar tendon-bone (BTB) graft using 3D CT models. METHODS Eighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture and 5, 10, and 15-mm distal from the aperture. The CSA was measured at 3 weeks and 1 year after surgery and compared between the two time points. The locations of the center and the anterior, posterior, medial, and lateral edges of the tunnel footprint were also evaluated based on the coordinate system for the tibial plateau and compared between the two time points. RESULTS At the aperture, the CSA of the tibial tunnel at 1 year after surgery was significantly larger by 21.9% than that at 3 weeks (P < 0.001). In contrast, the CSA at 1 year was significantly smaller than that at 3 weeks at 10 and 15-mm distal from the aperture (P = 0.041 and < 0.001, respectively). The center of the tunnel footprint significantly shifted postero-laterally with significant posterior shift of the anterior/posterior edges and lateral shift of the lateral edge (P < 0.001). CONCLUSION The tibial tunnel enlarged at the aperture by 22% 1-year after anatomic ACL reconstruction with a BTB graft, and the tunnel morphology changed in a postero-lateral direction at the aperture and into conical shape inside the tunnel.
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Affiliation(s)
- Tomoki Ohori
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Konsei Shino
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Yuta Tachibana
- Department of Sports Orthopaedics, Osaka Rosai Hospital, 1179-3, Nagasone-cho, Kita-ku, Sakai, Osaka, 591-8025, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
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Suzuki T, Shino K, Yamakawa S, Otsubo H, Suzuki D, Matsumura T, Fujimiya M, Fujie H, Yamashita T. A Biomechanical Comparison of Single-, Double-, and Triple-Bundle Anterior Cruciate Ligament Reconstructions Using a Hamstring Tendon Graft. Arthroscopy 2019; 35:896-905. [PMID: 30733036 DOI: 10.1016/j.arthro.2018.10.124] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The first objective of our cadaveric study was to perform a biomechanical comparison of single-bundle (SB), double-bundle (DB), and triple-bundle (TB) anterior cruciate ligament (ACL) reconstructions using a hamstring tendon graft to determine the laxity match pre-tension (LMP) value, which is the tension within the graft required to re-create the same anterior laxity as the ACL-intact knee. The second objective was to determine the anterior laxity and force distribution during the application of both an anterior force and a simulated pivot-shift test. METHODS Eleven fresh-frozen cadaveric knees were tested using a robotic/universal force-moment sensor system in the intact state, TB-reconstructed knee, DB-reconstructed knee, and SB-reconstructed knee. The LMP in each reconstruction was recorded. Each reconstructed knee was tested with an external load of 100-N anterior drawer and combined rotatory loads of 10-Nm valgus moment and 5-Nm internal rotation. The anterior tibial translation and tensile forces of each graft bundle were measured. RESULTS The LMP values for the TB reconstruction were 1.7 N for the anteromedial-medial graft, 1.7 N for the anteromedial-lateral graft, and 3.4 N for the posterolateral graft (PLG). The LMP value was 5.6 N for the anteromedial graft and PLG in the DB reconstruction. The LMP value was 26.3 N for the whole graft in the SB reconstruction. No statistically significant difference in stability was found between TB and DB reconstructions during the anterior load and the combined rotatory load test. For force distribution, the PLG tension in the TB reconstruction was statistically lower than that in the DB reconstruction. CONCLUSIONS Anatomic TB ACL reconstruction with the lowest initial tension on the graft stabilized the knee equally to DB or SB reconstruction, which required greater initial tension. CLINICAL RELEVANCE Although SB, DB, and TB ACL reconstructions through the anatomic tunnel position could equally restore stability, the initial tension on the graft required to restore stability was less in the latter 2 multi-tunnel reconstructions.
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Affiliation(s)
- Tomoyuki Suzuki
- Department of Orthopedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan.
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, Osaka, Japan
| | - Satoshi Yamakawa
- Biomechanics Laboratory, Faculty of System Design, Tokyo Metropolitan University, Tokyo, Japan
| | - Hidenori Otsubo
- Department of Orthopedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Daisuke Suzuki
- Department of Health Science, Hokkaido Chitose College of Rehabilitation, Chitose, Japan
| | - Takashi Matsumura
- Department of Orthopedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Mineko Fujimiya
- Second Department of Anatomy, Sapporo Medical University, Sapporo, Japan
| | - Hiromichi Fujie
- Biomechanics Laboratory, Faculty of System Design, Tokyo Metropolitan University, Tokyo, Japan
| | - Toshihiko Yamashita
- Department of Orthopedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
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Take Y, Shino K, Mae T, Tachibana Y, Iuchi R, Nakagawa S, Nakata K. Early Structural Results After Anatomic Triple Bundle Anterior Cruciate Ligament Reconstruction Validated by Tunnel Location, Graft Orientation, and Static Anteroposterior Tibia-Femur Relationship. Arthroscopy 2018; 34:2656-2665. [PMID: 30078691 DOI: 10.1016/j.arthro.2018.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 04/06/2018] [Accepted: 04/13/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To elucidate how closely the structural characteristics of the anterior cruciate ligament (ACL) grafts after anatomic triple bundle (ATB) reconstruction resembled those of the normal ACL. METHODS From 2012 to 2016, patients who underwent primary ATB ACL reconstruction using hamstring tendon autografts and the same number of healthy control subjects were included. Using magnetic resonance imaging (MRI) taken at 6 months postoperatively, ACL graft orientation was evaluated by the angles against the tibial plateau measured in the sagittal and oblique coronal planes at the anteromedial and posterolateral portions (ACL-tibial plateau angle [ATA]). For factors affecting the graft orientation, the static tibiofemoral relationship was evaluated by anteroposterior tibial translocation (APTT) in the identical MRI using a previously established method, and tunnel locations were evaluated using the quadrant method. To test equivalence, the widely used two one-sided test procedure was performed, with the equivalence margins of 5° and 3 mm for ATA and APTT, respectively. RESULTS Thirty-five patients were enrolled for each group. ATAs were not significantly different, and the 95% confidence interval (CI) of these differences was within 5° (sagittal: P = .211 [95% CI, -2.9 to 0.6]; oblique coronal ATA for the anteromedial and posterolateral portions: P = .269 [95% CI, -1.9 to 0.5] and P = .456 [95% CI,-2.1 to 0.9], respectively). The difference in APTT was neither statistically nor clinically significant (P = .114; 95% CI, -2.0 to 0.2). CONCLUSIONS These data suggest that ACL grafts using the ATB technique achieved a graft orientation equivalent to that of the normal ACL, with an equivalent postoperative anteroposterior tibiofemoral relationship in the static MRI. Thus, the ATB ACL reconstruction technique with the presented tunnel locations produced grafts that were similar to the native ACL in orientation. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Yasuhiro Take
