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Legler J, Laverdiere C, Boily M, Tarchala M, Hart A, Martineau PA. Evaluating femoral graft placement using three-dimensional magnetic resonance imaging in the reconstruction of the anterior cruciate ligament via independent or transtibial drilling techniques: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1297-1306. [PMID: 38078954 DOI: 10.1007/s00590-023-03788-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/15/2023] [Indexed: 04/02/2024]
Abstract
PURPOSE Anterior cruciate ligament (ACL) reconstruction is a common surgical procedure, yet failure still largely occurs due to nonanatomically positioned grafts. The purpose of this study was to retrospectively evaluate patients with torn ACLs before and after reconstruction via 3D MRI and thereby assess the accuracy of graft position on the femoral condyle. METHODS Forty-one patients with unilateral ACL tears were recruited. Each patient underwent 3D MRI of both knees before and after surgery. The location of the reconstructed femoral footprint relative to the patient's native footprint was compared. RESULTS Native ACL anatomical location of the native ACL had a significant impact on graft position. Native ACLs that were previously more anterior yielded grafts that were more posterior (3.70 ± 1.22 mm, P = 0.00018), and native ACL that were previously more proximal yielded grafts that were more distal (3.25 ± 1.09 mm, P = 0.0042). Surgeons using an independent drilling method positioned 76.2% posteriorly relative to the native location, with a mean 0.1 ± 2.8 mm proximal (P = 0.8362) and 1.8 ± 3.0 mm posterior (P = 0.0165). Surgeons using a transtibial method positioned 75% proximal relative to the native location, with a mean 2.2 ± 3.0 mm proximal (P = 0.0042) and 0.2 ± 2.6 mm posterior (P = 0.8007). These two techniques showed a significant difference in magnitude in the distal-proximal axis (P = 0.0332). CONCLUSION The femoral footprint position differed between the native and reconstructed ACLs, suggesting that ACL reconstructions are not accurate. Rather, they are converging to a normative reference point that is neither anatomical nor isometric.
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Affiliation(s)
- Jack Legler
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.
| | - Carl Laverdiere
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Mathieu Boily
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | | | - Adam Hart
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
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Zhang L, Huang T, Li C, Xing X, Zou D, Dimitriou D, Tsai T, Li P. Race and Gender Differences in Anterior Cruciate Ligament Femoral Footprint Location and Orientation: A 3D-MRI Study. Orthop Surg 2024; 16:216-226. [PMID: 37953405 PMCID: PMC10782238 DOI: 10.1111/os.13918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE The femoral tunnel position is crucial to anatomic single-bundle anterior cruciate ligament (ACL) reconstruction, but the ideal femoral footprint position are mostly based on small-sized cadaveric studies and elderly patients with a single ethnic background. This study aimed to identify potential race- or gender-specific differences in the ACL femoral footprint location and ACL orientation, determine the correlation between the ACL orientation and the femoral footprint location. METHODS Magnetic resonance images (MRIs) of 90 Caucasian participants and 90 matched Chinese subjects were used for reconstruction of three-dimensional (3D) femur and tibial models. ACL footprints were sketched by several experienced orthopedic surgeons on the MRI photographs. The anatomical coordinate system was applied to reflect the ACL footprint location and orientation of scanned samples. The femoral ACL footprint locations were represented by their distance from the origin in the anteroposterior (A/P) and distal-proximal (D/P) directions. The orientation of the ACL was described with the sagittal, coronal and transverse deviation angles. The ACL orientation and femoral footprint position were compared by the two-sided t-test. Multiple regression analysis was used to study the correlation between the orientation and femoral footprint position. RESULTS The average femur footprint A/P position was -6.6 ± 1.6 mm in the Chinese group and -5.1 ± 2.3 mm in the Caucasian group, (p < 0.001). The average femur footprint D/P position was -2.8 ± 2.4 mm in Chinese and - 3.9 ± 2.0 mm in Caucasians, (p = 0.001). The Chinese group had a mean difference of a 1.5 mm (6.1%) more posterior and 1.1 mm (5.3%) more proximal in the position from the flexion-extension axis (FEA). And the males have a sagittal plane elevation about 4-5° higher than females in both racial groups. Furthermore, for every 1% (0.40 mm) increase in A/P and D/P values, the sagittal angle decreased by about 0.12° and 0.24°, respectively; the coronal angle decreased by about 0.10° and 0.30°, respectively. For every 1% (0.40 mm) increase in D/P value, the transverse angle increased by about 0.14°. CONCLUSION The significant race- and gender-specific differences in the femoral footprint and orientation of the ACL should be taken in consideration during anatomic single-bundle ACL reconstruction. Furthermore, the quantitative relationship between the ACL orientation and the footprint location might provide some reference for surgeons to develop a surgical strategy in ACL single-bundle reconstruction and revision.
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Affiliation(s)
- Lihang Zhang
- Guangdong Key Lab of Orthopedic Technology and Implant, General Hospital of Southern Theater Command of PLA, The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
| | - Tianwen Huang
- Guangdong Key Lab of Orthopedic Technology and Implant, General Hospital of Southern Theater Command of PLA, The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Changzhao Li
- Guangdong Key Lab of Orthopedic Technology and Implant, General Hospital of Southern Theater Command of PLA, The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- Department of BiostatisticsBioinformatics & Biomathematics Georgetown UniversityWashington, DCUSA
| | - Xing Xing
- School of Biomedical Engineering & Med‐X Research InstituteShanghai Jiao Tong UniversityShanghaiChina
| | - Diyang Zou
- Engineering Research Center of Digital Medicine and Clinical TranslationMinistry of EducationShanghaiChina
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants and Clinical Translational R&D Center of 3D Printing Technology, Shanghai Ninth People's HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of OrthopedicsUniversity Hospital BalgristZurichSwitzerland
| | | | - Tsung‐Yuan Tsai
- Engineering Research Center of Digital Medicine and Clinical TranslationMinistry of EducationShanghaiChina
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants and Clinical Translational R&D Center of 3D Printing Technology, Shanghai Ninth People's HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of OrthopedicsUniversity Hospital BalgristZurichSwitzerland
| | - Pingyue Li
- Guangdong Key Lab of Orthopedic Technology and Implant, General Hospital of Southern Theater Command of PLA, The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
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Lin J, Zhang S, Xin E, Liang M, Yang L, Chen J. Anterior cruciate ligament femoral footprint is oblong-ovate, triangular, or two-tears shaped in healthy young adults: three-dimensional MRI analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:5514-5523. [PMID: 37828405 DOI: 10.1007/s00167-023-07606-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE This study aimed to evaluate the morphology of the anterior cruciate ligament (ACL) femoral footprint with three-dimensional magnetic resonance imaging (3D MRI) in healthy knees. METHODS Fifty subjects with healthy knees were recruited, utilising 3D-SPACE sequences for ACL evaluation. The ACL was manually segmented, and the shape, size and location of the ACL femoral footprint were evaluated on a reformatted oblique-sagittal plane, which aligned closely with the ACL attachment. Statistical analysis included one-way ANOVA for continuous variables and Fisher's exact test for categorical variables, with a P value < 0.05 considered significant. RESULTS Three types of ACL femoral footprint shape were identified, namely, oblong-ovate (OO) in 33 knees (66%), triangular (Tr) in 12 knees (24%) and two-tears (TT) in 5 knees (10%), with the mean areas being 58, 47 and 68 mm2, respectively. Within group TT, regions with similar sizes but different locations were identified: high tear (TT-H) and low tear (TT-L). Notably, group OO demonstrated a larger notch height index, whilst group TT was characterised by a larger α angle and lateral femoral condyle index. A noticeable variation was observed in the location of the femoral footprint centre across groups, with group TT-L and group Tr showing a more distal position relative to the apex of the deep cartilage. According to the Bernard and Hertel (BH) grid, the ACL femoral footprint centres in group TT-L exhibited a shallower and higher position than other groups. Furthermore, compared to group OO and TT-H, group Tr showed a significantly higher position according to the BH grid. CONCLUSION In this study, the morphology of the ACL femoral footprint in healthy young adults was accurately evaluated using 3D MRI, revealing three distinct shapes: OO, Tr and TT. The different ACL femoral footprint types showed similar areas but markedly different locations. These findings emphasise the necessity of considering both the shape and precise location of the ACL femoral footprint during clinical assessments, which might help surgeons enhance patient-specific surgical plans before ACL reconstruction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jinrong Lin
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Shurong Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Enhui Xin
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Meng Liang
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Liqin Yang
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Jing'an District, Shanghai, 200040, People's Republic of China.
| | - Jiwu Chen
- Department of Sports Medicine, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 100 Haining Road, Hongkou District, Shanghai, 200080, People's Republic of China.
