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Bhimani R, Shahriarirad R, Ranjbar K, Erfani A, Ashkani-Esfahani S. Transportal versus all-inside techniques of anterior cruciate ligament reconstruction: a systematic review. J Orthop Surg Res 2021; 16:734. [PMID: 34949188 PMCID: PMC8705139 DOI: 10.1186/s13018-021-02872-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/05/2021] [Indexed: 01/10/2023] Open
Abstract
Background Transportal (TP) and all-inside techniques (AIT) are the most commonly used anterior cruciate ligament (ACL) reconstruction procedures in current clinical practice. However, there is an ongoing debate over which procedure is superior. Therefore, the purpose of this systematic review was to evaluate and compare the clinical outcomes and complications of these two techniques to propose recommendations for future application. Our primary hypothesis was that AIT is a superior ACLR technique compared to TP. Methods A systematic literature review, using PRISMA guidelines, was conducted using PubMed, Medline, Google Scholar, and EMBASE, up to February 2021 to identify studies focusing on AIT and TP techniques of ACL reconstruction. We excluded animal experiments, cadaveric studies, retrospective studies, case reports, technical notes, and studies without quantitative data. Patients’ characteristics, surgical technical features, along with postoperative follow-up and complications were extracted and reported accordingly. Methodological quality of the included studies was assessed using the Modified Coleman Methodology Score (MCMS). Results A total of 44 studies were selected for this review, of which four were comparative studies. A total of 923 patients underwent AIT and 1678 patients underwent the TP technique for ACLR. A single semitendinosus graft was commonly used in the AIT compard to combined semitendinosus and gracilis graft in the TP group. The postoperative increase in International Knee Documentation Committee (IKDC), Lysholm, KT-1000, and Short Form-12 (physical and mental) scores were similar in the AIT group and the TP group. Contrastingly, the VAS pain score was significantly lower in the AIT group compared to the TP group. Furthermore, the pooled complication rates from all studies were similar between the two groups (AIT: 54 patients, 8.26% vs. PT: 55 patients, 6.62%). However, the four studies that prospectively compared AIT and TP techniques showed lesser complications in the AIT group than the TP group. Conclusion Since the future trend in orthopedic surgery is toward less invasive and patients’ satisfaction with good outcomes, AIT is a good alternative method considering preserving bony tissue and gracilis tendon with less post-operative pain, along with more knee flexor strength and equal outcomes compared to conventional ACL reconstruction surgery. Level of Evidence II. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02872-x.
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Affiliation(s)
- Rohan Bhimani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirhossein Erfani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran. .,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Soheil Ashkani-Esfahani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Techniques for Femoral Socket Creation in ACL Reconstruction. Sports Med Arthrosc Rev 2020; 28:56-65. [PMID: 32345927 DOI: 10.1097/jsa.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anterior cruciate ligament (ACL) injury is common and affects a wide variety of individuals. An ACL reconstruction is the treatment of choice for patients with subjective and objective symptoms of instability and is of particular importance to cutting or pivoting athletes. With many variables involved in ACL reconstruction, femoral tunnel placement has been found to affect clinical outcomes with nonanatomic placement being identified as the most common technical error. Traditionally the femoral tunnel was created through the tibial tunnel or transtibial with the use of a guide and a rigid reaming system. Because of proximal, nonanatomic tunnel placement using the transtibial technique, the use of the anteromedial portal and outside-in drilling techniques has allowed placement of the tunnel over the femoral footprint. In this paper, we discuss the difference between the 3 techniques and the advantages and disadvantages of each. The authors then explore the clinical differences and outcomes in techniques by reviewing the relevant literature.
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Tejpal T, Gupta A, Shanmugaraj A, Horner NS, Simunovic N, Peterson DC, Ayeni OR. Anteromedial Portal Double-Bundle Anterior Cruciate Ligament Reconstruction Yields Similar Outcomes to Non-AMP Femoral Drilling Double-Bundle Techniques: A Systematic Review of Comparative Studies. Orthop J Sports Med 2019; 7:2325967119888140. [PMID: 31853457 PMCID: PMC6906356 DOI: 10.1177/2325967119888140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Biomechanical studies have shown double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) to have increased anterior and rotational stability as compared with single-bundle ACLR. Various techniques exist to drill the femoral tunnel, such as anteromedial portal (AMP), outside-in (OI), and transtibial (TT) drilling. However, it is unclear whether one drilling technique is superior to others when a DB graft is used. Purpose To systematically assess the outcomes and complications in patients undergoing DB ACLR through an AMP technique as compared with other femoral drilling techniques. Study Design Systematic review; Level of evidence, 3. Methods PubMed, Medline, and EMBASE databases were searched in April 2018. Nonrandomized studies were assessed with the MINORS (Methodological Index for Nonrandomized Studies), whereas randomized studies were assessed with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Results Ten studies comprising 722 patients satisfied the inclusion criteria. A total of 351 patients underwent DB ACLR with AMP drilling (mean ± SD age, 32.7 ± 4.7 years); 318 patients had DB ACLR with OI drilling (age, 31.9 ± 4.1 years); and 53 received a DB ACLR with TT drilling (age, 26.5 ± 2.0 years). Graft types used included hamstring autograft (74.1%; n = 247), tibialis anterior autograft (6.0%; n = 20) and unspecified grafts (19.8%; n = 66). No significant difference in postoperative Tegner and Lysholm scores was found between the AMP and OI groups postoperatively. The AMP group had a lower anterior and posterior graft bending angle as compared with the OI group. Four patients (1.1%) in the AMP group had graft reruptures, as compared with 9 reruptures (2.8%) in the OI group. There were no reports of rerupture in the TT group. Conclusion DB AMP ACLR results in significantly improved functional outcome scores postoperatively. AMP techniques yield similar functional outcomes to OI ACLR. No direct comparison in functional outcomes scores were available between the AMP and TT techniques. Low overall complication and revision rates were observed for patients undergoing DB AMP ACLR and were found to be similar to those of other femoral drilling techniques. Owing to a steeper graft bending angle in patients undergoing OI or TT ACLR relative to AMP ACLR, patients treated with OI or TT femoral drilling may have increased strain placed on the graft. Based on the various limitations in the available literature, it is not currently possible to make a definite conclusion of whether AMP is superior to non-AMP techniques in the setting of DB ACLR.