- Department of Health and Sport Sciences, Medicine for Sports and Performing Arts, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Konsei Shino
- Sport Orthopaedic Center, Yukioka Hospital, Osaka, Japan
| | - Tatsuo Mae
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuta Tachibana
- Sport Orthopaedic Center, Yukioka Hospital, Osaka, Japan
| | - Ryo Iuchi
- Sport Orthopaedic Center, Yukioka Hospital, Osaka, Japan
| | | | - Ken Nakata
- Department of Health and Sport Sciences, Medicine for Sports and Performing Arts, Osaka University Graduate School of Medicine, Osaka, Japan
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Quiles C, Constantino JA, Gañán Y, Macías D, Quiles M. Stereophotogrammetric surface anatomy of the anterior cruciate ligament's tibial footprint: Precise osseous structure and distances to arthroscopically-relevant landmarks. Knee 2018; 25:531-544. [PMID: 29705076 DOI: 10.1016/j.knee.2018.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/16/2018] [Accepted: 03/27/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND While femoral tunnel malposition is widely recognized as the main technical error of failed anterior cruciate ligament (ACL) surgery, tibial tunnel malposition is likely underrecognized and underappreciated. PURPOSE To describe more precisely the qualitative and quantitative anatomy of the ACL's tibial attachment in vitro using widely available technology for stereophotogrammetric surface reconstruction, and to test its applicability in vivo. METHODS Stereophotogrammetric surface reconstruction was obtained from fourteen proximal tibias of cadaver donors. Measurements of areas and distances from the center of the ACL footprint and the footprint of the obtained bundles to selected arthroscopically-relevant anatomic landmarks were carried out using a three-dimensional design software program, and means and 95% confidence intervals were calculated for these measurements. Reference landmarks were tested in three-dimensional models obtained with arthroscopic videos. MAIN FINDINGS The osseous footprint of the ACL was described in detail, including its precise elevated limits, size, and shape, with its elevation pattern described as a quarter-turn-staircase-like ridge. Its internal indentations were related to inter-spaces identified as bundle divisions. Distances from the footprint center to arthroscopically relevant landmarks were obtained and compared to its internal structure, yielding a useful X-like landmark pointing to the most accurate placeholder for the ACL footprint's "anatomic" center. Certain structures and reference landmarks described were readily recognized in three-dimensional models from arthroscopic videos. CONCLUSIONS Stereophotogrammetric surface reconstruction is an accessible technique for the investigation of anatomic structures in vitro, offering a detailed three-dimensional depiction of the ACL's osseous footprint.
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Affiliation(s)
- Carlos Quiles
- Department of Orthopaedic Surgery and Traumatology, University Hospital Infanta Cristina, Badajoz 06080, Spain.
| | - Juan A Constantino
- Department of Orthopaedic Surgery and Traumatology, University Hospital Infanta Cristina, Badajoz 06080, Spain; Department of Medico-Surgical Therapy, University of Extremadura, Badajoz 06080, Spain.
| | - Yolanda Gañán
- Department of Anatomy, Cell Biology, and Zoology, University of Extremadura, Badajoz 06080, Spain.
| | - Domingo Macías
- Department of Anatomy, Cell Biology, and Zoology, University of Extremadura, Badajoz 06080, Spain.
| | - Manuel Quiles
- Department of Orthopaedic Surgery and Traumatology, University Hospital Infanta Cristina, Badajoz 06080, Spain; Department of Medico-Surgical Therapy, University of Extremadura, Badajoz 06080, Spain.
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Anterior cruciate ligament tibial insertion site is elliptical or triangular shaped in healthy young adults: high-resolution 3-T MRI analysis. Knee Surg Sports Traumatol Arthrosc 2018. [PMID: 28647841 DOI: 10.1007/s00167-017-4607-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To clarify the morphology of anterior cruciate ligament (ACL) tibial insertion site in healthy young knees using high-resolution 3-T MRI. METHODS Subjects were 50 ACL-reconstructed patients with a mean age of 21.4 ± 6.8 years. The contralateral healthy knees were scanned using high-resolution 3-T MRI. The tibial insertion sites of the anteromedial (AM) and posterolateral (PL) bundle fibres, and the ACL attachment on the anterior horn of lateral meniscus (AHLM) were segmented from the MR images, and 3D models were reconstructed to evaluate the morphology. The shape of ACL footprint was qualitatively analysed, and the size of AM and PL attachments and AHLM overlapped area was measured digitally. RESULTS Tibial AM and PL bundles were clearly identified in 42 of 50 knees (84.0%). Morphology of the whole ACL tibial insertion site was elliptical in 23 knees (54.8%) and triangular in 19 knees (45.2%), but not classified as C-shape in any knees. However, the AM bundle attachment was of C-shape in 29 knees (69.0%) and band-like in 13 knees (31.0%). Overlap of ACL on AHLM was found in 26 knees (61.9%), and the size of the overlapped area was 4.8 ± 4.7% of the whole ACL insertion site. CONCLUSION 3D morphology of the intact ACL tibial insertion site analysed by high-resolution 3-T MRI was elliptical or triangular in healthy young knees. However, the AM bundle insertion site was of C-shape or band-like. A small lateral portion of the ACL was overlapped with the AHLM. As for clinical relevance, these findings should be considered in order to reproduce the native ACL insertion site sufficiently. LEVEL OF EVIDENCE III.