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Wang X, Qi Y, Bao H, Xu Y. Application of the 3D-MRI on post-operative graft assessment in adolescent patients with ACL reconstruction: A minimal 2-year follow-up. Front Surg 2023; 9:1070324. [PMID: 36684206 PMCID: PMC9852513 DOI: 10.3389/fsurg.2022.1070324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 01/09/2023] Open
Abstract
Background The purpose of the present study was to assess the prognostic morphological changes of the reconstructed hamstring auto-grafts by using reconstructed three-dimensional MRI (3D-MRI) in adolescent patients with ACLR. Methods 22 adolescent patients (less than 17 years old) were retrospective included between January 1, 2018, and October 31, 2020, in our department. The patients were divided into 2 subgroups: subgroup A (<14 years old) and subgroup B (≥14 years old). 3D-MRI was used to detect the total cross-sectional area (TCA) and long-to-short axis (LSA) ratio of the reconstructed ACL graft at the proximal, mid-point, and distal regions. The minimal follow-up was 2 years. Results The averaged follow-up of subgroup A and B was 37.8 ± 5.6 and 37.6 ± 6.5 months, respectively. Comparing to the initial graft (ACLR operation), the TCA of reconstructed ACL was increased by 30.6% on average, and the TCAs at proximal, mid-point, and distal regions were increased by 56.4%, 50.0%, and 17.7%, respectively, inner-group comparisons showed that the TCAs of the 3 region in subgroup A were all increased at the follow-up (P = 0.002) (P < 0.001) (P < 0.001), however, only increased mid-point (P = 0.024) and distal TCAs (P < 0.001) were found in subgroup B. Comparing to the native ACL, the proximal LSA ratio in subgroup A was comparable, while it was lower in subgroup B than the native ACL (P = 0.004), the distal LSA ratios in the 2 subgroups were both lower than the native ACL (P = 0.004) (P = 0.006). Conclusions 3D-MRI assessment can exactly identify the morphological changes of the graft in adolescent patients with ACLR, the TCA of the constructed ACL was increased compared to the initial graft, however, the LSA ratio was still lower than the native ACL. Younger adolescent patients may have a better potential on the ligamentization after ACLR than the older adolescent patients.
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Affiliation(s)
- Xiaona Wang
- Department of Imaging Medicine, Inner Mongolia People's Hospital, Hohhot, China
| | - Yansong Qi
- Department of Orthopedics (Sports Medicine Center), Inner Mongolia People's Hospital, Hohhot, China,Correspondence: Yongsheng Xu Yansong Qi
| | - Huricha Bao
- Department of Orthopedics (Sports Medicine Center), Inner Mongolia People's Hospital, Hohhot, China
| | - Yongsheng Xu
- Department of Orthopedics (Sports Medicine Center), Inner Mongolia People's Hospital, Hohhot, China,Correspondence: Yongsheng Xu Yansong Qi
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Dimitriou D, Cheng R, Yang Y, Helmy N, Tsai TY. Influence of the Anteromedial Portal and Transtibial Drilling Technique on Femoral Tunnel Lengths in ACL Reconstruction: Results Using an MRI-Based Model. Orthop J Sports Med 2022; 10:23259671221096417. [PMID: 35651481 PMCID: PMC9149612 DOI: 10.1177/23259671221096417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background: In anatomic anterior cruciate ligament (ACL) reconstruction, graft placement
through the anteromedial (AM) portal technique requires more horizontal
drilling of the femoral tunnel as compared with the transtibial (TT)
technique, which may lead to a shorter femoral tunnel and affect
graft-to-bone healing. The effect of coronal and sagittal femoral tunnel
obliquity angle on femoral tunnel length has not been investigated. Purpose: To compare the length of the femoral tunnels created with the TT technique
versus the AM portal technique at different coronal and sagittal obliquity
angles using the native femoral ACL center as the starting point of the
femoral tunnel. The authors also assessed sex-based differences in tunnel
lengths. Study Design: Descriptive laboratory study. Methods: Magnetic resonance imaging scans of 95 knees with an ACL rupture (55 men, 40
women; mean age, 26 years [range, 16-45 years]) were used to create
3-dimensional models of the femur. The femoral tunnel was simulated on each
model using the TT and AM portal techniques; for the latter, several coronal
and sagittal obliquity angles were simulated (coronal, 30°, 45°, and 60°;
sagittal, 45° and 60°), representing the 10:00, 10:30, and 11:00 clockface
positions for the right knee. The length of the femoral tunnel was compared
between the techniques and between male and female patients. Results: The mean ± SD femoral tunnel length with the TT technique was 40.0 ± 6.8 mm.
A significantly shorter tunnel was created with the AM portal technique at
30° coronal/45° sagittal (35.5 ± 3.8 mm), whereas a longer tunnel was
created at 60° coronal/60° sagittal (53.3 ± 5.3 mm; P <
.05 for both). The femoral tunnel created with the AM portal technique at
45° coronal/45° sagittal (40.7 ± 4.8 mm) created a similar tunnel length as
the TT technique. For all techniques, the femoral tunnel was significantly
shorter in female patients than male patients. Conclusion: The coronal and sagittal obliquity angles of the femoral tunnel in ACL
reconstruction can significantly affect its length. The femoral tunnel
created with the AM portal technique at 45° coronal/45° sagittal was similar
to that created with the TT technique. Clinical Relevance: Surgeons should be aware of the femoral tunnel shortening with lower coronal
obliquity angles, especially in female patients.
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Affiliation(s)
- Dimitris Dimitriou
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Department of Orthopedics, Bürgerspital Solothurn, Solothurn, Switzerland
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Rongshan Cheng
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yangyang Yang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Naeder Helmy
- Department of Orthopedics, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Sivakumaran T, Jaffer R, Marwan Y, Hart A, Radu A, Burman M, Martineau PA, Powell T. Reliability of Anatomic Bony Landmark Localization of the ACL Femoral Footprint Using 3D MRI. Orthop J Sports Med 2021; 9:23259671211042603. [PMID: 34692880 PMCID: PMC8532227 DOI: 10.1177/23259671211042603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Nonanatomic placement of anterior cruciate ligament (ACL) grafts is a leading cause of ACL graft failure. Three-dimensional (3D) magnetic resonance imaging (MRI) femoral footprint localization could enhance planning for an ACL graft's position. Purpose: To determine the intra- and interobserver reliability of measurements of the ACL femoral footprint position and size obtained from 3D MRI scans. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 41 patients with complete ACL tears were recruited between November 2014 and May 2016. Preoperatively, a coronal-oblique proton-density fast spin echo 3D acquisition of the contralateral uninjured knee was obtained along the plane of the ACL using a 1.5T MRI scanner. ACL footprint parameters were obtained independently by 2 musculoskeletal radiologists (observers A and B). The distal and anterior positions of the center of the footprint were measured relative to the apex of the deep cartilage at the posteromedial aspect of the lateral femoral condyle, and the surface area of the ACL femoral footprint was approximated from multiplanar reformatted images. After 1 month, the measurements were repeated. Intraclass correlation coefficients (ICCs) were calculated to assess for intra- and interobserver reliability. Bland-Altman plots were produced to screen for potential systematic bias in measurement and to calculate limits of agreement. Results: The ICCs for intraobserver reliability of the ACL femoral distal and anterior footprint coordinates were 0.75 and 0.78, respectively, for observer A. For observer B, they were 0.75 and 0.74, respectively. The ICCs for interobserver reliability were 0.75 and 0.85 for the distal and anterior coordinates, respectively. Bland-Altman plots demonstrated no significant systematic bias. For surface area measurements, the intraobserver ICCs were 0.37 and 0.62 for observers A and B, respectively. The interobserver reliability was 0.60. Observer B consistently measured the footprints as slightly larger versus observer A (1.19 ± 0.27 vs 1 ± 0.22 cm2, respectively; P < .001). Conclusion: Locating the center of the anatomic footprint of the ACL with 3D MRI showed substantial intra- and interobserver agreement. Interobserver agreement for the femoral footprint surface area was fair to moderate.
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Affiliation(s)
- Thiru Sivakumaran
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rehana Jaffer
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Yousef Marwan
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Adam Hart
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Arnold Radu
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Mark Burman
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Paul A Martineau
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Tom Powell
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
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Dimitriou D, Cheng R, Yang Y, Baumgaertner B, Helmy N, Tsai TY. High variability in anterior cruciate ligament femoral footprint: Implications for anatomical anterior cruciate ligament reconstruction. Knee 2021; 30:141-147. [PMID: 33930701 DOI: 10.1016/j.knee.2021.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The study aimed to (1) investigate the variability of the femoral ACL center in ACL-ruptured patients, (2) identify whether the currently available over-the-top femoral ACL guides could allow for anatomical reconstruction of the native ACL footprint. MATERIAL AND METHODS Magnetic resonance images of 95 knees with an ACL rupture were used to create three-dimensional models of the femur. The femoral ACL footprint area was outlined on each model, and the location of the femoral ACL center was reported using an anatomical coordinate system. The distance of the femoral ACL center from the over-the-top position was measured. RESULTS The femoral ACL center demonstrated a high intersubject variability ranging from 1.8 mm (9%) to 12.3 mm (60%) posterior and from 7.7 mm (37%) distal to 4.8 mm (23%) proximal using the posterior condyle circle reference. The average distance of the femoral ACL center from the over-the-top position was 1.9 ± 1.5 mm posterior and 13.8 ± 2.7 mm distal, respectively. The contemporary over-the-top femoral ACL aimers could restore the femoral ACL center in only 6.5% of the patients. CONCLUSIONS The femoral ACL center demonstrated a high variation on its location, which resulted in a high intersubject variability from the over-the-top position. The contemporary over-the-top femoral tunnel guides do not provide sufficient offset to allow for an anatomical ACL reconstruction. Anteromedial-portal specific femoral ACL guides with a femoral offset ranging from 10 to 18 mm in the proximal/distal direction are required to restore the native ACL footprint.