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Affiliation(s)
- Tushar Tejpal
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Arnav Gupta
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nolan S Horner
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Devin C Peterson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Kim JG, Kang SH, Kim JH, Lim CO, Wang JH. Comparison of Clinical Results, Second-Look Arthroscopic Findings, and MRI Findings Between the Transportal and Outside-In Techniques for Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Trial With a Minimum 2-Year Follow-up. Am J Sports Med 2018; 46:544-556. [PMID: 29293362 DOI: 10.1177/0363546517744535] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques. PURPOSE To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups. RESULTS No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05). CONCLUSION With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.
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Affiliation(s)
- Jae Gyoon Kim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Seung Hoon Kang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Chae Ouk Lim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Hiramatsu K, Mae T, Tachibana Y, Nakagawa S, Shino K. Contact area between femoral tunnel and interference screw in anatomic rectangular tunnel ACL reconstruction: a comparison of outside-in and trans-portal inside-out techniques. Knee Surg Sports Traumatol Arthrosc 2018; 26:519-525. [PMID: 29058021 DOI: 10.1007/s00167-017-4732-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/25/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE The purpose of this study was to compare the femoral tunnel length, the femoral graft bending angle at the femoral tunnel aperture, and the contact area between the femoral tunnel wall and an interference screw used for fixation in anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction (ART ACLR). METHODS The study included 149 patients with primary ACL injury who underwent ART ACLR. Preoperatively, flexion angle of the index knee was checked under general anaesthesia. Those of less than 130° of passive flexion were assigned to the outside-in (OI) technique (78 patients), while the others to the trans-portal inside-out (TP) technique (71 patients). The patients underwent computed tomography with multiplanar reconstruction at 3-5 weeks post-operatively. Femoral tunnel length, graft bending angle, and contact ratio between the IFS and femoral tunnel were assessed. P < 0.05 was considered statistically significant. RESULTS The femoral tunnel length in the OI technique was significantly longer than that in the TP technique (P < 0.001). The femoral graft bending angle in the OI technique was significantly more acute than that in the TP technique (P < 0.001). The contact ratio in the OI technique was significantly larger than that in the TP technique at every point in the femoral tunnel (P < 0.001). CONCLUSIONS The OI technique resulted in a more acute femoral graft bending angle, longer mean femoral tunnel length, and larger contact ratio than the TP technique after ART ACLR. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Kunihiko Hiramatsu
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yuta Tachibana
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Shigeto Nakagawa
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
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Rezende FC, Moraes VY, Franciozi CES, Debieux P, Luzo MV, Belloti JC. One-incision versus two-incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults. Cochrane Database Syst Rev 2017; 12:CD010875. [PMID: 29243827 PMCID: PMC6486027 DOI: 10.1002/14651858.cd010875.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are serious knee injuries that are frequently treated surgically in the form of arthroscopically assisted reconstruction with grafts from the patella or hamstrings tendons. We reviewed the evidence for the choice of arthroscopically assisted ACL reconstruction technique in terms of whether it should involve one incision (femoral tunnel drilled from inside the knee joint under arthroscopic visualisation) or two incisions (femoral tunnel drilled from outside to inside the knee joint). OBJECTIVES To assess the effects (benefits and harms) of one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American and Caribbean Health Sciences (LILACS), the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, reference lists, and conference abstracts. The date of the search was 16 August 2017. SELECTION CRITERIA Randomised and quasi-randomised controlled clinical trials evaluating one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults. DATA COLLECTION AND ANALYSIS Two review authors independently searched and selected studies, and extracted data and assessed the risk of bias of the eligible studies. We undertook limited pooling of data using the fixed-effect model. MAIN RESULTS We included five trials (four randomised and one quasi-randomised) evaluating a total of 320 participants who were mainly in their 20s. All participants underwent ACL reconstruction with patella tendon grafts. All five included trials were at a high risk of bias, particularly performance bias. Based on these limitations and the insufficiency of the available data resulting in imprecision of effect estimates, we judged the quality of the evidence as very low for all outcomes. This means that we are uncertain of the findings of the review.We found very low-quality evidence of no clinically important differences between the two techniques in self reported knee function, measured using the Lysholm knee score (scale 0 to 100: best outcome), at short-term (3 months) (mean difference (MD) 2.73 favours one-incision technique, 95% confidence interval (CI) -2.70 to 8.15; 79 participants, 2 studies), intermediate-term (12 months) (MD -3.68 favours two-incision technique, 95% CI -6.61 to -0.75; 79 participants, 2 studies), and long-term follow-up. The data available for long-term follow-up (2 to 5 years) was expressed in terms of the numbers of participants with excellent Lysholm scores (90 points or more); we found no difference between the two groups (42/45 versus 36/40; risk ratio (RR) 1.04, 95% CI 0.91 to 1.18; 1 study). There were no data for quality of life measures or for overall numbers of participants incurring an adverse event. We found very low-quality evidence of little between-group differences in individual adverse events such as infection, knee stiffness, reoperation, and graft failure.We found very low-quality evidence from one study (59 participants) of little difference between the two groups in activity levels measured using Tegner scores (scale 0 to 10: highest sport activity) at two years (MD -0.80 favours two-incision technique, 95% CI -1.90 to 0.30). There was very low-quality evidence from four studies of minimal between-group difference in the number of participants with normal or nearly normal objectively measured knee function (International Knee Documentation Committee objective assessment grading) at intermediate follow-up (means 12 to 28 months): 56/78 versus 63/89; RR 1.01, 95% CI 0.85 to 1.21; 167 participants). AUTHORS' CONCLUSIONS The very low-quality and often absent evidence means that we are uncertain whether one-incision arthroscopically assisted ACL reconstruction techniques yield better, worse, or equivalent results compared with two-incision techniques in terms of short-, intermediate-, or long-term subjective function, quality of life, adverse outcomes, activity levels, and objectively rated knee function. The evidence was available only for single-bundle ACL reconstruction using patella tendon grafts.When considering priorities for high-quality randomised trials on techniques for ACL reconstruction, it is important to note the insufficiency of the evidence available to inform this key comparison.
