Morphological changes in femoral tunnels after anatomic anterior cruciate ligament reconstruction

Anterior cruciate ligament femoral side retained stump technique reduces enlargement of the femoral bone tunnel after anterior cruciate ligament reconstruction

BACKGROUND

Enlargement of the bone tunnel has become an unavoidable early complication after anterior cruciate ligament (ACL) reconstruction, whether it is a single or double-bundle ACL reconstruction. Preservation of the ACL stump in ACL reconstruction reduces enlargement of the bone tunnel. The purpose of this study was to investigate the question of whether single-bundle ACL reconstruction using the ACL femoral side retained stump technique reduces enlargement of the femoral tunnel.

METHODS

Forty patients who underwent single-bundle reconstruction of the ACL were included in this study. The patients were categorized into a Remnant preservation group (Group R) and the Non-remnant preservation group (Group N). In the Remnant preservation group, a high-flexion femoral side retained stump technique was used intraoperatively for the establishment of the femoral side bone tunnel, and in the Non-remnant preservation group, the conventional femoral positioning method was used (we used a femoral positioning drill for localization and drilling of the femoral bone tunnel), and MRI of the operated knee joints was performed at 6 months postoperatively. We measured the internal diameter of the femoral bone tunnel at 5 mm from the intra-articular outlet of the femoral bone tunnel on an MRI scan image perpendicular to the femoral bone tunnel. The size of the tunnel was compared between the intraoperative drilling of the bone tunnel and the size of the bone tunnel at 6 months postoperatively. Postoperative clinical assessment was Lysholm score.

RESULTS

After a 6-month follow-up of 40 patients, the diameter of the femoral tunnel at a distance of 5 mm from the inner opening of the femoral tunnel was 10.96 ± 0.67 mm and 10.11 ± 0.62 mm in patients of group N and group R, respectively, and the difference was statistically significant (P < 0.05).The diameter of the femoral tunnel at 6 months postoperatively in group N and group R compared to the intraoperative bone tunnel increased by 2.58 ± 0.24 mm and 1.94 ± 0.31 mm, and the difference was statistically significant (P < 0.05).The femoral tunnel enlargement rates of group N and group R were 30.94 ± 3.00% and 24.02 ± 5.10%, respectively, and the differences were significant (P < 0.05).

CONCLUSION

ACL femoral side retained stump technique does not sacrifice the ideal location of the femoral tunnel and is able to preserve the possible benefits of the ACL stump: reduced femoral tunnel enlargement.

Lateral posterior tibial slope does not affect femoral but does affect tibial tunnel widening following anatomic anterior cruciate ligament reconstruction using a Bone-Patellar Tendon-Bone graft

Background

Tunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction has been a research area of interest in ACL reconstruction. In recent years, it has been noted that posterior tibial slope (PTS) affects several types of outcomes after ACL reconstruction including TW. However, the relationships between femoral and tibial TW and between PTS and TW following anatomical ACL reconstruction using a bone–patellar tendon–bone (BTB) graft are often not understood. Therefore, the purpose of this study was to retrospectively clarify the magnitude of femoral and tibial TW and the effect of PTS on TW following anatomical ACL reconstruction using a BTB graft.

Methods

A total of 111 patients who underwent isolated ACL reconstructions using BTB grafts were included in this study. Femoral and tibial tunnel aperture areas were measured using three-dimensional computed tomography (3D CT) at 1 week and 1 year postoperatively, and femoral and tibial TW (%) was calculated. Lateral and medial PTS was also measured using 3D CT.

Results

As compared with 1 week postoperatively, the mean tibial tunnel aperture areas increased by 30.6% ± 28.5%, and the mean femoral tunnel aperture areas increased by 28.3% ± 27.9% when measured at 1 year postoperatively. Although no significant difference was observed between femoral and tibial TW, a significant positive correlation was noted between femoral and tibial TW (r = 0.240, p = 0.011). A significant correlation was observed only between lateral PTS and tibial TW (r = 0.354, p < 0.001). There was no significant correlation between medial PTS and tibial TW, lateral PTS and femoral TW, or medial PTS and femoral TW.

Conclusion

Significant positive correlation was observed between femoral and tibial TW. Steeper lateral PTS correlated with greater tibial TW; on the other hand, medial PTS did not correlate with tibial TW. Although lateral PTS affected tibial TW, it did not affect femoral TW.