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25
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Ohori T, Mae T, Shino K, Tachibana Y, Sugamoto K, Yoshikawa H, Nakata K. Morphological changes in tibial tunnels after anatomic anterior cruciate ligament reconstruction with hamstring tendon graft. J Exp Orthop 2017; 4:30. [PMID: 28916912 PMCID: PMC5602815 DOI: 10.1186/s40634-017-0104-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/04/2017] [Indexed: 02/05/2023] Open
Abstract
Background Three-dimensional (3D) reconstructed computed tomography (CT) is crucial for the reliable and accurate evaluation of tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purposes of this study were to evaluate the tibial tunnel enlargement at the tunnel aperture and inside the tunnel and to clarify the morphological change at the tunnel footprint 1 year after the anatomic triple-bundle (ATB) ACL reconstruction using 3D CT models. Methods Eighteen patients with unilateral ACL rupture were evaluated. The ATB ACL reconstruction with a semitendinosus tendon autograft was performed. 3D computer models of the tibia and the three tibial tunnels were reconstructed from CT data obtained 3 weeks and 1 year after surgery. The cross-sectional areas (CSAs) of the two anterior and the one posterior tunnels were measured at the tunnel aperture and 5 and 10 mm distal from the aperture and compared between the two periods. The locations of the center and the anterior, posterior, medial, and lateral edges of each tunnel footprint were also measured and compared between the two periods. Results The CSA of the posterior tunnel was significantly enlarged at the aperture by 40.4%, whereas that of the anterior tunnels did not change significantly, although the enlargement rate was 6.1%. On the other hand, the CSA was significantly reduced at 10 mm distal from the aperture in the anterior tunnels. The enlargement rate in the posterior tunnel was significantly greater than that in the anterior tunnels at the aperture. The center of the posterior tunnel footprint significantly shifted postero-laterally. The anterior and posterior edges of the posterior tunnel footprint demonstrated a significant posterior shift, while the lateral edge significantly shifted laterally. There was no significant shift of the center or all the edges of the anterior tunnels footprint. Conclusions The posterior tibial tunnel was significantly enlarged at the aperture by 40% with the morphological change in the postero-lateral direction reflected by the ACL fiber orientation 1 year after the ATB ACL reconstruction. The proper tibial tunnel location in the ACL reconstruction should be determined considering the tunnel enlargement in postero-lateral direction after surgery.
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Affiliation(s)
- Tomoki Ohori
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Konsei Shino
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Yuta Tachibana
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Kazuomi Sugamoto
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
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26
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Kusano M, Yonetani Y, Mae T, Nakata K, Yoshikawa H, Shino K. Tibial insertions of the anterior cruciate ligament and the anterior horn of the lateral meniscus: A histological and computed tomographic study. Knee 2017; 24:782-791. [PMID: 28559005 DOI: 10.1016/j.knee.2017.04.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 03/18/2017] [Accepted: 04/24/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND A positional relationship between the anterior cruciate ligament (ACL) and the anterior horn of the lateral meniscus (AHLM) has not previously been a topic of interest in the literature because the AHLM is already known to be obviously adjacent to the ACL and is assumed as a lateral border. The objective of this study was to investigate the positional anatomic relationship between the ACL and AHLM by histological evaluation of sequential slices and computed tomography (CT) of the tibial insertion sites. HYPOTHESIS/PURPOSE The ACL has a specific positional relationship with the AHLM and there is an identifiable distinct bony border between them. The position of the AHLM could be an important and useful landmark for accurate tibial tunnel positioning in anatomical ACL reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS Twelve ACL-intact knees from embalmed cadavers were used in this study. Six knees were sectioned into four slices for histologic examination in the coronal planes parallel to the AHLM alignment. Before sectioning, these knees were subjected to three-dimensional (3-D) volume-rendering CT. Each of the four slices demonstrated the insertion area of the ACL relative to the position of the AHLM. Each histologic slice was compared with the corresponding CT image. Only histological examination in the sagittal planes was performed in the other six knees. RESULTS The ACL fibres were broadly attached at the region anterior to the AHLM. However, the ACL and AHLM shared a clear border identifiable on the coronal CT images and appeared as a prominence of the bony ridge on the 3-D CT images. No dense ACL fibres were attached to the region posterior to the AHLM. Based on the histological data, the geometry of the ACL tibial insertion was L-shaped along the AHLM. CONCLUSION The ACL and AHLM have a specific positional relationship not only in the mediolateral direction but also anteroposteriorly. The AHLM serves not only as a lateral border, but also as a useful reference in an anterioposterior direction for tunnel positioning in ACL reconstruction. Specifically, the ACL fibres were found to be broadly attached onto the bony surface in the region anterior to the AHLM and there was no firm attachment of the ACL in the region posterior to the AHLM on the tibial side, which is useful in avoiding posterior tunnel placement.