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Affiliation(s)
- Fernando C Rezende
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Vinícius Y Moraes
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Carlos ES Franciozi
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Pedro Debieux
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Marcus V Luzo
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - João Carlos Belloti
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
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Kadija M, Milovanović D, Bumbaširević M, Carević Z, Dubljanin-Raspopović E, Stijak L. Length of the femoral tunnel in anatomic ACL reconstruction: comparison of three techniques. Knee Surg Sports Traumatol Arthrosc 2017; 25:1606-1612. [PMID: 26072031 DOI: 10.1007/s00167-015-3670-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 06/04/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this paper was to determine whether the change in the position of the patient's leg as well as the use of flexible reamers may help in obtaining a longer femoral tunnel with minimal risk of perforating the posterior cortex. METHODS One hundred and twenty-five patients who had undergone anatomic ACL reconstruction between 2010 and 2013 were included in this prospective cohort study. The first group was composed of patients whose femoral tunnel had been drilled with rigid reamers, while the leg being operated on was positioned on an arthroscopic leg holder (82 patients). In the second group of patients, the femoral tunnel was also drilled with rigid reamers, but the leg was positioned on the table (25 patients), while the third group was composed of patients whose femoral tunnel was drilled with flexible reamers, and the leg was positioned on a leg holder (18 patients). The length of the femoral tunnel was measured intraoperationally, while the site of femoral insertion and the position of the tunnel were read from native radiographic images. RESULTS When the femoral tunnel was drilled on the medial aspect of the lateral condyle, the centre of the tunnel was located at 31.4 % from the most proximal point of the femoral condyle and 34.7 % from the Blumensaat line. The length of the tunnel drilled with rigid reamers on the operating table (36.1 mm) was statistically significantly greater (p < 0.05) than the length of the tunnel drilled with the same reamers, but with the leg positioned on the leg holder (32.5 mm). The length of the tunnel drilled with flexible reamers with the leg positioned on the leg holder (42.5 mm) was highly statistically significantly greater than the length of the tunnel drilled with rigid reamers (p < 0.01), and it was statistically significantly greater than the length of the tunnel drilled with rigid reamers with the leg placed on the operating table (p < 0.05). CONCLUSION The drilling of the femoral tunnel during anatomic ACL reconstruction with the use of flexible reamers provides a longer femoral tunnel than when it is drilled with rigid reamers, without any danger of perforation of the posterior cortex. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Marko Kadija
- Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
| | - Darko Milovanović
- Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
| | - Marko Bumbaširević
- Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
| | - Zvonko Carević
- Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
| | | | - Lazar Stijak
- Department of Anatomy, School of Medicine, University of Belgrade, dr Subotića 4, 11000, Belgrade, Serbia.
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Sim JA, Kim JM, Lee S, Bae JY, Seon JK. Comparison of tunnel variability between trans-portal and outside-in techniques in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:1227-1233. [PMID: 26713326 DOI: 10.1007/s00167-015-3950-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 12/15/2015] [Indexed: 01/02/2023]
Abstract
PURPOSE Although trans-portal and outside-in techniques are commonly used for anatomical ACL reconstruction, there is very little information on variability in tunnel placement between two techniques. METHODS A total of 103 patients who received ACL reconstruction using trans-portal (50 patients) and outside-in techniques (53 patients) were included in the study. The ACL tunnel location, length and graft-femoral tunnel angle were analyzed using the 3D CT knee models, and we compared the location and length of the femoral and tibial tunnels, and graft bending angle between the two techniques. The variability in each technique regarding the tunnel location, length and graft tunnel angle using the range values was also compared. RESULTS There were no differences in the average of femoral tunnel depth and height between the two groups. The ranges of femoral tunnel depth and height showed no difference between two groups (36 and 41 % in trans-portal technique vs. 32 and 41 % in outside-in technique). The average value and ranges of tibial tunnel location also showed similar results in two groups. The outside-in technique showed longer femoral tunnel than the trans-portal technique (34.0 vs. 36.8 mm, p = 0.001). The range of femoral tunnel was also wider in trans-portal technique than in outside-in technique. Although the outside-in technique showed significant acute graft bending angle than trans-portal technique in average values, the trans-portal technique showed wider ranges in graft bending angle than outside-in technique [ranges 73° (SD 13.6) vs. 53° (SD 10.7), respectively]. CONCLUSIONS Although both trans-portal and outside-in techniques in ACL reconstruction can provide relatively consistent in femoral and tibial tunnel locations, trans-portal technique showed high variability in femoral tunnel length and graft bending angles than outside-in technique. Therefore, the outside-in technique in ACL reconstruction is considered as the effective method for surgeons to make more consistent femoral tunnel. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jae-Ang Sim
- Department of Orthopaedic Surgery, Gil Hospital, Gachon University, Incheon, South Korea
| | - Jong-Min Kim
- Department of orthopaedic surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sahnghoon Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Ji-Yong Bae
- Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, 160 Ilsimri, Hwasun-eup, Hwasun-gun, Jeollanamdo, 519-809, South Korea
| | - Jong-Keun Seon
- Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, 160 Ilsimri, Hwasun-eup, Hwasun-gun, Jeollanamdo, 519-809, South Korea.