Effects of the Ankle Flexion Angle During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

This study aimed to evaluate the effects of the ankle flexion angle during anterior talofibular ligament (ATFL) reconstruction on ankle kinematics, laxity, and in situ force of a graft.

METHODS

Twelve cadaveric ankles were evaluated using a 6-degrees of freedom robotic system to apply passive plantar flexion and dorsiflexion motions and multidirectional loads. A repeated measures experiment was designed using the intact ATFL, transected ATFL, and reconstructed ATFL. During ATFL reconstruction (ATFLR), the graft was fixed at a neutral position (ATFLR 0 degrees), 15 degrees of plantar flexion (ATFLR PF15 degrees), and 30 degrees of plantar flexion (ATFLR PF30 degrees) with a constant initial tension of 10 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ force of the ATFL and reconstructed grafts were calculated using the principle of superposition.

RESULTS

The in situ forces of the reconstructed grafts in ATFLR 0 degrees and ATFLR PF 15 degrees were significantly higher than those of intact ankles. The ankle kinematics and laxity produced by ATFLR PF 30 degrees were not significantly different from those of intact ankles. The in situ force on the ATFL was 19.0 N at 30 degrees of plantar flexion. In situ forces of 41.0, 33.7, and 21.9 N were observed at 30 degrees of plantar flexion in ATFLR 0, 15, and 30 degrees, respectively.

CONCLUSION

ATFL reconstruction with the peroneus longus (PL) tendon was performed with the graft at 30 degrees of plantar flexion resulted in ankle kinematics, laxity, and in situ forces similar to those of intact ankles. ATFL reconstructions performed with the graft fixed at 0 and 15 degrees of the plantar flexion resulted in higher in situ forces on the reconstructed graft.

CLINICAL RELEVANCE

Fixing the ATFL tendon graft at 30 degrees of plantar flexion results in an in situ force closest to that of an intact ankle and avoids the excessive tension on the reconstructed graft.

The Femoral Tunnel Drilling Angle at 45° Coronal and 45° Sagittal Provided the Lowest Peak Stress and Strain on the Bone Tunnels and Anterior Cruciate Ligament Graft

Purpose: The aims of this study were to 1) investigate the effects of femoral drilling angle in coronal and sagittal planes on the stress and strain distribution around the femoral and tibial tunnel entrance and the stress distribution on the graft, following anterior cruciate ligament reconstruction (ACLR), 2) identify the optimal femoral drilling angle to reduce the risk of the tunnel enlargement and graft failure.

Methods: A validated three-dimensional (3D) finite element model of a healthy right cadaveric knee was used to simulate an anatomic ACLR with the anteromedial (AM) portal technique. Combined loading of 103.0 N anterior tibial load, 7.5 Nm internal rotation moment, and 6.9 Nm valgus moment during normal human walking at joint flexion of 20° was applied to the ACLR knee models using different tunnel angles (30°/45°/60° and 45°/60° in the coronal and sagittal planes, respectively). The distribution of von Mises stress and strain around the tunnel entrances and the graft was calculated and compared among the different finite element ACLR models with varying femoral drilling angles.

Results: With an increasing coronal obliquity drilling angle (30° to 60°), the peak stress and maximum strain on the femoral and tibial tunnel decreased from 30° to 45° and increased from 45° to 60°, respectively. With an increasing sagittal obliquity drilling angle (45° to 60°), the peak stress and the maximum strain on the bone tunnels increased. The lowest peak stress and maximum strain at the ACL tunnels were observed at 45° coronal/45° sagittal drilling angle (7.5 MPa and 7,568.3 μ-strain at the femoral tunnel entrance, and 4.0 MPa and 4,128.7 μ-strain at the tibial tunnel entrance). The lowest peak stress on the ACL graft occurred at 45° coronal/45° sagittal (27.8 MPa) drilling angle.

Conclusions: The femoral tunnel drilling angle could affect both the stress and strain distribution on the femoral tunnel, tibial tunnel, and graft. A femoral tunnel drilling angle of 45° coronal/ 45° sagittal demonstrated the lowest peak stress, maximum strain on the femoral and tibial tunnel entrance, and the lowest peak stress on the ACL graft.

Influence of Graft Bending Angle on Femoral Tunnel Widening After Double-Bundle ACL Reconstruction: Comparison of Transportal and Outside-In Techniques

Background:

Previous studies have suggested that increased mechanical stress due to acute graft bending angle (GBA) is associated with tunnel widening and graft failure after anterior cruciate ligament (ACL) reconstruction. Few studies have compared the GBA between the outside-in (OI) and the transportal (TP) techniques.