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Affiliation(s)
- Masashi Kusano
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki, Hyogo 660-0064, Japan
| | - Yasukazu Yonetani
- Department Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka 565-0871, Japan.
| | - Tatsuo Mae
- Department Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Ken Nakata
- Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, 1-17, Machikaneyama, Toyonaka, Osaka 560-0043, Japan
| | - Hideki Yoshikawa
- Department Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Konsei Shino
- Center for Sports Orthopaedics, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka 530-0021, Japan
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Shimodaira H, Tensho K, Akaoka Y, Takanashi S, Kato H, Saito N. Tibial Tunnel Positioning Technique Using Bony/Anatomical Landmarks in Anatomical Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2017; 6:e49-e55. [PMID: 28373940 PMCID: PMC5368106 DOI: 10.1016/j.eats.2016.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/01/2016] [Indexed: 02/03/2023] Open
Abstract
Because various biomechanical studies and clinical results have shown the effectiveness of an anatomical approach for anterior cruciate ligament (ACL) reconstruction, this approach has become gradually commonplace to improve postoperative performance. Standard tunnel positioning methods with accuracy, reproducibility, and adaptability to varied concepts are essential for the success of anatomical ACL reconstruction. However, there were no standard tibial tunnel positioning methods to satisfy these conditions. This technical note reports our tibial tunnel positioning technique using bony and/or anatomical landmarks for anatomical ACL reconstruction.
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Affiliation(s)
- Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan,Address correspondence to Keiji Tensho, M.D., Ph.D., Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.Department of Orthopedic SurgeryShinshu University School of MedicineAsahi 3-1-1Matsumoto390-8621Japan
| | - Yusuke Akaoka
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Seiji Takanashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroyuki Kato
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoto Saito
- Institute for Biomedical Sciences, Interdisciplinary Cluster for Cutting Edge Research, Shinshu University School of Medicine, Matsumoto, Japan
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28
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YAMAKAWA S, DEBSKI RE, FUJIE H. Strain distribution in the anterior cruciate ligament in response to anterior drawer force to the knee. ACTA ACUST UNITED AC 2017. [DOI: 10.1299/jbse.16-00582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Richard E. DEBSKI
- Departments of Bioengineering and Orthopaedic Surgery University of Pittsburgh
| | - Hiromichi FUJIE
- Graduate School of System Design Tokyo Metropolitan University
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29
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Otsubo H, Akatsuka Y, Takashima H, Suzuki T, Suzuki D, Kamiya T, Ikeda Y, Matsumura T, Yamashita T, Shino K. MRI depiction and 3D visualization of three anterior cruciate ligament bundles. Clin Anat 2016; 30:276-283. [DOI: 10.1002/ca.22810] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 11/07/2022]
Affiliation(s)
- H. Otsubo
- Department of Orthopedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - Y. Akatsuka
- Department of Radiology; Sapporo Medical University Hospital; Sapporo Japan
| | - H. Takashima
- Department of Radiology; Sapporo Medical University Hospital; Sapporo Japan
| | - T. Suzuki
- Department of Orthopedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - D. Suzuki
- Musculoskeletal Biomechanics and Surgical Development; Sapporo Medical University; Japan
| | - T. Kamiya
- Department of Orthopedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - Y. Ikeda
- Department of Orthopedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - T. Matsumura
- Department of Orthopedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - T. Yamashita
- Department of Orthopedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - K. Shino
- Sports Orthopaedic Center, Yukioka Hospital; Osaka Japan
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30
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Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Williams A. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J 2016; 98-B:1020-6. [DOI: 10.1302/0301-620x.98b8.37117] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/26/2015] [Indexed: 01/14/2023]
Abstract
Anterior cruciate ligament (ACL) reconstruction is commonly performed and has been for many years. Despite this, the technical details related to ACL anatomy, such as tunnel placement, are still a topic for debate. In this paper, we introduce the flat ribbon concept of the anatomy of the ACL, and its relevance to clinical practice. Cite this article: Bone Joint J 2016;98-B:1020–6.