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Affiliation(s)
- Dimitris Dimitriou
- Department of Orthopedics Bürgerspital Solothurn, Schöngrünstrasse 42, CH-4500 Solothurn, Switzerland
| | - Rongshan Cheng
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China; Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yangyang Yang
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China; Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bodo Baumgaertner
- Department of Orthopedics Bürgerspital Solothurn, Schöngrünstrasse 42, CH-4500 Solothurn, Switzerland
| | - Naeder Helmy
- Department of Orthopedics Bürgerspital Solothurn, Schöngrünstrasse 42, CH-4500 Solothurn, Switzerland
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China; Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Dimitriou D, Wang Z, Zou D, Helmy N, Tsai TY. Do Sex-Specific Differences Exist in ACL Attachment Location? An MRI-Based 3-Dimensional Topographic Analysis. Orthop J Sports Med 2020; 8:2325967120964477. [PMID: 33294470 PMCID: PMC7708719 DOI: 10.1177/2325967120964477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Female sex is an independent risk factor for an anterior cruciate ligament (ACL) injury, as the incidence of an ACL rupture is 4- to 6-fold higher in female athletes compared with their male counterparts. The ACL attachment location as a potential risk factor for the increased ACL rupture rate in women has never been reported in the literature. Purpose/Hypothesis The purpose of the present study was to investigate the 3-dimensional topographic anatomy of the ACL bundle attachment in female and male patients, with and without an ACL rupture, and identify potential sex-related differences. We hypothesized that the ACL attachment location would be significantly different between men and women, in both the intact- and ruptured-ACL states. Study Design Cross-sectional study; Level of evidence, 3. Methods Magnetic resonance images of the knee from 90 patients (55 men, 35 women) with a ruptured ACL and 90 matched controls (55 men, 35 women), who suffered a noncontact knee injury without ACL rupture, were used to create 3-dimensional models of the femur and tibia. The ACL bundles' origin and insertion were outlined on each model, and their location was measured using an anatomical coordinate system. A 2-way analysis of variance was used to compare the ACL attachment location between male and female patients, with and without an ACL rupture. Results No significant differences were found between female and male participants regarding ACL attachment location (femoral origin and tibial insertion). Patients with a ruptured ACL demonstrated a significantly different ACL origin compared with the participants with an intact ACL by an average difference of 8.9% more posterior (P < .05) and 4.0% more proximal (P < .05) in men and 13.0% more posterior (P < .05) and 5.5% more proximal (P < .05) to the flexion-extension axis of the knee in women. Conclusion The ACL attachment location should not be considered a risk factor for the increased ACL rupture rates in female compared with male athletes. However, a more posterior and proximal location of the femoral ACL origin might be a predisposing factor to an ACL rupture regardless of sex.
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Affiliation(s)
- Dimitris Dimitriou
- Department of Orthopedics, Bürgerspital Solothurn, Solothurn, Switzerland
| | | | | | - Naeder Helmy
- Department of Orthopedics, Bürgerspital Solothurn, Solothurn, Switzerland
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Cremer P, Peltier A, Maubisson L, Neyret P, Lustig S, Servien E. Positioning of the Tibial Tunnel After Single-Bundle ACL Primary Reconstruction on 3D CT scans: A New Method. Arthrosc Sports Med Rehabil 2020; 2:e615-e622. [PMID: 33135002 PMCID: PMC7588642 DOI: 10.1016/j.asmr.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 07/16/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To assess intra-articular tunnel aperture positioning after primary anterior cruciate ligament (ACL) reconstruction with either the reference standard method or the intercondylar area method in a single center using 3-dimensional (3D) computed tomography (CT) scans and to evaluate the intra-articular position of the tibial tunnel relative to the ACL footprint. Methods 3D CT scans were performed after 120 single-bundle primary ACL reconstruction cases. The center of the tibial tunnel aperture and the center of the ACL footprint were referenced on axial views of the tibial plateau in the anteroposterior (AP) and mediolateral (ML) planes according to a centimetric grid system including the whole plateau (reference standard). This was compared with a grid system based on intercondylar area bony anatomy. The posterior aspect of intertubercular fossa, anterior aspect of the tibial plateau, medial intercondylar ridge, and crossing point between lateral intercondylar ridge and posterior margin were used as landmarks to define the grid. Results According to the reference standard method, the center of the tibial tunnel aperture was positioned 0.57 ± 2.62 mm more posterior and 0.67 ± 1.55 mm more medial than the center of the footprint. According to the intercondylar area method, the center of the tibial tunnel aperture was positioned 1.32 ± 2.74 mm more posterior and 0.66 ± 1.56 mm more medial than the center of the footprint. The position difference between the center of the tunnel aperture and the center of the footprint were statistically correlated for both grids, with r = –0.887, P < .001 for AP positioning and r = 0.615, P < .001 for ML positioning. Conclusion This intercondylar area method using arthroscopic landmarks can be used to assess tunnel placement on 3D CT scans after ACL reconstruction. Level of Evidence III, retrospective comparative study.
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Affiliation(s)
| | | | | | - Philippe Neyret
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
| | | | - Elvire Servien
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
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10
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Laverdiere C, Schupbach D, Schupbach J, Harvey E, Boily M, Burman M, Martineau PA. Can Surgeons Identify ACL Femoral Ridges Landmark and Optimal Tunnel Position? A 3D Model Study. Arthrosc Sports Med Rehabil 2020; 2:e361-e368. [PMID: 32875301 PMCID: PMC7451917 DOI: 10.1016/j.asmr.2020.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/13/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose To examine the ability of surgeons to identify the osseous landmarks associated with the femoral anterior cruciate ligament (ACL) footprint and locate optimal tunnel placement on 3-dimensional (3D) printed models compared with intraoperative placement. Methods Twelve sports fellowship-trained orthopaedic surgeons were asked to identify a femoral landmark and an ACL footprint on 10 different 3D printed knees. The 3D models were made based on 20 real patients with different anatomical morphology who later received ACL reconstructive surgery using independent drilling. ImageJ software was used to quantify the measurements, which were then analyzed using descriptive statistics. Results Overall, none of the surgeons were able to consistently identify the junction of the bony ridges. The mean error per participant ranged from 2.81 to 7.34 mm in the proximal direction (P = 3.30e-05) and from 2.42 to 8.05 mm in the posterior direction (P =4.88e-12). None of the surgeons were able to appropriately identify the center of the femoral footprint on the anatomic 3D models. The difference between the center of the footprint surgeons identified on the 3D model and the tunnel graft location in surgery was significantly different (P = .0046). On average, the magnitude of the error when the surgeons performed the actual surgery was 3.72 ± 2.43 mm, whereas on the 3D models it was 5.82 ± 1.97 mm. Conclusions Experienced sports fellowship-trained orthopaedic surgeons were unable to correctly identify the junction of the intercondylar and bifurcate ridges and the native ACL footprint on 3D models. Operatively placed tunnels were more accurate implying that looking either through a scope or soft-tissue landmarks play a significant role in surgeons ACL footprint localization. Clinical Relevance The graft position for ACL reconstruction plays an important role on the kinematics of the knee. This paper shows that soft tissue landmarks are needed to provide reliable reference points for reconstruction.
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Affiliation(s)
- Carl Laverdiere
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Drew Schupbach
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Justin Schupbach
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Eric Harvey
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Mathieu Boily
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Mark Burman
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
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11
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Marwan Y, Böttcher J, Laverdière C, Jaffer R, Burman M, Boily M, Martineau PA. Three-Dimensional Magnetic Resonance Imaging for Guiding Tibial and Femoral Tunnel Position in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study. Orthop J Sports Med 2020; 8:2325967120909913. [PMID: 32284939 PMCID: PMC7137122 DOI: 10.1177/2325967120909913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Femoral and tibial tunnel malposition for anterior cruciate ligament (ACL) reconstruction (ACLR) is correlated with higher failure rate. Regardless of the surgical technique used to create ACL tunnels, significant mismatches between the native and reconstructed footprints exist. Purpose: To compare the position of tunnels created by a standard technique with the ones created based on preoperative 3-dimensional magnetic resonance imaging (3D MRI) measurements of the ACL anatomic footprint. Study Design: Controlled laboratory study. Methods: Using 3D MRI, the native ACL footprints were identified. Tunnels were created on 16 knees (8 cadavers) arthroscopically. On one knee of a matched pair, the tunnels were created based on 3D MRI measurements that were provided to the surgeon (roadmapped technique), while on the contralateral knee, the tunnels were created based on a standard anatomic ACLR technique. The technique was randomly assigned per set of knees. Postoperatively, the positions of the tunnels were measured using 3D MRI. Results: On the tibial side, the median distance between the center of the native and reconstructed ACL footprints in relation to the root of the anterior horn of the lateral meniscus medially was 1.7 ± 2.2 mm and 1.9 ± 2.8 mm for the standard and roadmapped techniques, respectively (P = .442), while the median anteroposterior distance was 3.4 ± 2.4 mm and 2.5 ± 2.5 mm for the standard and roadmapped techniques, respectively (P = .161). On the femoral side, the median distance in relation to the apex of the deep cartilage (ADC) distally was 0.9 ± 2.8 mm and 1.3 ± 2.1 mm for the standard and roadmapped techniques, respectively (P = .195), while the median distance anteriorly from the ADC was 1.2 ± 1.3 mm and 4.6 ± 4.5 mm for the standard and roadmapped techniques, respectively (P = .007). Conclusion: Providing precise radiological measurements of the ACL footprints does not improve the surgeon’s ability to position the tunnels. Future studies should continue to attempt to provide tools to improve the tunnel position in ACLR. Clinical Relevance: This cadaveric study indicates that despite the use of 3D MRI in understanding the ACL anatomy, re-creating the native ACL footprints remains a challenge.