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9
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Niki Y, Nagai K, Harato K, Suda Y, Nakamura M, Matsumoto M. Effects of femoral bone tunnel characteristics on graft-bending angle in double-bundle anterior cruciate ligament reconstruction: a comparison of the outside-in and transportal techniques. Knee Surg Sports Traumatol Arthrosc 2017; 25:1191-1198. [PMID: 26294057 DOI: 10.1007/s00167-015-3761-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 08/11/2015] [Indexed: 01/10/2023]
Abstract
PURPOSE Bone tunnel creation techniques influence the 3-dimensional (3D) position of bone tunnels and graft-bending angle in anterior cruciate ligament (ACL) reconstruction. This study assessed graft-bending angle and 3D characteristics of femoral bone tunnels and compared them between outside-in (OI) and transportal (TP) techniques. METHODS Participants comprised 64 patients who underwent anatomic double-bundle ACL reconstruction, allocated to OI and TP groups (n = 32 each). The graft orientation plane exhibiting the largest graft-bending angle at the femoral tunnel aperture with the knee in extension was reconstructed from CT data using 3D imaging software. In this plane, graft-bending angle was compared between the OI and TP techniques. RESULTS Although positionings of the intra-articular apertures of the femoral and tibial bone tunnels were similar, several spatial parameters of bone tunnels differed between techniques. Graft-bending angles of both anteromedial and posterolateral bundles were significantly more acute with the OI technique than with the TP technique. On coronal-plane CT, angle of the bone tunnel axis relative to the distal condylar axis correlated negatively with graft-bending angle, while in the axial plane, angle of the bone tunnel axis relative to the posterior condylar axis correlated positively with graft-bending angle. Lysholm score, pivot shift test, and anteroposterior laxity at >2.5-year follow-up demonstrated no significant differences between techniques. DISCUSSION Different bone tunnel directions in OI and TP techniques substantially affected graft-bending angle , despite similar positionings of the intra-articular apertures. Graft-bending angle with the OI technique was acute, but risk of posterior blowout of the lateral femoral condyle was decreased. Surgeons should create the femoral tunnel while considering an obtuse graft-bending angle without increasing the risk of posterior blowout. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yasuo Niki
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Katsuya Nagai
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kengo Harato
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yasunori Suda
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Sánchez-Carrasco MA, Abellán JF, Qudsi-Sinclair S, Ruiz-Merino G, Carrillo-Juliá FJ, Bo-Rueda D. Comparison of Outcomes of Two Femoral Fixation Devices in Hamstring Anterior Cruciate Ligament Reconstruction. Indian J Orthop 2017; 51:487-492. [PMID: 28966371 PMCID: PMC5609369 DOI: 10.4103/ortho.ijortho_13_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tear of the anterior cruciate ligament (ACL) is a common ligamentous injury of the knee. Reconstruction of this ligament is often required to restore functional stability of the knee. Outcome of ACL reconstruction is significantly affected by how the graft is fixed to the bone. This study is to determine if there is a different clinical outcome after cortical versus cortical-cancellous suspension femoral fixation in hamstring based anterior cruciate ligament (ACL) reconstruction. MATERIALS AND METHODS This is a retrospective comparative study conducted between 2006 and 2010. We enrolled patients who underwent arthroscopic ACL reconstruction. Sixty two patients met inclusion criteria and 41 agreed to come for followup assessment. Median age was of 28 years (range 18-39 years). Demographic baseline profile of both groups was similar. The femoral fixation devices were cortical (n = 16) and cortical-cancellous suspension techniques (n = 25). The average period of evolution at the time of assessment was 40 months (range 12-72 months). The patients were examined according to Lachman test (using Rolimeter knee tester), anterior drawer test, pivot shift test, International Knee Documentation Committee questionnaire, and Tegner-Lysholm knee scoring scale. RESULTS The objective evaluation of the patients (Lachman test) showed better results in terms of stability in the group of patients who underwent the cortical-cancellous suspension method. These differences were not reflected in the assessment of activity level (Tegner-Lysholm), where both groups showed the same results. CONCLUSIONS ACL reconstruction with both cortical and cortical-cancellous suspension femoral fixation techniques show the same clinical results at medium long followup. However, cortical-cancellous fixations seem to provide greater stability to the reconstruction.
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Affiliation(s)
- Miguel Angel Sánchez-Carrasco
- Department of Orthopaedic Surgery and Traumatology, HGU Santa Lucia, Cartagena. Doctoral Program in Health Sciences. Catholic University of Murcia (UCAM), Murcia, Spain,Address for correspondence: Dr. Miguel Angel Sanchez-Carrasco, Secretaría de Traumatología, HGU Santa Lucía, C/Mezquita, s/n, Paraje Los Arcos, 30202, Cartagena, Murcia, Spain. E-mail:
| | - Juan Francisco Abellán
- Department of Orthopaedic Surgery and Traumatology, HGU José María Morales Meseguer, Murcia, Spain
| | | | - Guadalupe Ruiz-Merino
- Department of Statistics, Foundation for Training and Health Research in the Region of Murcia, Murcia, Spain
| | | | - David Bo-Rueda
- Department of Orthopaedic Surgery and Traumatology, HGU José María Morales Meseguer, Murcia, Spain
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Figueroa D, Calvo R, Figueroa F, Paccot D, Izquierdo G, Morales N. Clinical and arthrometric outcomes of an anatomic outside-in single-bundle anterior cruciate ligament reconstruction using a retrodrill. Knee 2016; 23:1098-1105. [PMID: 27816290 DOI: 10.1016/j.knee.2016.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 05/28/2016] [Accepted: 07/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The main option to perform an anatomic anterior cruciate ligament (ACL) reconstruction is the anteromedial portal (AMP) technique. It has several reported complications (iatrogenic chondral injury, posterior-wall blowout, short sockets, increased risk of injury to common peroneal nerve). In an attempt to avoid these complications the outside-in (OI) technique was revived with the addition of a retrodrill. The aim of this study is to evaluate the clinical and arthrometric outcomes of a series of anatomical OI single bundle ACL reconstruction using a retrodrill. METHODS Prospective case series. KT-1000 and Pivot Shift Test were done at 24 months follow-up. International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores preoperatively and at final follow-up. Complications were reported. Statistical analysis was done with t-test. RESULTS 275 knees of 200 (73%) males and 75 (27%) females were enrolled in the study. Mean age 29.1 years (15-54). Mean follow-up 34.5 months (24-49). Mean preoperatively Lysholm Score 62 (25-95) versus 95 (76-100) at final follow-up (p<0.001) Mean preoperatively IKDC score 60 (26.4-90.8) versus 92 (59.8-100) at final follow-up (p<0.001) Mean Tegner activity Score pre injury 5 versus 5 at final follow-up. (p=0.59) Mean KT-1000 side-to-side difference 2mm (1-6). Pivot Shift test negative in 243 patients (90%); positive in 32 (10%) patients. 13 (5%) ACL re-ruptures. 2 (0.7%) infections. No other complications were reported. CONCLUSION OI single bundle anatomic ACL reconstruction using a retrodrill is a valid and safe option that avoids the complications reported with the AMP technique.