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Affiliation(s)
- R. Śmigielski
- Carolina Medical Center, Pory
78, 02-757 Warsaw, Poland
| | - U. Zdanowicz
- Carolina Medical Center, Pory
78, 02-757 Warsaw, Poland
| | - M. Drwięga
- Carolina Medical Center, Pory
78, 02-757 Warsaw, Poland
| | - B. Ciszek
- Medical University of Warsaw, Chalbinskiego
5, 02-004 Warsaw, Poland
| | - A. Williams
- Fortius Clinic, 17
Fitzhardinge Street, London, W1h
6EQ, UK
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31
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Tachibana Y, Mae T, Shino K, Kanamoto T, Sugamoto K, Yoshikawa H, Nakata K. Morphological changes in femoral tunnels after anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:3591-600. [PMID: 25160473 DOI: 10.1007/s00167-014-3252-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/17/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Few studies investigated the enlargement inside the tunnel as well as the morphological change at the aperture after anterior cruciate ligament (ACL) reconstruction, whereas the tunnel enlargement has been well documented. The purposes were to evaluate the change in the cross-sectional area along the femoral tunnel and to morphologically clarify the enlargement at the femoral tunnel aperture after anatomic triple-bundle (ATB) ACL reconstruction. METHODS The study included 15 patients with unilateral ACL rupture. ATB ACL reconstruction was performed using semitendinosus tendon autografts. Three-dimensional computer models of the femur and bone tunnels were reconstructed from computed tomography images obtained 3 weeks and 1 year postoperatively. The cross-sectional area at the aperture as well as inside the tunnel was compared between the two periods. Likewise, the location of tunnel walls and center in the tunnel footprint were evaluated. RESULTS The cross-sectional area enlarged by 22.7 % for anteromedial/intermediate graft (P = 0.002) and 28.6 % for posterolateral graft (P = 0.002) at the aperture, while decreased by 36.2 % at 10 mm from the aperture for anteromedial/intermediate graft (P = 0.004). Both the anterior and posterior walls shifted anteriorly, while the distal wall shifted distally in both tunnels. Consequently, the center in the footprint significantly shifted anteriorly (4.9-6.6 %) and distally (2.2-2.6 %) in both tunnels. CONCLUSIONS The femoral tunnel enlargement occurred at the aperture after ATB ACL reconstruction, but did not occur in the middle of the femoral tunnel. The morphology at the aperture changed with time after surgery as the tunnel walls translated anteriorly and distally. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Yuta Tachibana
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Konsei Shino
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Takashi Kanamoto
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Kazuomi Sugamoto
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
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32
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Beaulieu ML, Carey GE, Schlecht SH, Wojtys EM, Ashton-Miller JA. Quantitative comparison of the microscopic anatomy of the human ACL femoral and tibial entheses. J Orthop Res 2015; 33:1811-7. [PMID: 26134706 PMCID: PMC4628572 DOI: 10.1002/jor.22966] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 06/10/2015] [Indexed: 02/04/2023]
Abstract
The femoral enthesis of the human anterior cruciate ligament (ACL) is known to be more susceptible to injury than the tibial enthesis. To determine whether anatomic differences might help explain this difference, we quantified the microscopic appearance of both entheses in 15 unembalmed knee specimens using light microscopy, toluidine blue stain and image analysis. The amount of calcified fibrocartilage and uncalcified fibrocartilage, and the ligament entheseal attachment angle were then compared between the femoral and tibial entheses via linear mixed-effects models. The results showed marked differences in anatomy between the two entheses. The femoral enthesis exhibited a 3.9-fold more acute ligament attachment angle than the tibial enthesis (p<0.001), a 43% greater calcified fibrocartilage tissue area (p<0.001), and a 226% greater uncalcified fibrocartilage depth (p<0.001), with the latter differences being particularly pronounced in the central region. We conclude that the ACL femoral enthesis has more fibrocartilage and a more acute ligament attachment angle than the tibial enthesis, which provides insight into why it is more vulnerable to failure.
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Affiliation(s)
- Mélanie L. Beaulieu
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Grace E. Carey
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Stephen H. Schlecht
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Edward M. Wojtys
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan,MedSport, University of Michigan, Ann Arbor, Michigan
| | - James A. Ashton-Miller
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
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33
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Suzuki D, Otsubo H, Watanabe T, Kamiya T, Nagoya S, Yamashita T, Shino K. Ultrastructure of the three anterior cruciate ligament bundles. Clin Anat 2015; 28:910-6. [DOI: 10.1002/ca.22586] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 06/05/2015] [Accepted: 06/06/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Daisuke Suzuki
- Department of Musculoskeletal Biomechanics and Surgical Development; Sapporo Medical University; Sapporo Japan
| | - Hidenori Otsubo
- Department of Orthopaedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - Takafumi Watanabe
- Faculty of Agriculture; Shinshu University, Minami-minowa, Kami-ina; Nagano Japan
| | - Tomoaki Kamiya
- Department of Orthopaedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - Satoshi Nagoya
- Department of Musculoskeletal Biomechanics and Surgical Development; Sapporo Medical University; Sapporo Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital; Osaka Japan
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34
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Skelley NW, Castile RM, York TE, Gruev V, Lake SP, Brophy RH. Differences in the microstructural properties of the anteromedial and posterolateral bundles of the anterior cruciate ligament. Am J Sports Med 2015; 43:928-36. [PMID: 25634908 DOI: 10.1177/0363546514566192] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tissue properties of the anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) have not been previously characterized with real-time dynamic testing. The current study used a novel polarized light technique to measure the material and microstructural properties of the ACL. HYPOTHESIS The AM and PL bundles of the ACL have similar material and microstructural properties. STUDY DESIGN Controlled laboratory study. METHODS The AM and PL bundles were isolated from 16 human cadaveric ACLs (11 male, 5 female; average age, 41 years [range, 24-53 years]). Three samples from each bundle were loaded in uniaxial tension, and a custom-built polarized light imaging camera was used to quantify collagen fiber alignment in real time. A bilinear curve fit was applied to the stress-strain data of a quasistatic ramp-to-failure to quantify the moduli in the toe and linear regions. Fiber alignment was quantified at zero strain, the transition point of the bilinear fit, and in the linear portion of the stress-strain curve by computing the degree of linear polarization (DoLP) and angle of polarization (AoP), which are measures of the strength and direction of collagen alignment, respectively. Data were compared using t tests. RESULTS The AM bundle exhibited significantly larger toe-region (AM 7.2 MPa vs. PL 4.2 MPa; P < .001) and linear-region moduli (AM 27.0 MPa vs. PL 16.1 MPa; P = .017) compared with the PL bundle. Average DoLP values were similar at low strain but were significantly larger (ie, more uniform alignment) for the AM bundle in the linear region of the stress-strain curve (AM 0.22 vs. PL 0.19; P = .036) compared with the PL bundle. The standard deviation AoP values was larger for the PL bundle at both transition (P = .041) and linear-region strain (P = .014), indicating more disperse orientation. CONCLUSION Material and microstructural properties of the AM and PL bundles of the ACL differ during loading. The AM bundle possessed higher tissue modulus and failure stress, as well as more uniform fiber alignment under load. CLINICAL RELEVANCE These insights into native ligament microstructure can be used to assess graft options for ACL reconstruction and optimize surgical reconstruction techniques.