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Affiliation(s)
- Yousef Marwan
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Jens Böttcher
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Carl Laverdière
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Rehana Jaffer
- Department of Radiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Mark Burman
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Mathieu Boily
- Department of Radiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Paul A Martineau
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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12
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Laverdiere C, Harvey E, Schupbach J, Boily M, Burman M, Martineau PA. Effect of Teaching Session on Resident Ability to Identify Anatomic Landmarks and Anterior Cruciate Ligament Footprint: A Study Using 3-Dimensional Modeling. Orthop J Sports Med 2020; 8:2325967120905795. [PMID: 32201706 PMCID: PMC7068746 DOI: 10.1177/2325967120905795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 01/22/2023] Open
Abstract
Background: Femoral tunnel positioning in anterior cruciate ligament reconstruction
(ACLR) is an intricate procedure that requires highly specific surgical
skills. Purpose: To report the ability of residents to identify femoral landmarks and the
native ACL footprint before and after a structured formal teaching session
as a reflection of overall surgical skill training for orthopaedic surgery
residents in Canada. Study Design: Controlled laboratory study. Methods: A total of 13 senior orthopaedic residents were asked to identify a femoral
landmark and an ACL footprint on ten 3-dimensional (3D)–printed knee models
before and after a teaching session during the fall of 2018. The 3D models
were made based on actual patients with different anatomic morphologic
features. ImageJ software was used to quantify the measurements, which were
then analyzed through use of descriptive statistics. Results: Before and after the teaching session, residents attempted to identify a
specific anatomic location (bifurcate and intercondylar ridge intersection)
with a mean error per participant ranging from 5.00 to 10.95 mm and 4.79 to
12.13 mm in magnitude, respectively. Furthermore, before and after the
teaching session, residents identified the specific position to perform the
surgical procedure (ACL femoral footprint), with a mean error per
participant ranging from 4.58 to 8.80 mm and 3.87 to 11.07 mm in magnitude,
respectively. The teaching session resulted in no significant improvement in
identification of either the intersection of the bifurcate and intercondylar
ridges (P = .9343 in the proximal-distal axis and
P = .8133 in the anteroposterior axis) or the center of
the femoral footprint (P = .7761 in the proximal-distal
axis and P = .9742 in the anteroposterior axis). Conclusion: Although a formal teaching session was combined with a hands-on session that
entailed real surgical instrumentation and fresh cadaveric specimens, the
intervention seemed to have no direct impact on senior residents’
performance or their ability to demonstrate the material taught. This puts
into question the format and efficacy of present teaching methods. Also, it
is possible that the 3D spatial perception required to perform these skills
is not something that can be taught effectively through a teaching session
or at all. Further investigation is required regarding the effectiveness and
application of surgical skill laboratories and simulations on the
competencies of orthopaedic residents.
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Affiliation(s)
- Carl Laverdiere
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Eric Harvey
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Justin Schupbach
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Mathieu Boily
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Mark Burman
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Centre, Montréal, Quebec, Canada
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13
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Dimitriou D, Wang Z, Zou D, Tsai TY, Helmy N. The Femoral Footprint Position of the Anterior Cruciate Ligament Might Be a Predisposing Factor to a Noncontact Anterior Cruciate Ligament Rupture. Am J Sports Med 2019; 47:3365-3372. [PMID: 31647682 DOI: 10.1177/0363546519878706] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the femoral tunnel position is crucial to anatomic single-bundle anterior cruciate ligament (ACL) reconstruction, the recommendations for the ideal femoral footprint position are mostly based on cadaveric studies with small sample sizes, elderly patients with unknown ACL status, and 2-dimensional techniques. Furthermore, a potential difference in the femoral ACL footprint position and ACL orientation between ACL-ruptured and ACL-intact knees has not been reported in the literature. HYPOTHESIS The femoral ACL footprint position and ACL orientation vary significantly between ACL-ruptured and matched control ACL-intact knees. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Magnetic resonance images of the knees of 90 patients with an ACL rupture and 90 matched control participants who had a noncontact knee injury without an ACL rupture were used to create 3-dimensional models of the femur and tibia. The ACL footprints were outlined on each model, and their positions (normalized to the lateral condyle width) as well as ACL orientations were measured with an anatomic coordinate system. RESULTS The femoral ACL footprint in patients with an ACL rupture was located at 36.6% posterior and 11.2% distal to the flexion-extension axis (FEA). The ACL orientation was 46.9° in the sagittal plane, 70.3° in the coronal plane, and 20.8° in the transverse plane. The ACL-ruptured group demonstrated a femoral ACL footprint position that was 11.0% more posterior and 7.7% more proximal than that of the control group (all P < .01). The same patients also exhibited 5.7° lower sagittal elevation, 3.1° higher coronal plane elevation, and 7.9° lower transverse plane deviation (all P < .01). The optimal cutoff value of the femoral ACL footprint position to prevent an ACL rupture was at 30% posterior and 12% distal to the FEA. CONCLUSION The ACL femoral footprint position might be a predisposing factor to an ACL rupture. Patients with a >30% posterior and <12% distal position of the femoral ACL footprint from the FEA might have a 51.2-times increased risk of an ACL rupture.
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Affiliation(s)
- Dimitris Dimitriou
- Department of Orthopaedics, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Zhongzheng Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Clinical Translational Digital Medicine, Ministry of Education of the People's Republic of China, Beijing, China
| | - Diyang Zou
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Clinical Translational Digital Medicine, Ministry of Education of the People's Republic of China, Beijing, China
| | - Tsung-Yuan Tsai
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Clinical Translational Digital Medicine, Ministry of Education of the People's Republic of China, Beijing, China
| | - Naeder Helmy
- Department of Orthopaedics, Bürgerspital Solothurn, Solothurn, Switzerland
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14
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Pedneault C, Laverdière C, Hart A, Boily M, Burman M, Martineau PA. Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2019; 47:3187-3194. [PMID: 31513428 DOI: 10.1177/0363546519873633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic anterior cruciate ligament (ACL) reconstruction improves knee kinematics and joint stability in symptomatic patients who have ACL deficiency. Despite a concerted effort to place the graft within the ACL's native attachment sites, the accuracy of tunnel placement using contemporary techniques is not well established. PURPOSE To use 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate the accuracy of tibial tunnel placement after anatomic ACL reconstruction. STUDY DESIGN Case series; Level of evidence, 4. METHODS Forty patients with symptomatic, ACL-deficient knees were prospectively enrolled in the study and underwent 3D MRI of both their injured and uninjured knees before and after surgery through use of a validated imaging protocol. The root ligament of the anterior horn of the lateral meniscus was used as a radiographic reference, and the center of the reconstructed graft was compared with that of the contralateral normal knee. The tunnel angles and intra-articular graft angles were also measured, as was the percentage overlap between the native tibial footprint and tibial tunnel. RESULTS The reconstructed tibial footprint was placed at a mean ± SD of 2.14 ± 2.45 mm (P < .001) medial and 5.11 ± 3.57 mm (P < .001) posterior to the native ACL footprint. The mean distance between the center of the native and reconstructed ACL at the tibial attachment site was 6.24 mm. Of the 40 patients, 18 patients had a tibial tunnel that overlapped more than 50% of the native footprint, and 10 patients had maximal (100%) overlap. Further, 22 of the 40 patients had less than 50% overlap with the native footprint, and in 12 patients the footprint was missing completely. CONCLUSION Despite the use of contemporary surgical techniques to perform anatomic ACL reconstruction, a significant positioning error in tibial tunnel placement remains.