Purpose:

To evaluate the influence of GBA on clinical outcomes and tunnel widening after ACL reconstruction with OI versus TP technique.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in the study were 56 patients who underwent double-bundle ACL reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical outcomes (Lysholm, International Knee Documentation Committee, Tegner score, and knee laxity) 1 year postoperatively were evaluated. Computed tomography scans at 5 days and 1 year postoperatively were used for imaging measurements, and the femoral tunnel was divided into the proximal third, middle, and aperture sections. The GBA and cross-sectional area (CSA) were measured using image analysis software and were compared between groups. A correlation analysis was performed to determine if the GBA affected clinical outcomes or tunnel widening.

Results:

No significant difference was observed in clinical outcomes between the groups. The GBA of both the anteromedial (AM) and posterolateral bundles were more acute in the OI group compared with the TP group (P < .05). The CSA at the AM tunnel aperture increased significantly in the OI group (84.2% ± 64.3%) compared with the TP group (51.4% ± 36.7%) (P = .04). However, there were no differences in the other sections. In the Pearson correlation test, GBA was not correlated with tunnel widening or clinical outcomes.

Conclusion:

Regardless of technique, the GBA did not have a significant influence on tunnel widening or clinical outcomes. Considering a wider AM tunnel aperture, a more proximal and posterior AM tunnel position might be appropriate with the OI technique.

Anatomical Triple Bundle Anterior Cruciate Ligament Reconstructions With Hamstring Tendon Autografts: Tunnel Locations and 2-Year Clinical Outcomes

PURPOSE

To anatomically clarify the location of the tunnel apertures created using the bony landmark strategy and to elucidate clinical outcomes after anatomic triple-bundle (ATB) anterior cruciate ligament (ACL) reconstruction.

METHODS

Thirty-two patients with unilateral ACL injury who had consented to undergo computed tomography (CT) at 3 weeks, as well as 2-year follow-up evaluation, were enrolled. At the time of surgery, remnant tissues were thoroughly cleared to create 2 femoral and 3 tibial tunnels inside the ACL attachment areas bordered by the bony landmarks. Two double-looped semitendinosus tendon autografts were prepared and fixed on the femur with two EndoButton-CLs and secured to the tibia with pullout sutures and plates with 10-20N of tension. The location of the tunnel aperture areas was assessed using 3-dimensional CT images, and 2-year postoperative clinical outcomes were evaluated.

RESULTS

The CT evaluation showed 100% of the femoral tunnel aperture area and at least 79% of the tibial tunnel aperture area were located inside the anatomic attachment areas. Thirty patients were available for clinical evaluation. The International Knee Documentation Committee subjective assessment showed all of the patients were classified as "normal" or "nearly normal." Lachman and pivot-shift tests were negative in 100% and 93%, respectively. The mean side-to-side difference of anterior laxity at the maximum manual force with a KT-1000 Knee Arthrometer was 0.7 ± 0.7 mm, ranging from 0 to 2 mm.

CONCLUSION

In ATB ACL reconstructions with hamstring tendon grafts, the tunnels can be created in proper locations using the arthroscopically-identifiable bony landmarks. Moreover, ATB ACL reconstruction with hamstring tendon grafts via the proper tunnels result in consistently satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Femoral Tunnel Widening After Double-Bundle Anterior Cruciate Ligament Reconstruction With Hamstring Autograft Produces a Small Shift of the Tunnel Position in the Anterior and Distal Direction: Computed Tomography-Based Retrospective Cohort Analysis

PURPOSE

To determine whether the femoral tunnel position remains in an anatomical footprint after tunnel widening and shifting.

METHODS

Patients who underwent unilateral double-bundle anterior cruciate ligament reconstruction with hamstring autograft and performed computed tomography scan evaluation at the time of 5 days and 1 year postoperatively were included in this retrospective cohort study. Three-dimensional models of the femur and femoral tunnels were reconstructed from computed tomography scan data. The location of the tunnel center and tunnel margins in the anatomical coordinate system, and the mean shifting distance of tunnel center and margin were measured with image analysis software during the period. The change of tunnel center location in Bernard quadrant was confirmed if the tunnel center remained within the boundaries of anatomical position after tunnel widening.