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Affiliation(s)
- David Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile.
| | - Rafael Calvo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Francisco Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Daniel Paccot
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Guillermo Izquierdo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Nelson Morales
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
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Okazaki K, Osaki K, Nishikawa K, Matsubara H, Tashiro Y, Iwamoto Y. Overestimation of femoral tunnel length during anterior cruciate ligament reconstruction using the retrograde outside-in drilling technique. Arch Orthop Trauma Surg 2016; 136:1159-63. [PMID: 27370882 DOI: 10.1007/s00402-016-2492-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Indexed: 01/12/2023]
Abstract
PURPOSE When the femoral tunnel socket is reamed in an oblique direction from the wall of inter-condylar notch in anterior cruciate ligament (ACL) reconstruction, the tunnel length can be shorter at the periphery than at the centre. Because surgeons can manipulate the direction of tunnel in the outside-in femoral tunnel drilling technique, this length mismatch would vary depending on the direction of the tunnel. The purpose of this study was to investigate this length mismatch when reamed in various directions. METHODS In total of thirteen points were defined as femoral drilling entry points on concentric lines with 0, 1, 2, and 3 cm radius from the lateral epicondyle of a three-dimensional bone model from 40 subjects. Femoral tunnel drilling was simulated on the models by connecting the centre of the ACL footprint with each defined point on the lateral femoral surface. The mismatch length was measured between the centre and the shortest peripheral side of the tunnel socket. RESULTS When the distance between the drilling entry point on the lateral femoral surface and the lateral epicondyle was increased to anterior proximal direction, there was a significant increase in the mismatch length. The mismatch length became more than 2 mm when the entry point was located more than 2 cm away from the lateral epicondyle. CONCLUSIONS When the drilling entry point is set far away from the lateral epicondyle, a significant increase was observed in tunnel length mismatch between the centre of the tunnel and its shortest peripheral side. Because the tunnel length is measured with a guide pin introduced at the centre of the tunnel before reaming in retrograde outside-in technique, this length mismatch could cause an overestimation of the tunnel length. Surgeons should recognise this mismatch when preparing the length of graft and socket to optimise the graft insertion length into the socket.
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Affiliation(s)
- Ken Okazaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazutaka Nishikawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirokazu Matsubara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasutaka Tashiro
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Osti M, Krawinkel A, Ostermann M, Hoffelner T, Benedetto KP. Femoral and tibial graft tunnel parameters after transtibial, anteromedial portal, and outside-in single-bundle anterior cruciate ligament reconstruction. Am J Sports Med 2015; 43:2250-8. [PMID: 26138734 DOI: 10.1177/0363546515590221] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic graft tunnel placement is recommended in anterior cruciate ligament (ACL) reconstruction to restore knee joint stability and function. Transtibial (TT), anteromedial portal (AMP), and outside-in (OI) retrograde drilling surgical techniques have been described for tibial and femoral bone tunnel preparation. PURPOSE/HYPOTHESIS The purpose of this study was to evaluate the bone tunnel parameters and compare the ability of 3 different surgical techniques to achieve placement of the ACL femoral and tibial bone tunnels at the center of the native ACL femoral and tibial attachment sites. The hypothesis was that tunnel placement using an AMP or OI technique would result in optimized tunnel parameters and more closely reconstruct the center of the native ACL femoral attachment site. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study population consisted of 100 patients undergoing anatomic single-bundle ACL reconstruction using multiple-stranded hamstring tendon grafts. In group 1 (n = 36), the femoral tunnel was drilled using a TT surgical technique; in group 2 (n = 32), the femoral tunnel was drilled through an AMP; and in group 3 (n = 32), the femoral tunnel was created by use of an OI technique with retrograde drilling. Computed tomography (CT) scans were obtained postoperatively, and characteristics of femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. The position of the resulting tibial and femoral bone tunnels for each group was compared with the center of the native ACL attachment sites. RESULTS There were statistically significant differences (P < .05) for the ACL femoral tunnel between the 3 groups with respect to intercondylar height, total tunnel length, graft fixation length, tunnel axis, and tunnel entry angle. Statistically significant differences (P < .05) were found for the ACL tibial tunnel with respect to anteroposterior tunnel position and sagittal tunnel axis between the TT and both the OI and AMP techniques. The OI surgical technique produced more oblique and anatomically correct femoral tunnel apertures and longer femoral tunnel lengths compared with the AMP technique. Both AMP and OI techniques resulted in a more precise replication of intercondylar tunnel depth and height. There was no statistically significant difference for graft fixation length between the AMP and OI techniques. CONCLUSION The AMP and OI surgical techniques were superior in positioning the ACL femoral tunnel at the center of the native ACL attachment site compared with the TT technique. An acceptable graft fixation length was obtained for all 3 surgical techniques.
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Affiliation(s)
- Michael Osti
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Alessa Krawinkel
- Department for Diagnostic and Interventional Radiology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Michael Ostermann
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Thomas Hoffelner
- Department for Trauma Surgery and Sports Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Karl Peter Benedetto
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
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Rodríguez C, García TE, Montes S, Rodríguez L, Maestro A. In vitro comparison between cortical and cortico-cancellous femoral suspension devices for anterior cruciate ligament reconstruction: implications for mobilization. Knee Surg Sports Traumatol Arthrosc 2015; 23:2324-2329. [PMID: 24839039 DOI: 10.1007/s00167-014-3055-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 05/02/2014] [Indexed: 01/10/2023]
Abstract
PURPOSE To analyse the capability of cortical and cortical-cancellous suspension devices to provide a strong fixation in order to follow an aggressive early mobilization protocol. METHODS Anterior cruciate ligament (ACL) reconstruction was performed in vitro on 40 porcine femurs employing a high-strength braided cord as a graft. Four femoral suspension devices were analysed: the cortical suspension devices Endobutton and XO Button and the cortical-cancellous suspension devices Biosteon Cross-pin and Cross-pin ACL. Two kinds of biomechanical testing were carried out: static and post-fatigue failure strength tests. Stiffness, failure load, elongation at failure load, elongation after 20 cycles and elongation after 1,000 cycles were assessed. The bones were cut after testing to analyse the failure pattern. RESULTS All of the devices exceed 50 % of total elongation in the first 20 cycles of fatigue. In the static failure tests, there were significant differences (p < 0.05) in elongation to failure between the cortical-cancellous suspension devices Biosteon Cross-pin and Cross-pin ACL and the cortical suspension device Endobutton. No significant differences were found in the failure tests after 1,000 cycles of loading. The failure mode of the cortical devices comprised breakage of the cortical bone, accompanied by introduction of the device into the tunnel. The failure mode of the cortical-cancellous devices was pin breakage accompanied by tunnel enlargement. CONCLUSION The first cycles of mobilization are critical for elongation. This mobilization process does not significantly diminish the mechanical characteristics of the reconstructions. All the fixations support an intensive early mobilization protocol, with loads of over 500 N.