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Affiliation(s)
- Christopher Pedneault
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | | | - Adam Hart
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | - Mathieu Boily
- Department of Musculoskeletal Radiology, McGill University Health Center, Montreal, Québec, Canada
| | - Mark Burman
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
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15
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Mayer C, Barner K, Lorimer S, Tran Q, Baer J, Keim Janssen S, McCumber T, Wright B. Side Variations of Anterior Cruciate Ligament Coronal Angles: Implications for ACL Reconstruction. Clin Anat 2019; 32:1102-1106. [PMID: 31444834 DOI: 10.1002/ca.23464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 08/09/2019] [Accepted: 08/17/2019] [Indexed: 11/09/2022]
Abstract
Current literature has shown a biomechanical advantage of recreating the native coronal obliquity of the anterior cruciate ligament (ACL) during grating procedures; however, the majority of studies on ACL morphological variation have been performed unilaterally. This cadaveric study aimed to evaluate sided ACL coronal angle of inclination variation including trend analysis with sex, age, height, and femoral condyle width. The ACLs of 57 embalmed cadaveric specimens were evaluated bilaterally for a total of 114 ACLs. The knees were flexed to 110°. A 0.70-mm wire measured coronal angulation through the lateral tibial plateau and the medial ACL border. An image taken of the wire allowed digital measurement with the ImageJ software. IBM SPSS was utilized for statistical analysis. Bilateral measurements demonstrated a difference in an individual's sided ACL angulation (P < 0.001). Right-sided angulation was greater in 61.4% (35/57). In cadavers with greater right-side angulation, right ACLs averaged 66.2° versus left ACLs averaged 60.9° (P < 0.001). Cadavers with greater left-sided ACL angles demonstrated average left ACLs measuring 65.5° versus right ACLs measuring 60.6° (P < 0.001). Right-sided angles were greater in 69.7% of females. Understanding the anatomy of the ACL's native coronal angle and variations between a patient's knees is imperative during reconstruction surgery to aid in anatomic tunnel placement for improved knee motion and rotational knee kinematics following surgery. A statistically significant difference exists between an individual's right and left ACL coronal angles of inclination. Clin. Anat. 32:1102-1106, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Catherine Mayer
- Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri
| | - Kyle Barner
- Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri
| | - Shannon Lorimer
- Department of Orthopedics, CAPT James A. Lovell FHCC, North Chicago, Illinois
| | - Quoc Tran
- Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri
| | - Jacob Baer
- Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri
| | - Sarah Keim Janssen
- Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri
| | - Travis McCumber
- Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center College of Medicine, Omaha, Nebraska
| | - Barth Wright
- Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri
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16
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Astur DDC, Novaretti JV, Liggieri AC, Janovsky C, Nicolini AP, Cohen M. Ultrasonography for evaluation of hamstring tendon diameter: is it possible to predict the size of the graft? Rev Bras Ortop 2018; 53:404-409. [PMID: 30027070 PMCID: PMC6051959 DOI: 10.1016/j.rboe.2018.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 11/16/2022] Open
Abstract
Objective Perform the preoperative measurement of the hamstring tendons using ultrasound imaging, validating and correlating the measured value with that found during surgical reconstruction of the ligament. Methods A cross-sectional study was carried out with 24 patients who underwent ultrasonographic measurement of the semitendinosus and gracilis muscle tendons and were subsequently submitted to surgical reconstruction of the ACL, with ipsilateral semitendinosus and gracilis tendon grafting. Results The patients’ ages ranged from 16 to 43 years, with a mean of 24.8 years (SD = 8.4 years), 79.2% were men, and the distribution by side was 41.7% right knees and 58.3% left knees. A non-significant correlation coefficient was found between the area calculated by ultrasound (2 × semitendinosus area + 2 × gracilis area) and the intraoperative measurement (r = 0.16; p = 0.443). No evidence of a difference between intraoperative measurements <8 mm and ≥8 mm was found for the area calculated by the ultrasound (p = 0.746). The difference observed between the groups was −0.01 (95% CI: −0.09 to 0.07). Conclusion Preoperative ultrasound imaging of the semitendinosus and gracilis tendons does not present a statistically significant correlation with the intraoperative measurement of the quadruple hamstring graft for ligament reconstruction.
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Affiliation(s)
- Diego da Costa Astur
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - João Victor Novaretti
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Andre Cicone Liggieri
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - César Janovsky
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Pedro Nicolini
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Moises Cohen
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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17
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Astur DDC, Novaretti JV, Liggieri AC, Janovsky C, Nicolini AP, Cohen M. Ultrassonografia para avaliação do diâmetro dos tendões flexores do joelho: é possível predizer o tamanho do enxerto? Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Kim SH, Lee HJ, Park YB, Jeong HS, Ha CW. Anterior Cruciate Ligament Tibial Footprint Size as Measured on Magnetic Resonance Imaging: Does It Reliably Predict Actual Size? Am J Sports Med 2018; 46:1877-1884. [PMID: 29738676 DOI: 10.1177/0363546518767874] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Measuring the size of the anterior cruciate ligament (ACL) tibial footprint on magnetic resonance image (MRI) is common for preoperative planning of ACL reconstruction. However, the accuracy of such measurement has not been well documented. PURPOSE To investigate whether the actual size of the ACL tibial footprint could be predicted by its measurement on MRI and to develop equations to improve the accuracy of predicting the actual size based on MRI measurement. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS A total of 164 patients with normal visualized ACL in gross evaluation and MRI were included (mean ± SD age, 67.3 ± 8.3 years). Cases with ACL tear, severe mucoid degeneration, osteophyte around the ACL tibial insertion, or intervals >12 months between MRI and actual measurement were excluded. The ACL tibial footprint was carefully dissected and measured during total knee arthroplasty. The length of the ACL tibial footprint on MRI was measured on a sagittal image, while the width was measured on an oblique coronal image. For the ACL tibial footprint, the association between measurement on MRI and actual measurement of length and width was analyzed via univariable and multivariable regression analyses. Reliability of measurements on MRI was also evaluated. RESULTS The length and width of the ACL tibial footprint as measured on MRI showed strong correlation with the actual length and width (coefficients: ρ = 0.904 and ρ = 0.808, respectively). There were differences between ACL size on MRI and its actual size: length, 12.4 mm (range, 9.7-15.3 mm) vs 13.8 (10.6-17.8) ( P < .001); width, 8.8 mm (range, 7.0-12.1 mm) vs 7.2 (5.8-10.4) ( P < .001). Based on sex, there were also differences between the size per MRI and the actual size ( P < .001 for all): length in men, 12.6 mm (range, 10.9-15.3 mm) vs 14.2 (12.3-17.8); length in women, 12.4 mm (range, 9.7-14.5 mm) vs 13.7 (10.6-15.8); width in men, 9.3 mm (range, 8.0-12.1 mm) vs 7.6 (5.8-10.4); width in women, 8.7 mm (range, 7.0-10.4 mm) vs 7.2 (5.8-9.7). The actual length of the ACL tibial footprint could be predicted by its length on MRI and sex ( R2 = 0.83, P < .001). Similarly, actual width could be predicted by the width on MRI and sex ( R2 = 0.75, P < .001). All intraclass correlation coefficients were >0.8, indicating good reliability. CONCLUSION Measurements of the size of the ACL tibial footprint on MRI showed strong correlation with its actual size. Prediction equations showed good concordance correlation coefficients.
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Affiliation(s)
- Seong Hwan Kim
- Department of Orthopedic Surgery, Hanmaeum Changwon Hospital, Han-Yang University, Changwon-Si, KyungSangNam-Do, Republic of Korea
| | - Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Dongjak-gu, Seoul, Republic of Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Dongjak-gu, Seoul, Republic of Korea
| | - Han-Sol Jeong
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Dongjak-gu, Seoul, Republic of Korea
| | - Chul-Won Ha
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
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Three-dimensional isotropic magnetic resonance imaging can provide a reliable estimate of the native anterior cruciate ligament insertion site anatomy. Knee Surg Sports Traumatol Arthrosc 2018; 26:1311-1318. [PMID: 28612204 PMCID: PMC5729064 DOI: 10.1007/s00167-017-4560-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 04/26/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE This study quantified the error in anterior cruciate ligament (ACL) insertion site location and area estimated from three-dimensional (3D) isotropic magnetic resonance imaging (MRI) by comparing to native insertion sites determined via 3D laser scanning. METHODS Isotropic 3D DESS MRI was acquired from twelve fresh-frozen, ACL-intact cadaver knees. ACL insertion sites were manually outlined in each MRI slice, and the resulting contours combined to determine the 3D insertion site shape. Specimens were then disarticulated, and the boundaries of the ACL insertion sites were digitized using a high-accuracy laser scanner. MRI and laser scan insertion sites were co-registered to determine the percent overlapping area and difference in insertion centroid location. RESULTS Femoral ACL insertion site area averaged 112.7 ± 17.9 mm2 from MRI and 109.7 ± 10.9 mm2 from laser scan (p = 0.345). Tibial insertion area was 134.7 ± 22.9 mm2 from MRI and 135.2 ± 15.1 mm2 from laser scan (p = 0.881). Percentages of overlapping area between modalities were 82.2 ± 10.2% for femurs and 81.0 ± 9.0% for tibias. The root-mean-square differences for ACL insertion site centroids were 1.87 mm for femurs and 2.49 mm for tibias. The MRI-estimated ACL insertion site centroids were biased on average 0.6 ± 1.6 mm proximally and 0.3 ± 1.9 mm posteriorly for femurs, and 0.3 ± 1.1 mm laterally and 0.5 ± 1.5 mm anteriorly for tibias. CONCLUSION Errors in ACL insertion site location and area estimated from 3D-MRI were determined via comparison with a high-accuracy 3D laser scanning. Results indicate that MRI can provide estimates of ACL insertion site area and centroid location with clinically applicable accuracy. MRI-based assessment can provide a reliable estimate of the native ACL anatomy, which can be helpful for surgical planning as well as assessment of graft tunnel placement.