RESULTS

A total of 56 patients satisfied the inclusion criteria. The mean shifting distance of AM and PL tunnel centers were 1.7 ± 0.9 mm and 1.6 ± 0.6 mm. The Tunnel margin of the anteromedial (AM) and posteromedial (PL) tunnels were shifted to 2.5 ± 1.3 mm and 2.6 ± 1.4 mm in the anterior direction, and 1.4 ± 0.9 mm and 1.0 ± 0.7 mm in the distal direction, respectively. Among the anatomical located tunnel, 97% (32/33) and 87.1% (27/31) of AM and PL tunnel centers remained in a range of anatomical footprint. The tunnel center was shifted from the anatomical position into a nonanatomical position in 3% (1/33) of the AM tunnel and 12.9% (4/31) of PL tunnel after tunnel widening. The tunnel location which shifted nonanatomically were relatively anterior and distal position.

CONCLUSIONS

Tunnel widening shifts the tunnel position to the anterior and distal direction, which could change the initial tunnel position. Nevertheless, the majority of tunnel positions remained in the anatomical position after tunnel widening and shifting.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Editorial Commentary: Tunnel Widening After Anterior Cruciate Ligament Reconstruction May Increase Laxity and Complicate Revision

Tunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction has been a research area of interest in ACL reconstruction. It has been demonstrated that femoral tunnels enlarge anteriorly and distally (ie, the direction where the mechanical traction force of the graft works) rather than concentrically after anatomic double-bundle ACL reconstruction using hamstring autografts. This finding suggests that the wall supporting the graft moves closer to the direction of the pull, leading to increased laxity of the knee joint due to TW. The causes of TW are presumed to be multifactorial, with both biological and mechanical features. Biological factors include osteolytic cytokines that enter the space between the graft and the bone through the synovial fluid. Mechanical factors include longitudinal graft motion by extracortical femoral fixation (known as the bungee effect), transverse graft motion (also called the windshield-wiper effect), improper graft placement, higher initial graft tension, accelerated rehabilitation, and so on. Although TW does not seem to affect short-term clinical outcomes from studies published to date, it is plausible to speculate that the expansion of the bone tunnel (ie, the edge where the graft tendon is fixed) would theoretically increase joint laxity to some extent, and it would be premature to conclude that TW has no effect on clinical outcomes relative to graft-tunnel micromotion. In addition, there is a general consensus that the presence of expanded tunnels often severely complicates revision ACL reconstruction. In ACL reconstruction using the hamstring tendon, it is necessary to take into account the possibility of a shift in the tunnel position when determining the location of the femoral tunnel.

Allograft Bone Dowels Show Better Incorporation in Femoral Versus Tibial Tunnels in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Computed Tomography-Based Analysis

PURPOSE

The purpose of this study was to quantitatively evaluate the radiographic outcomes of allograft dowels used in 2-stage revision anterior cruciate ligament reconstruction (ACLR) and to compare the incorporation rates of dowels placed in tibial and femoral tunnels.

METHODS

Prospective review of patients who underwent 2-stage revision ACLR with allograft bone dowels. Inclusion criteria were tibial/femoral tunnel diameter of ≥14 mm on preoperative computed tomography (CT) or overlapping of prior tunnels with planned tunnels. Second-stage timing was determined based on qualitative dowel integration on CT obtained at ∼3 months after the first stage. Quantitative analysis of incorporation rates was performed with the union ratio (UR) and occupying ratio (OR) on postoperative CT scans.

RESULTS

Twenty-one patients, with a mean (SD) age of 32.1 (11.4; range, 18-50) years, were included. Second-stage procedures were performed at a mean (SD) of 6.5 (2.1; range, 2.4-11.5) months after first-stage revision. All dowels showed no signs of degradation at the host bone/graft junction at the second-stage procedure. The mean (SD) diameter of the dowels placed in tibial tunnels was greater than those placed in femoral tunnels (16.1 [2.3] mm vs 12.4 [1.6] mm; P < .05). CT was obtained at a mean (SD) of 121 (28; range, 59-192) days after the first-stage surgery. There was no difference between the OR of femoral and tibial tunnels (mean [SD], 87.6% [4.8%] vs 85.7% [10.1%]; P = .484), but the UR was significantly higher in femoral tunnels (mean [SD], 83% [6.2%] vs 74% [10.5%], P = .005). The intraclass correlation coefficients of OR and UR measurements indicated good reliability.

CONCLUSIONS

Allograft bone dowels are a viable graft choice to replenish bone stock in the setting of a staged revision ACL reconstruction. Allograft dowels placed in femoral tunnels had a higher healing union ratio than tibial tunnel allografts and no evidence of degradation at the bone/graft junction, with no difference seen in occupying ratio.