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Affiliation(s)
- Nathan W Skelley
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital/Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Ryan M Castile
- Department of Computer Science & Engineering, Washington University in St Louis, St Louis, Missouri, USA
| | - Timothy E York
- Department of Computer Science & Engineering, Washington University in St Louis, St Louis, Missouri, USA
| | - Viktor Gruev
- Department of Computer Science & Engineering, Washington University in St Louis, St Louis, Missouri, USA
| | - Spencer P Lake
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital/Washington University in St Louis School of Medicine, St Louis, Missouri, USA Department of Mechanical Engineering and Material Science, Washington University in St Louis, St Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital/Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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35
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Siebold R, Schuhmacher P, Fernandez F, Śmigielski R, Fink C, Brehmer A, Kirsch J. Flat midsubstance of the anterior cruciate ligament with tibial "C"-shaped insertion site. Knee Surg Sports Traumatol Arthrosc 2015; 23:3136-42. [PMID: 24841941 PMCID: PMC4611027 DOI: 10.1007/s00167-014-3058-6] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 05/02/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE This anatomical cadaver study was performed to investigate the flat appearance of the midsubstance shape of the anterior cruciate ligament (ACL) and its tibial "C"-shaped insertion site. METHODS The ACL midsubstance and the tibial ACL insertion were dissected in 20 cadaveric knees (n = 6 fresh frozen and n = 14 paraffined). Magnifying spectacles were used for all dissections. Morphometric measurements were performed using callipers and on digital photographs. RESULTS In all specimens, the midsubstance of the ACL was flat with a mean width of 9.9 mm, thickness of 3.9 mm and cross-sectional area of 38.7 mm(2). The "direct" "C"-shaped tibial insertion runs from along the medial tibial spine to the anterior aspect of the lateral meniscus. The mean width (length) of the "C" was 12.6 mm, its thickness 3.3 mm and area 31.4 mm(2). The centre of the "C" was the bony insertion of the anterior root of the lateral meniscus overlayed by fat and crossed by the ACL. No posterolateral (PL) inserting ACL fibres were found. Together with the larger "indirect" part (area 79.6 mm(2)), the "direct" one formed a "duck-foot"-shaped footprint. CONCLUSION The tibial ACL midsubstance and tibial "C"-shaped insertion are flat and are resembling a "ribbon". The centre of the "C" is the bony insertion of the anterior root of the lateral meniscus. There are no central or PL inserting ACL fibres. Anatomical ACL reconstruction may therefore require a flat graft and a "C"-shaped tibial footprint reconstruction with an anteromedial bone tunnel for single bundle and an additional posteromedial bone tunnel for double bundle.
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Affiliation(s)
- Rainer Siebold
- HKF: Center for Hip-Knee-Foot Surgery, ATOS Hospital Heidelberg, Bismarckstrasse 9-15, 69115, Heidelberg, Germany.
- Institute for Anatomy and Cell Biology, INF, Ruprecht-Karls University, Heidelberg, Germany.
| | - Peter Schuhmacher
- HKF: Center for Hip-Knee-Foot Surgery, ATOS Hospital Heidelberg, Bismarckstrasse 9-15, 69115, Heidelberg, Germany
| | - Francis Fernandez
- HKF: Center for Hip-Knee-Foot Surgery, ATOS Hospital Heidelberg, Bismarckstrasse 9-15, 69115, Heidelberg, Germany
| | - Robert Śmigielski
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757, Warsaw, Poland
| | - Christian Fink
- Sportsclinic Austria, Tivoli Ost, Olympiastr. 39, 6020, Innsbruck, Austria
| | - Axel Brehmer
- Institute for Anatomy Lehrstuhl I, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstr. 9, 91054, Erlangen, Germany
| | - Joachim Kirsch
- Institute for Anatomy and Cell Biology, INF, Ruprecht-Karls University, Heidelberg, Germany
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Anatomic ACL reconstruction: rectangular tunnel/bone-patellar tendon-bone or triple-bundle/semitendinosus tendon grafting. J Orthop Sci 2015; 20:457-68. [PMID: 25753837 PMCID: PMC4518079 DOI: 10.1007/s00776-015-0705-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/30/2014] [Indexed: 12/16/2022]
Abstract
Anatomic ACL reconstruction is the reasonable approach to restore stability without loss of motion after ACL tear. To mimic the normal ACL like a ribbon, our preferred procedures is the anatomic rectangular tunnel (ART) technique with a bone-patellar tendon-bone (BTB) graft or the anatomic triple bundle (ATB) procedure with a hamstring (HS) tendon graft. It is important to create tunnel apertures inside the attachment areas to lessen the tunnel widening. To identify the crescent-shaped ACL femoral attachment area, the upper cartilage margin, the posterior cartilage margin and the resident's ridge are used as landmarks. To delineate the C-shaped tibial insertion, medial intercondylar ridge, Parson's knob and anterior horn of the lateral meniscus are helpful. In ART-BTB procedure which is suitable for male patients engaged in contact sports, the parallelepiped tunnels with rectangular apertures are made within the femoral and tibial attachment areas. In ATB-HS technique which is mainly applied to female athletes engaged in non-contact sports including skiing or basketball, 2 femoral and 3 tibial round tunnels are created inside the attachment areas. These techniques make it possible for the grafts to run as the native ACL without impingement to the notch or PCL. After femoral fixation with an interference screw or cortical fixation devices including Endobutton, the graft is pretensioned in situ by repetitive manual pulls at 15-20° of flexion, monitoring the graft tension with tensioners on a tensioning boot installed on the calf. Tibial fixation with pullout sutures is achieved using Double Spike Plate and a screw at the pre-determined amount of tension of 10-20N. While better outcomes with less failure rate are being obtained compared to those in the past, higher graft tear rate remains a problem. Improved preventive training may be required to avoid secondary ACL injuries.