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Hart A, Sivakumaran T, Burman M, Powell T, Martineau PA. A Prospective Evaluation of Femoral Tunnel Placement for Anatomic Anterior Cruciate Ligament Reconstruction Using 3-Dimensional Magnetic Resonance Imaging. Am J Sports Med 2018; 46:192-199. [PMID: 28972789 DOI: 10.1177/0363546517730577] [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: 01/31/2023]
Abstract
BACKGROUND The recent emphasis on anatomic reconstruction of the anterior cruciate ligament (ACL) is well supported by clinical and biomechanical research. Unfortunately, the location of the native femoral footprint can be difficult to see at the time of surgery, and the accuracy of current techniques to perform anatomic reconstruction is unclear. PURPOSE To use 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate patients with torn ACLs before and after reconstruction and thereby assess the accuracy of graft position on the femoral condyle. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Forty-one patients with unilateral ACL tears were recruited into the study. Each patient underwent 3D MRI of both the injured and uninjured knees before surgery. The contralateral (uninjured) knee was used to define the patient's native footprint. Patients then underwent ACL reconstruction, and the injured knee underwent reimaging after surgery. The location and percentage overlap of the reconstructed femoral footprint were compared with the patient's native footprint. RESULTS The center of the native ACL femoral footprint was a mean 12.0 ± 2.6 mm distal and 9.3 ± 2.2 mm anterior to the apex of the deep cartilage. The position of the reconstructed graft was significantly different, with a mean distance of 10.8 ± 2.2 mm distal ( P = .02) and 8.0 ± 2.3 mm anterior ( P = .01). The mean distance between the center of the graft and the center of the native ACL femoral footprint (error distance) was 3.6 ± 2.6 mm. Comparing error distances among the 4 surgeons demonstrated no significant difference ( P = .10). On average, 67% of the graft overlapped within the native ACL femoral footprint. CONCLUSION Despite contemporary techniques and a concerted effort to perform anatomic ACL reconstruction by 4 experienced sports orthopaedic surgeons, the position of the femoral footprint was significantly different between the native and reconstructed ACLs. Furthermore, each surgeon used a different technique, but all had comparable errors in their tunnel placements.
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Affiliation(s)
- Adam Hart
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Thiru Sivakumaran
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | - Mark Burman
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Tom Powell
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
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Can we predict the size of frequently used autografts in ACL reconstruction? Knee Surg Sports Traumatol Arthrosc 2017; 25:3704-3710. [PMID: 26183732 DOI: 10.1007/s00167-015-3695-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/01/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE This study presents a method to measure the size of quadriceps, patellar tendon and hamstring autografts using preoperative magnetic resonance imaging (MRI). METHODS Sixty-two subjects with a mean age of 25 ± 10 years who underwent ACL surgery between 2011 and 2014 were included. Patient anthropometric data were recorded for all subjects. During surgery, the respective autograft was harvested and measured using commercially available graft sizers. MRI measurements were performed by two raters, who were blinded to the intra-operative measurements. RESULTS The inter- and intra-rater reliability was ≥0.8 for all MRI measurements. The intra-class correlation coefficient between the MRI measurement of the graft and the actual size of the harvested graft was 0.639. There were significant correlations between quadriceps tendon thickness and height (r = 0.3, p < 0.03), weight (r = 0.3, p < 0.01), BMI (r = 0.3, p < 0.04) and gender (r = -0.4, p < 0.002) and patellar tendon thickness and height (r = 0.4, p < 0.01), weight (r = 0.3, p < 0.01) and gender (r = -0.4, p < 0.012). CONCLUSION Preoperative MRI measurements of quadriceps, patellar tendon and hamstring graft size are highly reliable with moderate-to-good accuracy. Significant correlations between patient anthropometric data and the thicknesses of the quadriceps and patellar tendons were observed. Obtaining this information can be useful for preoperative planning and to help counsel patients on appropriate graft choices prior to surgery. LEVEL OF EVIDENCE III.
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Ahmed A, Razzaque MA, Kaleem M, Zaman AU, Akram R, Javed S. Diagnostic accuracy of magnetic resonance imaging in detecting anterior cruciate ligament injuries. MEDICAL JOURNAL OF INDONESIA 2017. [DOI: 10.13181/mji.v26i3.1873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Background: The anterior cruciate ligament (ACL) stabilizes the joint during hyperextension and prevents anterior translation over femur. The objective of this study was to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting ACL injury by taking arthroscopy as gold standard in patients with traumatic knee injury.Methods: Patients fulfilling the study criteria were treated with clinical examination, MRI and then arthroscopy at the Department of Orthopedics and Spine in the Ghurki Trust Teaching Hospital, Lahore. The accuracy, sensitivity and specificity of MRI in diagnosing the anterior cruciate ligament injury were calculated based on arthroscopic findings. All the data were analyzed using SPSS 17.0 version.Results: A total 185 patients were included. 91.1% were males and 8.9% were females with Mean age of 28.25±0.433. The accuracy of MRI in diagnosing the anterior cruciate ligament was 91.89%, with sensitivity of 93.33%, specificity of 85.71%, positive predictive value of 96.55% and the negative predictive value of 75%.Conclusion: MRI is accurate and non-invasive modality for the assessment of ligamentous injuries. It can be used as a first line investigation to patients with suspicion of ACL injury.
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Preoperative prediction of anterior cruciate ligament tibial footprint size by anthropometric variables. Knee Surg Sports Traumatol Arthrosc 2017; 25:1638-1645. [PMID: 27193008 DOI: 10.1007/s00167-016-4164-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to evaluate whether the ACL tibial footprint size can be predicted by anthropometric variables including height, weight, leg length, femur length, tibia length, and anteroposterior and mediolateral diameters of proximal tibia. METHODS This study included 209 out of the 378 eligible patients. The inclusion criterion was ACL with normal gross appearance. Patients with conditions that could have affected the measurement were excluded: torn ACL, osteophyte formation around the ACL tibial attachment, presence of inflammatory arthritis, or history of knee joint infection. According to the above criteria, 169 patients were excluded from this study; 138 had torn ACL, 24 had osteophyte around the ACL footprint, 5 had history of rheumatoid arthritis, and 2 had history of previous knee joint infection. The ACL tibial footprint was carefully dissected and measured during total knee arthroplasty. Anthropometric variables regarding bone lengths were measured on radiography. The association of the ACL tibial footprint size (length and width) with anthropometric variables was analysed using simple and multiple linear regression analyses. RESULTS The height, weight, leg length, femur length, tibia length, and the size of proximal tibia were associated with the ACL tibial footprint length and width. The ACL tibial footprint length could be predicted by the equation using tibia length: ACL tibial footprint length = -9.361 + 0.759 * (tibia length in cm) (R 2 = 0.44, P < 0.001) and width by the equation using weight and tibia length: ACL tibial footprint width = -0.5615 + 0.279 * (tibia length in cm) + 0.0333 * (weight in kgs) (R 2 = 0.17, P < 0.001). The concordance correlation coefficient for the measured and predicted values of ACL tibial footprint length and width showed moderate and low agreement, respectively (0.61, 95 % CI 0.53-0.68; 0.30, 95 % CI 0.21-0.38). CONCLUSION The ACL tibial footprint length and width are associated with anthropometric variables, especially with tibial length. The predictive equation developed from this study can serve as supplementary guides to determine the surgical techniques and graft options in preoperative planning of an individual ACL reconstruction. LEVEL OF EVIDENCE IV.
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Xu H, Zhang C, Zhang Q, Du T, Ding M, Wang Y, Fu SC, Hopkins C, Yung SH. A Systematic Review of Anterior Cruciate Ligament Femoral Footprint Location Evaluated by Quadrant Method for Single-Bundle and Double-Bundle Anatomic Reconstruction. Arthroscopy 2016; 32:1724-34. [PMID: 27140814 DOI: 10.1016/j.arthro.2016.01.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/23/2016] [Accepted: 01/27/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To unravel the standard position of anterior cruciate ligament (ACL) femoral origin and deduce practical arthroscopic localization and postsurgical evaluation method. METHODS Two independent reviewers searched PubMed using the terms ACL, footprint, femur, etc. We included studies published since January 1, 2000, in which the results were measured by Bernard's quadrant method. This method consists of 4 distances, including total diameter of lateral condyle along Blumensaat's line (distance t), maximum intercondylar notch height (distance h), distance from center of footprint to proximal border (distance x), and distance from center of footprint to Blumensaat's line (distance y). The data of included studies were combined to calculate theoretical centers and standard area for both ACL as a whole bundle and as anteromedial (AM) and posterolateral (PL) bundles individually. Finally, we translated the combined data to arthroscopic localization and postsurgical evaluation. RESULTS A total of 13 studies were included. The theoretical centers of ACL as a whole bundle is 28.4% ± 5.1% (x) of distance t and 35.7% ± 6.9% (y) of distance h, whereas AM bundle is 24.2% ± 4%, 21.6% ± 5.2% (x, y) and PL bundle is 32.8% ± 4.7%, 46.7% ± 4.9% (x, y), respectively. The standard area of ACL footprint is a circle with a center of 27.53%, 35.85% (x, y), and a radius of 4.58%, 9.2% (x, y), respectively. Translation of combined data shows that under arthroscopy, for single-bundle ACL reconstruction, the midpoint of distance from border of proximal to distal articular cartilage is the center of anatomic femoral socket. CONCLUSIONS Combined data unravel the standard position of ACL femoral origin. It can be used by clinicians to localize anatomic tunnel both in surgery and postsurgical evaluation. For single-bundle ACL reconstruction, the midpoint of lateral femoral condyle corresponds to anatomic socket. LEVEL OF EVIDENCE Level V, systematic review of anatomic studies.