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Affiliation(s)
- Cristina Rodríguez
- University Institute of Industrial Technology of Asturias (IUTA), University of Oviedo, Edificio Departamental Oeste. 7.1.17. Campus Universitario de Gijón, 33203, Gijón, Spain
| | - Tomás Eduardo García
- University Institute of Industrial Technology of Asturias (IUTA), University of Oviedo, Edificio Departamental Oeste. 7.1.17. Campus Universitario de Gijón, 33203, Gijón, Spain.
| | - Susana Montes
- University Institute of Industrial Technology of Asturias (IUTA), University of Oviedo, Edificio Departamental Oeste. 7.1.17. Campus Universitario de Gijón, 33203, Gijón, Spain
| | - Luis Rodríguez
- Orthopaedic Surgery and Sport Medicine, FREMAP, Juan Carlos I, 1, 33212, Gijón, Spain
| | - Antonio Maestro
- Orthopaedic Surgery and Sport Medicine, FREMAP, Juan Carlos I, 1, 33212, Gijón, Spain
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Kim JG, Chang MH, Lim HC, Bae JH, Lee SY, Ahn JH, Wang JH. An in Vivo 3D Computed Tomographic Analysis of Femoral Tunnel Geometry and Aperture Morphology Between Rigid and Flexible Systems in Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal Technique. Arthroscopy 2015; 31:1318-29. [PMID: 25823674 DOI: 10.1016/j.arthro.2015.01.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 01/05/2015] [Accepted: 01/21/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to compare femoral tunnel length, femoral graft-bending angle, posterior wall breakage, and femoral aperture morphologic characteristics between rigid and flexible systems after double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using the transportal (TP) technique. METHODS We evaluated 3-dimensional computed tomography (3D-CT) results for 54 patients who underwent DB ACL reconstruction using the TP technique with either a flexible system (n = 27) or a rigid system (n = 27). The femoral tunnel length, femoral graft-bending angle, posterior wall breakage, femoral tunnel aperture height to width (H:W) ratio, aperture axis angle, and femoral tunnel position were assessed using OsiriX Imaging Software and Geomagic Qualify 2012 (Geomagic, Cary, NC). RESULTS The mean anteromedial (AM) femoral tunnel length of the flexible group was significantly longer than that of the rigid group (P = .009). The mean femoral graft-bending angles in the flexible group were significantly less acute than those in the rigid group (AM, P < .001; posterolateral [PL], P = .003]. Posterior wall breakage was observed in both groups (P = 1.00). The mean H:W ratios in the rigid group were significantly larger (more elliptical) than those of the flexible group (AM, P < .001; PL, P = .006). The mean aperture axis angle of the PL femoral tunnel in the rigid group was more parallel to the femoral shaft axis than that in the flexible group (P < .001). There were no significant differences in femoral tunnel position between the 2 groups. CONCLUSIONS The AM femoral tunnel length and the AM/PL femoral graft-bending angle of the flexible system were significantly longer and less acute than those of the rigid system. However, the aperture morphologic characteristics of the AM/PL femoral tunnel and the aperture axis angle of the PL femoral tunnel in the rigid system were significantly more elliptical and closer to parallel to the femoral shaft axis than those of the flexible system. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Jae Gyoon Kim
- Department of Orthopaedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan, Gyeonggi-do, Republic of Korea
| | - Min Ho Chang
- School of Mechanical Engineering, Korea University, Seoul, Republic of Korea
| | - Hong Chul Lim
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Seoul, Republic of Korea
| | - Ji Hoon Bae
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Seoul, Republic of Korea
| | - Seung Yup Lee
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Seoul, Republic of Korea
| | - Jin Hwan Ahn
- Department of Orthopaedic 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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Abdelkafy A. Anatomic single-bundle anterior cruciate ligament reconstruction using the outside-in femoral tunnel drilling technique: a prospective study and short- to mid-term results. Arch Orthop Trauma Surg 2015; 135:383-92. [PMID: 25631248 DOI: 10.1007/s00402-015-2160-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Anatomic positioning of the femoral and tibial tunnels in the native ACL femoral and tibial footprints requires an independent drilling either via an accessory medial portal (trans-portal drilling) or using an outside-in drilling technique. Conventional trans-tibial drilling (dependant drilling) was found to lack the ability to accurately position the femoral tunnel in the native ACL footprint. The purpose of the current study was to evaluate the functional outcome results of anatomic single-bundle ACLR using the OI femoral tunnel drilling technique. MATERIALS AND METHODS Single surgeon single center prospective case series study. 64 patients having complete ACL tears were included in the current study. Average follow-up was 15.8 months (range 8-25). Objective and subjective IKDC scores, Lysholm knee score, SF-36 score, VAS for patients' satisfaction, VAS for pain and Kellgren and Lawrence (K/L) classification of osteoarthritis were used for follow-up evaluation. RESULTS Objective IKDC score revealed that 60 patients had grade ''A'' and 4 had grade ''B'', while no single patient had neither grade ''C'' nor ''D''. The average Lysholm Score was 92.4, average subjective IKDC was 91.5. Average SF-36 score was 96.7. The average VAS for operation satisfaction was 9.7. Average VAS for pain was 0.3. Forty-nine patients were classified as normal K/L classification, 7 were grade ''1'', 8 were grade ''2''. Comparing pre-operative and follow-up Objective IKDC, Subjective IKDC, Lysholm, SF-36 and VAS for pain scores revealed statistically significant differences (P value <0.05). CONCLUSION Arthroscopic-assisted ACL reconstruction using the outside-in femoral tunnel drilling technique shows a good and satisfactory functional outcome results at short- to mid-term follow-up. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ashraf Abdelkafy
- Orthopaedic Surgery and Traumatology Department, Faculty of Medicine, Suez Canal University, Circular Road, Ismailia, 41522, Egypt,
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17