LEVEL OF EVIDENCE

Level IV, case series.

Tunnel Enlargement Correlates With Postoperative Posterior Laxity After Double-Bundle Posterior Cruciate Ligament Reconstruction

Background:

There exists little information in the relevant literature regarding tunnel enlargement after posterior cruciate ligament (PCL) reconstruction (PCLR).

Purpose:

To sequentially evaluate tunnel enlargement and radiographic posterior laxity through double-bundle PCLR using autologous hamstring tendon grafts.

Study Design:

Case series; Level of evidence, 4.

Methods:

We prospectively analyzed 13 patients who underwent double-bundle PCLR for an isolated PCL injury. Three-dimensional computed tomography images were obtained at 3 weeks, 6 months, and 1 year postoperatively, and the tunnel enlargement was calculated by sequentially comparing the cross-sectional areas of the bone tunnels. We also sequentially measured radiographic posterior laxity. The correlation between the tunnel enlargement ratio and the postoperative increase in posterior laxity was evaluated.

Results:

The cross-sectional area at the aperture in each tunnel significantly increased from 3 weeks to 6 months (P < .003), but it did not continue doing so thereafter. The 6-month tunnel enlargement ratios of the femoral anterolateral tunnel, the femoral posteromedial tunnel, the tibial anterolateral tunnel, and the tibial posteromedial tunnel were 31.6% ± 23.5%, 90.3% ± 54.7%, 30.5% ± 26.8%, and 49.6% ± 37.0%, respectively, while the corresponding ratios at 1 year were 28.1% ± 19.8%, 83.1% ± 56.9%, 26.8% ± 32.8%, and 47.6% ± 39.0%, respectively. The posterior laxity was 9.0 ± 4.0 mm, −1.5 ± 2.3 mm, 3.4 ± 2.0 mm, and 3.9 ± 1.9 mm, preoperatively, immediately after surgery, 6 months and 1 year postoperatively, respectively. From the immediate postoperative period, the posterior laxity significantly increased at 6 months postoperatively (P < .001), but it did not thereafter. The postoperative increase in posterior laxity had a significant positive correlation with the anterolateral tunnel enlargement ratio in both femoral and tibial tunnels at 6 months (ρ = 0.571-0.699; P = .011-.041) and 1 year (ρ = 0.582-0.615; P = .033-.037).

Conclusion:

Tunnel enlargement after PCLR mainly occurred within 6 months, with no progression thereafter. The anterolateral tunnel enlargement positively correlated with postoperative increase in posterior laxity.

A steep coronal graft bending angle is associated with bone tunnel enlargement of the posterolateral bundle after anterior cruciate ligament reconstruction

PURPOSE

The correlation between the graft bending angle (GBA) of the anteromedial bundle and posterolateral bundle after anterior cruciate ligament reconstruction (ACLR) and postoperative tunnel enlargement was evaluated.

METHODS

Two hundred fifty-eight patients (137 males, 121 females; mean age 27.3 years) who had undergone double-bundle ACLR were included. Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months postoperatively. The area of the tunnel aperture for femoral anteromedial tunnel (FAMT) and femoral posterolateral tunnel (FPLT) was measured; the area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The femoral tunnel angles were obtained with Cobb angle measurements. The femoral tunnel angle in the coronal plane was measured relative to the tibial plateau (coronal GBA). On the median value, the patients were divided into two groups in each of FAMT and FPLT; those with a coronal GBA of FAMT of ≥27° were classified as group A, while those with a coronal GBA of <27° were classified as group B, those with a coronal GBA of FPLT of ≥23° were classified as group C, while those with a coronal GBA of<23° were classified as group D.

RESULTS

Group A included 129 knees, while group B included 129 knees. Groups A and B did not significantly differ regarding FAMT enlargement. Group C included 133 knees, while group D included 125 knees. The percentage of FPLT enlargement in group C was significantly smaller than that in group D (p = 0.001).

CONCLUSIONS

A steep coronal GBA of the FPLT after ACLR results in greater FPLT enlargement. The present findings suggest that surgeons should avoid creating a steep GBA of the FPLT in the outside-in technique.

Stiffness and shape of the ACL graft affects tunnel enlargement and graft wear

PURPOSE

Tunnel enlargement and graft rupture are common complications associated with ACL reconstruction (ACLR). This study aims to explore how variations in graft stiffness and shape affect the strain energy density (SED) around bone tunnel entrances and stress on the graft and subsequently influencing the level of tunnel enlargement and graft wear.