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Affiliation(s)
- Hu Xu
- Institution of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Chunli Zhang
- Institution of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Qiang Zhang
- Institution of Orthopedics, The Third People's Hospital, Hefei, China
| | - Tianshu Du
- Institution of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ming Ding
- Institution of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yingchun Wang
- Institution of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chelsea Hopkins
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Lee BH, Seo DY, Bansal S, Kim JH, Ahn JH, Wang JH. Comparative Magnetic Resonance Imaging Study of Cross-Sectional Area of Anatomic Double Bundle Anterior Cruciate Ligament Reconstruction Grafts and the Contralateral Uninjured Knee. Arthroscopy 2016; 32:321-9.e1. [PMID: 26603824 DOI: 10.1016/j.arthro.2015.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 07/15/2015] [Accepted: 08/06/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the differences between cross-sectional area of the reconstructed graft by 2 anatomic double-bundle anterior cruciate ligament (ACL) reconstruction techniques, transportal and outside-in and contralateral uninjured knee. METHODS In prospective, randomized controlled trials, magnetic resonance imaging of both the reconstructed anatomic double-bundle ACL graft side and the contralateral uninjured knee of 92 patients (mean age, 34.7 ± 10.7 years) between November 2010 and January 2013 were compared. The 3-dimensional curved multiplanar reconstruction function of OsiriX v5.6 was used. Cross-sectional area was measured from the femoral insertion site to the tibial insertion site at 5 different locations, including the midsubstance. RESULTS A significant difference was observed between areas of the uninjured side and reconstructed side at the 5 locations. The area of the reconstructed graft at the femoral insertion site (64 ± 13 mm(2)) and midsubstance (62 ± 11 mm(2)) was larger that of the normal ACL (femoral insertion site; 60 ± 13 mm(2), P = .005 and midsubstance; 47 ± 13 mm(2), P = .0001), whereas at the tibial insertion site (71 ± 13 mm(2)) it was smaller than normal ACL (97 ± 22 mm(2), P = .0001). The measured area between the reconstructed graft and normal uninjured side at the femoral insertion site was relatively closer than that at midsubstance and the tibial insertion-site area. CONCLUSIONS A double-bundle anterior cruciate ligament reconstruction graft relatively closely restored the cross-sectional area of the femoral footprint area but was smaller than that of the tibial footprint area; however, the cross-sectional area of graft was much larger than that of the midsubstance.
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Affiliation(s)
- Byung Hoon Lee
- Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Dong Yeon Seo
- Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Samarjit Bansal
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jun Ho Kim
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Hwan Ahn
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Helito CP, Bonadio MB, Gobbi RG, da Mota e Albuquerque RF, Pécora JR, Camanho GL, Demange MK. Combined Intra- and Extra-articular Reconstruction of the Anterior Cruciate Ligament: The Reconstruction of the Knee Anterolateral Ligament. Arthrosc Tech 2015; 4:e239-44. [PMID: 26258037 PMCID: PMC4523866 DOI: 10.1016/j.eats.2015.02.006] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 02/13/2015] [Indexed: 02/07/2023] Open
Abstract
We present a new technique for the combined intra- and extra-articular reconstruction of the anterior cruciate ligament. Intra-articular reconstruction is performed in an outside-in manner according to the precepts of the anatomic femoral tunnel technique. Extra-articular reconstruction is performed with the gracilis tendon while respecting the anatomic parameters of the origin and insertion points and the path described for the knee anterolateral ligament.
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Affiliation(s)
- Camilo Partezani Helito
- Address correspondence to Camilo Partezani Helito, M.D., Department of Orthopedics and Traumatology, Faculty of Medicine, University of São Paulo, 333 Dr. Ovídio Pires de Campos St, São Paulo, Brazil 05403-010.
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Swami VG, Cheng-Baron J, Hui C, Thompson RB, Jaremko JL. Reliability of 3D localisation of ACL attachments on MRI: comparison using multi-planar 2D versus high-resolution 3D base sequences. Knee Surg Sports Traumatol Arthrosc 2015; 23:1206-14. [PMID: 24651978 DOI: 10.1007/s00167-014-2948-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Anatomic placement of anterior cruciate ligament (ACL) grafts at arthroscopic reconstruction can be challenging. Localising ACL attachments on magnetic resonance imaging (MRI) sequences pre-operatively could aid with planning for anatomic graft placement. Though ACL attachments can be identified on two-dimensional (2D) MRI, slice thickness theoretically limits out-of-plane accuracy and a 3D MRI base sequence with smaller isotropic voxels may improve observer reliability in localising ACL attachment locations. The purpose of this study was to test whether a high-resolution 3D sequence improved inter- and intra-observer reliability of ACL attachment localisation compared with conventional 2D MRI for this application. METHODS Twenty paediatric knees were retrospectively scanned at 1.5 Tesla with multi-planar 2D proton density (slice thickness 3-4 mm) and T2-weighted 3D multiple-echo data image combination gradient echo (isotropic 0.8 mm voxels) sequences. Two observers blinded to each others' findings identified ACL attachments on MRI slices, and 3D reconstructions showing ACL attachments were produced. ACL attachment centre locations and areas were calculated, and reliability assessed. RESULTS Inter-observer variation of centre locations of ACL attachments identified on 3D versus 2D sequences was not significantly different (mean ± SD): 1.8 ± 0.6 versus 1.5 ± 0.7 mm at femoral attachments, 1.7 ± 0.7 versus 1.5 ± 0.8 mm at tibial attachments (p > 0.05). The 95 % confidence interval for centre locations was <4.0 mm in all cases. Inter-observer reliability of attachment areas was not higher for 3D sequences. CONCLUSIONS ACL attachment centres were localised with high and similar inter- and intra-observer reliability on a high-resolution 3D and multi-planar conventional 2D sequences. Using this technique, MRI could potentially be used for planning and intra-operative guidance of anatomic ACL reconstruction, whether from 2D or 3D base sequences. Surgeons in clinical practice need not order a lengthy dedicated 3D MRI to localise ligament attachments, but can confidently use a standard 2D MRI for this application. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Vimarsha Gopal Swami
- Department of Radiology and Diagnostic Imaging, University of Alberta, 2A2.41 WC Mackenzie Health Sciences Centre, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada,
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Han Y, Hart A, Martineau PA. Is the clock face an accurate, precise, and reliable measuring tool for anterior cruciate ligament reconstruction? Arthroscopy 2014; 30:849-55. [PMID: 24821225 DOI: 10.1016/j.arthro.2014.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 03/04/2014] [Accepted: 03/10/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE (1) To assess the use and practice of the clock face among surgeons who routinely perform anterior cruciate ligament (ACL) reconstructions, and (2) to assess the accuracy, precision, and reliability of 3 commonly used clock-face schemes in ACL reconstruction. METHODS First, 9 surgeons completed a questionnaire assessing the use and definition of the clock-face technique. Next, to assess the accuracy, precision, and reliability of the clock face, each surgeon estimated the "time" of 8 artificial femur models with a black dot located on the posterior aspect of the lateral condylar wall. The estimates were performed using 3 different clock-face schemes and were repeated 10 months later. Solutions for each specimen were obtained by use of a computer graphical interface. RESULTS More than half of the respondents (55%) use the clock face in ACL reconstructions, with the reported mean ideal "time" for a femoral tunnel in a right knee of 10:05 (SD, 31 minutes). When we accounted for the different clock definitions, this ideal position was found along the entire lateral condylar wall. In the assessment of the performance of the clock face, the mean error was 32 to 40 minutes (which translates to 3 to 4 mm) among the 3 clock schemes. The maximum error was 4 hours 0 minutes, and the range of responses was 1 hour 0 minutes to 4 hours 0 minutes depending on the specimen and clock scheme. Regardless of the clock scheme used, the intrarater and inter-rater reliabilities were similar-measuring, on average, 0.78 and 0.68, respectively. CONCLUSIONS The clock face continues to be commonly used in ACL reconstruction. Different clock-face definitions affect the position for the same "time." When the clock-face parameters were strictly defined, there was good reliability with borderline accuracy and poor precision. CLINICAL RELEVANCE Considering the borderline performance of the clock face in accuracy and poor precision, we recommend against using the clock face in ACL reconstruction.