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Comparison of femoral tunnel geometry, using in vivo 3-dimensional computed tomography, during transportal and outside-in single-bundle anterior cruciate ligament reconstruction techniques. Arthroscopy 2015; 31:83-91. [PMID: 25239169 DOI: 10.1016/j.arthro.2014.07.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 07/21/2014] [Accepted: 07/25/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the transportal (TP) and outside-in (OI) techniques regarding femoral tunnel position and geometry after anatomic single-bundle (SB) anterior cruciate ligament (ACL) reconstruction. METHODS This study included 51 patients who underwent anatomic SB ACL reconstruction with the TP (n = 21) or OI (n = 30) technique. All patients underwent 3-dimensional computed tomography 3 days after the operation. The femoral tunnel position (quadrant method), femoral graft bending angle, femoral tunnel length, and posterior wall breakage were assessed by immediate postoperative 3-dimensional computed tomography with OsiriX imaging software. RESULTS The OI technique had a shallower femoral tunnel position (arthroscopic position) than did the TP technique (P = .005). The mean femoral graft bending angle was significantly more acute with the OI technique (101.3° ± 8.2°) than with the TP technique (107.9° ± 10.0°) (P = .02). The mean femoral tunnel length was significantly greater with the OI technique (33.0 ± 3.5 mm) than with the TP technique (29.6 ± 3.9 mm) (P = .003). Posterior wall breakage occurred in 7 cases (33.3%) with the TP technique and 1 case (3.3%) with the OI technique (P = .02). CONCLUSIONS The mean femoral tunnel position was significantly shallower (arthroscopic position) with the OI technique than with the TP technique. The OI technique resulted in a more acute femoral graft bending angle, longer femoral tunnel length, and lower incidence of posterior wall breakage than did the TP technique. These results might be helpful for anatomic SB ACL reconstruction using TP and OI techniques. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Lee YS, Lee BK, Oh WS, Cho YK. Comparison of femoral tunnel widening between outside-in and trans-tibial double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:2033-9. [PMID: 23851922 DOI: 10.1007/s00167-013-2597-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 06/26/2013] [Indexed: 01/10/2023]
Abstract
PURPOSE The objectives of this study were to compare (1) the degree of widening by comparing the diameter at the most widened area and the site of widening by measuring the distance from the tunnel entrance to the most widened area in two femoral tunnels (anteromedial and posterolateral), and (2) the morphologic change at the tunnel entrance between outside-in and trans-tibial double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS A retrospective study that included 17 trans-tibial and 19 outside-in double-bundle ACL reconstructed patients was conducted for evaluation of serial computed tomography (CT) scan (immediate post-operation and post-operative 1 year). Digital image communication in medicine (DICOM) data was extracted from the PiViewSTAR and imported into OsiriX, which was installed on a Macbook Pro laptop computer. Diameter of the most widened area and distance from the entrance to this point were measured from each of two perpendicular (sagittal and coronal) planes that were accurately realigned parallel to the tunnel direction. Change in the morphology of the tunnel entrance between immediate post-operation and 1-year post-operation was evaluated. RESULTS Widening was observed in both planes of both tunnels in the two techniques. However, no statistical significances in the diameter of most widened area and distance from the tunnel entrance to the most widened point were observed between the both techniques (n.s.). Distances from the centre point to each four sections showed an increase in all four sections of all both tunnels in both techniques. However, no statistical significance was observed between the two techniques (n.s.). CONCLUSION Widening was observed in all tunnels using both techniques and degrees, and sites of the widening did not differ between groups. Morphologic change at the tunnel entrance was not limited to the specific direction and occurred in all directions without significant difference between groups. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopedic Surgery, School of Medicine, Gil Hospital, Gachon University, Incheon, Korea,
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Okazaki K, Matsubara H, Osaki K, Tashiro Y, Mizu-Uchi H, Hamai S, Doi T, Iwamoto Y. Femoral tunnel apertures on the lateral cortex in anterior cruciate ligament reconstruction: an analysis of cortical button fixation. Arthroscopy 2014; 30:841-8. [PMID: 24793207 DOI: 10.1016/j.arthro.2014.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 02/28/2014] [Accepted: 03/06/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE If the aperture of the oval-shaped femoral tunnel on the lateral cortex becomes bigger than half the size of the cortical button, the risk of fixation failure increases. This study investigated the effect of the location of the entry point and diameter of the femoral tunnel on the length of the major axis of the tunnel aperture in anterior cruciate ligament (ACL) reconstruction using an outside-in technique. METHODS Simulation of femoral tunnel drilling was performed on computed tomography (CT)-based 3-dimensional (3D) bone models obtained from 40 participants. The tunnel connected the center of the ACL footprint and various points on the lateral femoral surface. The diameter of the tunnel was set at 4.2 mm, 5.2 mm, or 6 mm, depending on the commercially available outside-in surgical systems (Arthrex, Naples, FL and Smith & Nephew, Andover, MA). The length of the major axis of the oval-shaped aperture on the lateral femoral surface was measured. RESULTS When the tunnel was introduced at 2 cm from the lateral epicondyle in a 45° anteroproximal direction, the major axis was lengthened to 130.7% ± 9.0% (P < .001) of the tunnel diameter, and it was more than 6.5 mm in 65% of participants in whom a 5.2-mm-diameter tunnel was drilled. When the entry point was 3 cm from the lateral epicondyle, 60% of participants had an oval-shaped aperture with a major axis of more than 6.5 mm, even though the diameter of the tunnel was only 4.2 mm. CONCLUSIONS The risk of fixation failure of a cortical button increases if the entry point for drilling is 2 cm or further from the lateral epicondyle and the tunnel diameter is more than 5 mm. CLINICAL RELEVANCE This study indicates the potential risk of cortical button fixation failure caused by an oval tunnel aperture on the lateral femoral surface in ACL reconstruction using the outside-in technique.