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Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Ciszkowska-Łysoń B, Siebold R. Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc 2015; 23:3143-50. [PMID: 24972997 PMCID: PMC4611008 DOI: 10.1007/s00167-014-3146-7] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 05/06/2014] [Indexed: 01/13/2023]
Abstract
PURPOSE Recently, the configuration of the anterior cruciate ligament (ACL) from its direct femoral insertion to midsubstance was found to be flat. This might have an important impact for anatomical ACL reconstruction. The purpose of this anatomical study was to evaluate the macroscopic appearance of the ACL from femoral to midsubstance. METHODS The ACL was dissected in 111 human fresh frozen cadaver knees from its femoral insertion to midsubstance, and the shape was described. The anatomical findings were documented on digital photographs and on video. Thirty knees were sent for computed tomography (CT), magnetic resonance imaging (MRI) and histology of the femoral ACL insertion. RESULTS Two millimetres from its direct femoral insertion, the ACL fibres formed a flat ribbon in all dissected knees without a clear separation between AM and PL bundles. The ribbon was in exact continuity of the posterior femoral cortex. The width of the ribbon was between 11.43 and 16.18 mm and the thickness of the ACL was only 2.54-3.38 mm. 3D CT, MRI and the histological examination confirmed above findings. CONCLUSION This is a detailed anatomical study describing the ribbon-like structure of the ACL from its femoral insertion to midsubstance. A key point was to carefully remove the surface fibrous membrane of the ACL. A total of 2-3 mm from its bony femoral insertion, the ACL formed a flat ribbon without a clear separation between AM and PL bundles. The ribbon was in exact continuity of the posterior femoral cortex. The findings of a flat ligament may change the future approach to femoral ACL footprint and midsubstance ACL reconstruction and to graft selection.
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Affiliation(s)
- Robert Śmigielski
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757, Warsaw, Poland.
| | - Urszula Zdanowicz
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
| | - Michał Drwięga
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
| | - Bogdan Ciszek
- Department of Descriptive and Clinical Anatomy, Medical University of Warsaw, Chalbinskiego 5, 02-004 Warsaw, Poland
| | | | - Rainer Siebold
- Institute for Anatomy and Cell Biology, INF, Ruprecht-Karls University Heidelberg, Heidelberg, Germany. .,HKF: Center for Spezialised Hip-Knee-Foot Surgery, ATOS Hospital Heidelberg, Bismarckstr. 9-15, 69115, Heidelberg, Germany.
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Matsuo T, Mae T, Shino K, Kita K, Tachibana Y, Sugamoto K, Yoshikawa H, Nakata K. Tibiofemoral relationship following anatomic triple-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:2128-35. [PMID: 23989763 DOI: 10.1007/s00167-013-2646-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 08/21/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to investigate the tibiofemoral relationship sequentially before and after anatomic triple-bundle (TB) anterior cruciate ligament (ACL) reconstruction in the same patients. METHODS Nine patients with complete unilateral ACL rupture participated in this study. Anatomic TB ACL reconstruction was performed using autogenous semitendinosus tendon grafts. Computed tomography images were obtained before surgery as well as 3 weeks and 6 months afterwards. During image acquisition, the patient's knees were fully extended in the supine position. Using three-dimensional computer models, anterior-posterior and medial-lateral displacement of the tibia relative to the femur were evaluated for each period, as were internal-external and varus-valgus rotation, followed by calculation of side-to-side differences in parameters. As the control group, 7 healthy volunteers were evaluated. RESULTS The tibia was located anteriorly by 1.4 ± 0.9 mm and rotated internally by 2.1 ± 1.7° before surgery, while the tibia was located posteriorly by 2.0 ± 1.2 mm and rotated externally by 3.4 ± 3.5° 3 weeks after surgery. Six months after surgery, there was no significant difference between the patient and control groups. CONCLUSIONS The anteriorly located and internally rotated tibia in ACL-deficient knees was over-constrained (posterior displacement and external rotation) 3 weeks after anatomic TB ACL reconstruction, but returned to the normal position 6 months afterwards. Therefore, anatomic tunnel placement, appropriate initial tension, and moderate rehabilitation can be the key for return to the normal tibiofemoral relationship after ACL reconstruction. LEVEL OF EVIDENCE Therapeutic study, Level IV.
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Affiliation(s)
- Tomohiko Matsuo
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
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Tan K, Yoong P, Toms AP. Normal anatomical variants of the menisci and cruciate ligaments that may mimic disease. Clin Radiol 2014; 69:1178-85. [PMID: 25060935 DOI: 10.1016/j.crad.2014.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 06/06/2014] [Accepted: 06/16/2014] [Indexed: 11/30/2022]
Abstract
There are many normal anatomical variants of the knee joint. Some are common and others are rare. With continuing improvements in the spatial resolution of MRI, smaller variants are more clearly demonstrated and can be mistaken for disease. They can all be differentiated from pathological conditions by understanding their anatomy and key differentiating features. This review compares normal variants of the menisci and cruciate ligaments with the pathological disorders that can mimic them.