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Affiliation(s)
- Yung Han
- Department of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada.
| | - Adam Hart
- Department of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Paul A Martineau
- Department of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
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Kiekara T, Järvelä T, Huhtala H, Paakkala A. MRI evaluation of the four tunnels of double-bundle ACL reconstruction. Acta Radiol 2014; 55:579-88. [PMID: 24005561 DOI: 10.1177/0284185113502743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The double-bundle (DB) reconstruction of the anterior cruciate ligament (ACL) has gained popularity in recent years. The positioning of anteromedial (AM) and posterolateral (PL) tunnels is aimed at the anatomic femoral and tibial attachments of AM and PL bundles of the native ACL. PURPOSE To use magnetic resonance imaging (MRI) to evaluate the tunnel locations and tunnel findings in DB ACL reconstruction. MATERIAL AND METHODS Sixty-six patients with DB ACL reconstruction were evaluated with 1.5-T MRI 2 years postoperatively. Two musculoskeletal radiologists separately measured the locations and the diameters of the tunnels. Inter-observer agreements were estimated according to the method of Bland and Altman. RESULTS In the femur, the mean AM tunnel location was 32% from the proximal condylar surface and 18% from the notch roof. The mean PL tunnel location was 42% and 43%, respectively. In the tibia, the mean AM tunnel location was 54% of the lateral-to-medial tibial width and 42% of the anterior-to-posterior tibial depth. The mean PL tunnel location was 54% and 56%, respectively. The mean tunnel enlargement was 3.8 mm (56%). Tunnel communication was seen in seven patients (11%) in the femur and in 19 patients (29%) in the tibia. Greater femoral AM tunnel distance from the proximal condylar surface was associated with more tunnel enlargement, and more posterior tibial PL tunnel location was associated with less tunnel enlargement. CONCLUSION The tunnel locations of DB ACL reconstruction can be evaluated with MRI. Tunnel location was associated with tunnel enlargement that in turn was associated with tunnel communication.
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Affiliation(s)
- Tommi Kiekara
- Medical Imaging Centre, Tampere University Hospital, Tampere, Finland
| | - Timo Järvelä
- Sports Clinic and Hospital Mehiläinen, Tampere, Finland
| | - Heini Huhtala
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Antti Paakkala
- Medical Imaging Centre, Tampere University Hospital, Tampere, Finland
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Swami VG, Cheng-Baron J, Hui C, Thompson R, Jaremko JL. Reliability of estimates of ACL attachment locations in 3-dimensional knee reconstruction based on routine clinical MRI in pediatric patients. Am J Sports Med 2013; 41:1319-29. [PMID: 23576685 DOI: 10.1177/0363546513482298] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current techniques of anterior cruciate ligament (ACL) reconstruction focus on the placement of femoral and tibial tunnels at anatomic ACL attachments, which can be difficult to identify intraoperatively. PURPOSE To determine whether the 3-dimensional (3D) center of ACL attachments can be reliably detected from routine magnetic resonance imaging (MRI) in patients with intact ACLs and whether the reliability of this technique changes if the ACL is torn. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS A computer technique was developed in which users identify points along ACL attachments on routine clinical MRI of preoperative knees. These attachments are then displayed on a 3D MRI reconstruction, which can be used as a visual guide for the surgeon during arthroscopic surgery. Thirty-seven pediatric patients (age range, 10-17 years) with ACL tears and 37 controls with intact ACLs were examined. Two blinded observers identified cruciate ligament attachments on routine clinical 1.5-T MRI of knees. From the resulting 3D model, the location of the center of each ligament attachment site and its area were calculated and reliability assessed. RESULTS Mean interobserver variation of the centers of ACL attachments for the intact versus torn ACL was 1.7 ± 0.9 mm versus 1.8 ± 1.1 mm (femoral) and 1.4 ± 0.9 mm versus 1.7 ± 1.0 mm (tibial), respectively (P > .05). The 95% confidence interval for the center location was at most 4 mm. The identified ACL attachment areas were more variable, with interobserver reliability ranging from fair to excellent by the intraclass correlation coefficient. Overlap of ligament areas between observers for the intact versus torn ACL was 70% ± 15% versus 73% ± 12% (femoral) and 79% ± 9% versus 78% ± 10% (tibial), respectively (P > .05). In all cases, intraobserver reliability was superior to interobserver reliability. CONCLUSION The 3D locations of ACL tibial and femoral attachment centers were identified from routine clinical MRI with variability averaging less than 2 mm between 2 observers. The margin of error was at most 4 mm, representing the thickness of a single axial MRI slice, whether the ACL was intact or torn. Remnant tissue at attachments allows a reliable assessment even of torn ligaments. Identification of the ligament attachment areas was more user dependent than was identification of the attachment centers.
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Affiliation(s)
- Vimarsha Gopal Swami
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
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Lefevre N, Naouri JF, Bohu Y, Klouche S, Herman S. Partial tears of the anterior cruciate ligament: diagnostic performance of isotropic three-dimensional fast spin echo (3D-FSE-Cube) MRI. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 24:85-91. [PMID: 23412260 DOI: 10.1007/s00590-012-1135-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 11/06/2012] [Indexed: 12/29/2022]
Abstract
PURPOSE To compare the performance of 3D-FSE-Cube MRI to arthroscopy, the reference test for the diagnosis of partial anterior cruciate ligament (ACL) tears. METHODS A retrospective study was performed including all patients who underwent surgery for an ACL tear in our Sports Surgery Unit from January 2008 to December 2009. All patients underwent a preoperative MRI, conventional 2D or 3D-Cube. The diagnosis of a partial tear was based on the appearance of the ligament bundles and signal quality on MRI, and on the continuity of the fibers on arthroscopy and the quality of the remaining ligament. Sixty-four of the 312 included patients underwent MRI 3D-Cube and 248 conventional 2D-MRI. The series included 82 women and 223 men, mean age 33.3 ± 19.6 years. Arthroscopy did not reveal any normal ACL, 247/312 (79.2 %) complete tears, and 65/312 (20.8 %) partial tears, with 50/65 (76.9 %) involving the anteromedial bundle and 15/65 (23.1 %) the posterolateral. RESULTS The results of MRI 3D-Cube were as follows: sensitivity 95 % CI = 62.5 ± 23.7 %, specificity 95 % CI = 93.7 ± 6.9 %, likelihood ratio LR(+) = 9.9, LR(-) = 0.4 and accuracy 85.9 %. Results of conventional 2D-MRI were as follows: sensitivity 95 % CI = 10.2 ± 8.5 %, specificity 95 % CI = 96.5 ± 2.5 %, LR(+) = 2.9, LR(-) = 0.9 and accuracy 79.4 %. The diagnostic performance of MRI 3D-Cube was better than conventional 2D-MRI. CONCLUSION The diagnostic performance of MRI 3D-Cube in partial ACL tears was good and significantly better than conventional 2D-MRI. The likelihood of having a positive test was 9.9 times higher in a patient with a partial tear. A negative result did not exclude this diagnosis.
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Affiliation(s)
- N Lefevre
- Orthopaedic Surgery Department, Clinique Du Sport Paris V, 36 Boulevard Saint Marcel, 75005, Paris, France,
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Bourke HE, Gordon DJ, Salmon LJ, Waller A, Linklater J, Pinczewski LA. The outcome at 15 years of endoscopic anterior cruciate ligament reconstruction using hamstring tendon autograft for 'isolated' anterior cruciate ligament rupture. ACTA ACUST UNITED AC 2012; 94:630-7. [PMID: 22529082 DOI: 10.1302/0301-620x.94b5.28675] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The purpose of this study was to report the outcome of 'isolated' anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with 'isolated' ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time. ACL reconstructive surgery in patients with an 'isolated' rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis.
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Affiliation(s)
- H E Bourke
- North Sydney Orthopaedic & Sports Medicine Centre, The Mater Clinic, Suite 2, 3 Gillies Street, Wollstonecraft, Sydney, New South Wales 2010, Australia
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Tompkins M, Milewski MD, Brockmeier SF, Gaskin CM, Hart JM, Miller MD. Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling. Am J Sports Med 2012; 40:1313-21. [PMID: 22523370 DOI: 10.1177/0363546512443047] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND During anatomic anterior cruciate ligament (ACL) reconstruction, we have found that the femoral footprint can best be visualized from the anteromedial portal. Independent femoral tunnel drilling can then be performed through an accessory medial portal, medial and inferior to the standard anteromedial portal. PURPOSE To compare the accuracy of independent femoral tunnel placement relative to the ACL footprint using an accessory medial portal versus tunnel placement with a traditional transtibial technique. STUDY DESIGN Controlled laboratory study. METHODS Ten matched pairs of cadaveric knees were randomized such that within each pair, one knee underwent arthroscopic transtibial (TT) drilling, and the other underwent drilling through an accessory medial portal (AM). All knees underwent computed tomography (CT) both preoperatively and postoperatively with a technique optimized for ligament evaluation (80 keV with maximum mAs). Computed tomography was performed with a dual-energy scanner. Commercially available third-party software was used to fuse the preoperative and postoperative CT scans, allowing anatomic comparison of the ACL footprint to the drilled tunnel. The ACL footprint was marked in consensus by an orthopaedic surgeon and a musculoskeletal radiologist and then compared with the tunnel aperture after drilling. The percentage of tunnel aperture contained within the native footprint as well as the distance from the center of the tunnel aperture to the center of the footprint was measured. RESULTS The AM technique placed 97.7% ± 5% of the tunnel within the native femoral footprint, significantly more than 61.2% ± 24% for the TT technique (P = .001). The AM technique placed the center of the femoral tunnel 3.6 ± 1.2 mm from the center of the native footprint, significantly closer than 6.0 ± 1.9 mm for the TT technique (P = .003). CONCLUSION This study demonstrates that use of an accessory medial portal will facilitate more accurate placement of the femoral tunnel in the native ACL femoral footprint. CLINICAL RELEVANCE More accurate placement of the femoral tunnel in the native ACL femoral footprint should improve the ability to achieve more anatomic positioning of the ACL graft.
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Affiliation(s)
- Marc Tompkins
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA.
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