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Affiliation(s)
- Ken Okazaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Hirokazu Matsubara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasutaka Tashiro
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hideki Mizu-Uchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Hamai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshio Doi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Martin CM, Roach VA, Nguyen N, Rice CL, Wilson TD. Comparison of 3D reconstructive technologies used for morphometric research and the translation of knowledge using a decision matrix. ANATOMICAL SCIENCES EDUCATION 2013; 6:393-403. [PMID: 23633266 DOI: 10.1002/ase.1367] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 03/12/2013] [Accepted: 03/14/2013] [Indexed: 06/02/2023]
Abstract
The use of three-dimensional (3D) models for education, pre-operative assessment, presurgical planning, and measurement have become more prevalent. With the increase in prevalence of 3D models there has also been an increase in 3D reconstructive software programs that are used to create these models. These software programs differ in reconstruction concepts, operating system requirements, user features, cost, and no one program has emerged as the standard. The purpose of this study was to conduct a systematic comparison of three widely available 3D reconstructive software programs, Amira(®), OsiriX, and Mimics(®) , with respect to the software's ability to be used in two broad themes: morphometric research and education to translate morphological knowledge. Cost, system requirements, and inherent features of each program were compared. A novel concept selection tool, a decision matrix, was used to objectify comparisons of usability of the interface, quality of the output, and efficiency of the tools. Findings indicate that Mimics was the best-suited program for construction of 3D anatomical models and morphometric analysis, but for creating a learning tool the results were less clear. OsiriX was very user-friendly; however, it had limited capabilities. Conversely, although Amira had endless potential and could create complex dynamic videos, it had a challenging interface. These results provide a resource for morphometric researchers and educators to assist the selection of appropriate reconstruction programs when starting a new 3D modeling project.
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Affiliation(s)
- Charys M Martin
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Georgia Regents University, Augusta, Georgia
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Kim JG, Chang MH, Lim HC, Bae JH, Ahn JH, Wang JH. Computed tomography analysis of the femoral tunnel position and aperture shape of transportal and outside-in ACL reconstruction: do different anatomic reconstruction techniques create similar femoral tunnels? Am J Sports Med 2013; 41:2512-20. [PMID: 23982402 DOI: 10.1177/0363546513500626] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The desire to perform independent femoral drilling in anterior cruciate ligament (ACL) reconstruction has prompted interest in both the transportal (TP) and outside-in (OI) techniques. However, there have been no in vivo studies on the differences in femoral aperture shape between the 2 techniques. PURPOSE To evaluate the femoral tunnel aperture shape and femoral tunnel position between ACL reconstruction using the TP and OI techniques. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 80 patients were randomized to undergo double-bundle ACL reconstruction using either the TP (n = 40) or OI (n = 40) technique. The femoral tunnel aperture shape (height/width ratio), aperture axis angle (angle between the aperture axis and femoral shaft axis), and femoral tunnel position were assessed by computed tomography. RESULTS The mean height/width ratio of the anteromedial (AM) femoral tunnels in the TP group (1.35 ± 0.16) was significantly more ellipsoidal than that in the OI group (1.22 ± 0.16) (P = .008). There was no difference between the 2 groups in the posterolateral (PL) tunnels (TP, 1.32 ± 0.23; OI, 1.35 ± 0.29; P = .99). The mean aperture axis angle of the PL femoral tunnels in the OI group was significantly more perpendicular to the femoral shaft axis and had a more variable range than that in the TP group (P = .007). The mean PL femoral tunnel position in the OI group was significantly shallower and a little higher than that in the TP group (P = .006). CONCLUSION The TP technique revealed a more ellipsoidal AM femoral tunnel aperture than the OI technique. The mean PL femoral tunnel position in the OI group was significantly shallower than that in the TP group, with a more variable and more perpendicular aperture axis angle to the femoral shaft axis. CLINICAL RELEVANCE The TP technique might be more advantageous than the OI technique in terms of graft coverage, with a more ellipsoidal AM femoral tunnel and more horizontal and consistent PL aperture axis angle. In addition, it may be useful to consider the shallower PL femoral tunnel positions created with the OI technique.
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Affiliation(s)
- Jae Gyoon Kim
- Joon Ho Wang, Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-dong #50, Kangnam-gu, Seoul, 135-710, Korea.
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Chang MJ, Chang CB, Won HH, Je MS, Kim TK. Anteromedial portal versus outside-in technique for creating femoral tunnels in anatomic anterior cruciate ligament reconstructions. Arthroscopy 2013; 29:1533-9. [PMID: 23992990 DOI: 10.1016/j.arthro.2013.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 06/10/2013] [Accepted: 06/10/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the anteromedial (AM) portal and outside-in techniques in anterior cruciate ligament reconstruction differ (1) in the coronal femoral tunnel position, (2) in the femoral tunnel length, and (3) in the incidence of femoral tunnel-related complications, such as femoral socket blowout. METHODS We examined 63 knees undergone primary anterior cruciate ligament reconstructions using the AM portal technique (AM portal group) and 54 knees using the outside-in technique (outside-in group). Coronal femoral tunnel positions between the 2 groups were assessed on postoperative tunnel-view radiographs and compared. Comparisons of femoral tunnel lengths, proportions of knees with a femoral tunnel length of less than 30 mm, and incidences of femoral tunnel-related complications were performed between the 2 groups. RESULTS There were no significant differences in coronal femoral tunnel positions between the AM portal and outside-in groups (56.6° v 56.4°, P > .99). Differences in femoral tunnel lengths between the AM portal and outside-in groups did not reach statistical significance (37.6 mm and 39.0 mm, respectively; P = .097), but the tunnel length of the outside-in group showed smaller variation than that of the AM portal group in terms of standard deviation (2.7 v 6.0). In addition, the AM portal group had a significantly greater proportion of knees with a femoral tunnel length of less than 30 mm than the outside-in group (14% v 0%, P = .004). There were 2 tunnel-related complications (3%) (highly suspicious cortical blowouts) in the AM portal group and none in the outside-in group (P = .499). CONCLUSIONS This study shows that compared with the AM portal technique, the outside-in technique can achieve a similar femoral tunnel position in the coronal plane with a reduced chance of a femoral tunnel length of less than 30 mm. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Moon Jong Chang
- Joint Reconstruction Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do 463-707, South Korea
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Benedetto KP, Osti M. Vordere Kreuzbandrekonstruktion. ARTHROSKOPIE 2013. [DOI: 10.1007/s00142-012-0747-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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