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Affiliation(s)
- K Tan
- Department of Radiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK.
| | - P Yoong
- Department of Radiology, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK
| | - A P Toms
- Department of Radiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
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MacKay JW, Whitehead H, Toms AP. Radiological evidence for the triple bundle anterior cruciate ligament. Clin Anat 2014; 27:1097-102. [DOI: 10.1002/ca.22420] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/29/2014] [Accepted: 05/02/2014] [Indexed: 11/08/2022]
Affiliation(s)
- James W. MacKay
- Department of Radiology; Norfolk & Norwich University Hospital; Norwich United Kingdom
| | - Harry Whitehead
- Department of Radiology; Norfolk & Norwich University Hospital; Norwich United Kingdom
| | - Andoni P. Toms
- Department of Radiology; Norfolk & Norwich University Hospital; Norwich United Kingdom
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Anterior cruciate ligament: an anatomical exploration in humans and in a selection of animal species. Knee Surg Sports Traumatol Arthrosc 2014; 22:961-71. [PMID: 23471530 DOI: 10.1007/s00167-013-2463-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 02/20/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Many anatomical anterior cruciate ligament (ACL) studies have indicated that the human ACL is composed of two functional bundles: the antero-medial (AM) and postero-lateral (PL). The purpose of this study is to compare the ACL anatomy among human and assorted animal species. METHODS Twenty fresh-frozen knees specimen were used: five humans, ten porcine, one goat, one Kodiak bear, one African lion, one Diana monkey and one Gazelle antelope. All the specimens were dissected to expose the ACL and to visualize the number of bundles and attachment patterns on the tibia and femur. Following the fibre orientation of the individual bundles, a wire loop was used to bluntly separate the bundles starting from the tibial insertion site to the femoral insertion site. In the human and porcine ACL, each bundle was separated into approximately 2 mm diameter segments and then tracked in order to establish the individual bundle's specific pattern of insertion on the femur and tibia. RESULTS It appeared that all human and animal knee specimens had three bundles that made up their ACL. In addition, it was noted that among the various specimens species, all viewed with an anterior view, and at 90° knee flexion, the ACL bony insertion sites had similar attachment patterns. CONCLUSION In all the specimens, including human, the ACL had three distinct bundles: AM, intermediate (IM) and PL. The bundles were composed of multiple fascicles arranged in a definite order and similar among the different species.
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Mochizuki T, Fujishiro H, Nimura A, Mahakkanukrauh P, Yasuda K, Muneta T, Akita K. Anatomic and histologic analysis of the mid-substance and fan-like extension fibres of the anterior cruciate ligament during knee motion, with special reference to the femoral attachment. Knee Surg Sports Traumatol Arthrosc 2014; 22:336-44. [PMID: 23344119 DOI: 10.1007/s00167-013-2404-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 01/14/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the morphology of the mid-substance and fan-like extension fibres of ACL during knee motion with reference to the femoral attachment. METHODS This study used six fresh-frozen cadaveric knees and 22 embalmed cadaveric knees to macroscopically evaluate morphological changes in the ACL attachment during knee motion. Three embalmed specimens fixed at knee extension and another three specimens fixed at 120° flexion were used for histologic observations. RESULTS The fan-like extension fibres were adhered to the bone surface and the fibre location and orientation in relation to the femoral surface did not change, regardless of the knee flexion angle, while the orientation of the mid-substance fibres in relation to the femur did change during knee motion. During knee flexion, a fold in the ACL femoral attachment was observed at the border between the mid-substance and the fan-like extension fibres. The attachment of the mid-substance fibres was significantly smaller than the attachment of the fan-like extension fibres. CONCLUSION The present study clarified anatomic and histologic character of the mid-substance fibres and fan-like extension fibres, and provided critical information for future clinical and biomechanical studies concerning both two different fibres. Specifically for ACL reconstruction, it is difficult to reconstruct the natural fan-like extension fibres by creating a tunnel at the femoral and tibial ends of each fibre bundle, although the mid-substance fibres can be reconstructed by such procedures.
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Affiliation(s)
- Tomoyuki Mochizuki
- Department of Joint Reconstruction, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Suomalainen P, Kannus P, Järvelä T. Double-bundle anterior cruciate ligament reconstruction: a review of literature. INTERNATIONAL ORTHOPAEDICS 2012; 37:227-32. [PMID: 23073927 DOI: 10.1007/s00264-012-1680-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 10/03/2012] [Indexed: 01/16/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) reconstruction has been under intensive discussion and debate, although the anatomy of this ligament was resolved thoroughly almost 200 years ago. The ACL consist of two bundles, anteromedial (AM) and posterolateral (PL). The conventional single-bundle method reconstructs the AM bundle only, while the modern double-bundle technique recreates both bundles for their anatomical sites. METHODS An English language literature search was undertaken over the years 2000-2012 for ACL reconstruction, double-bundle versus single bundle technique. The search found 14 RCTs and two meta-analyses published to date. RESULTS Two of the 14 studies (14 %) showed no difference between the two reconstruction methods while the remaining majority (12 trials, 86 %) concluded that the DB technique was better than the SB method. After the DB reconstruction, rotational stability of the knee was better in seven studies (50 %) and anteroposterior stability in six (43 %). No study spoke for the single-bundle technique. In addition, with the double-bundle technique knee scores were reported to be better in five (36 %) studies, and three trials (21 %) revealed less reoperations in the double-bundle group. CONCLUSIONS The double-bundle ACL reconstruction technique was reported to have better or at least the same results as the conventional single-bundle method-even at a five-year follow-up. However, the majority of these studies had a rather short follow-up, and thus, longer studies are needed to confirm the true long-term results of ACL surgery. Long follow-up periods are also needed to find out whether double-bundle ACL reconstruction can eventually prevent knee osteoarthritis.
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Affiliation(s)
- Piia Suomalainen
- Tampere University Hospital (TAYS), Teiskontie 35, 33520, Tampere, Finland.
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