METHODS

Finite element ACLR models were developed using different graft stiffnesses (323 N/mm, 545 N/mm and 776 N/mm) and shapes (circular and elliptical). The models were subjected to a combined loading of 103 N anterior tibial load, 7.5 Nm internal tibial moment, and 6.9 Nm valgus tibial moment at joint flexion of 30°. SED at tunnel entrances and stresses on the graft was recorded and compared among the different models.

RESULTS

Increasing the graft stiffness resulted in greater stress on the graft (17.2, 24.4 and 31.7 MPa for graft stiffnesses of 323 N/mm, 545 N/mm and 776 N/mm), but had little effect on the SED reduction around the tunnel entrances. Changing the cross section of the graft from circular to elliptical caused an additional reduction in SED (56.8 vs 2.8 kJ/m³) at the posterior zone of the femoral tunnel entrance and increased the stress on the graft (31.7 MPa vs 38.9 MPa).

CONCLUSIONS

This study recommends using ACL grafts with lower stiffness and a circular cross section to reduce tunnel enlargement and graft wear following ACLR.

A novel protection liner to improve graft-tunnel interaction following anterior cruciate ligament reconstruction: a finite element analysis

Background

Deteriorated bone-graft interaction at the tunnel entrance following ACL reconstruction (ACLR) is considered one of the primary causes of long-term tunnel enlargement and graft wear. Methods have been introduced to improve the long-term outcome, such as novel graft materials or alternative fixation methods, but have been met with varying degrees of success. This study aims to design a protection liner to improve the bone-graft interaction at the tunnel entrances.

Methods

A finite element model of a human cadaveric knee was used to simulate traditional ACLR and ACLR using the protection liner. Stress distribution around the tunnel entrances and on the ACL graft were calculated under a combined loading of 103 N anterior tibial load, 7.5 Nm internal tibial moment, and 6.9 Nm valgus tibial moment at a joint flexion angle of 20°. Results were compared between the traditional ACLR and ACLR using a double liner (femoral and tibial) setup, as well as between the ACLR using a double liner setup and a single liner (femoral side) setup. Different materials (PEEK, Ti-6Al-4V, CoCrMo) for the liner were also evaluated.

Results

The traditional ACLR resulted in concentrated stress on the graft where it contacted the tunnel entrance. Correspondingly, there were stress concentrations at the distal posterior zone of the femoral tunnel entrance and medial posterior zone of the tibial tunnel entrance, while the other zones suffered from a stress reduction. Use of the protection liner reduced the stress concentration around the tunnel entrances by up to 89% and increased the stress at the unloaded zones by up to 106%. Also, stress concentration on the graft was slightly decreased (15.4 vs 15.1 MPa) after using the liner. The single liner setup increased the stress concentration around the tibial tunnel entrance. Stiffer materials improved the stress distribution around tunnel entrances but had little effect on the stress on the graft.

Conclusions

The novel protection liner can improve the stress distribution on the graft and at the tunnel entrances, which may be beneficial for improving the clinical outcome of ACLR.

Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

Although a variety of surgical procedures for anterior talofibular ligament (ATFL) reconstruction have been reported, the effect of initial graft tension during ATFL reconstruction remains unclear.

PURPOSE/HYPOTHESIS

This study investigated the effects of initial graft tension on ATFL reconstruction. We hypothesized that a high degree of initial graft tension would cause abnormal kinematics and laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a robotic system with 6 degrees of freedom to apply passive plantarflexion and dorsiflexion motions and a multidirectional load. A repeated measures experiment was designed with the intact ATFL, transected ATFL, and reconstructed ATFL at initial tension conditions of 10, 30, 50, and 70 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ forces of the ATFL and reconstructed graft were calculated with the principle of superposition.

RESULTS

Initial tension of 10 N was sufficient to imitate normal ankle kinematics and laxity, which were not significantly different when compared with those of the intact ankles. The in situ force on the reconstructed graft tended to increase as the initial tension increased. In situ force on the reconstructed graft >30 N was significantly greater than that of intact ankles. The in situ force on the ATFL was 19 N at 30° of plantarflexion. In situ forces of 21.9, 30.4, 38.2, and 46.8 N were observed at initial tensions of 10, 30, 50, and 70 N, respectively, at 30° of plantarflexion.

CONCLUSION

Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. Moreover, excessive initial graft tension during ATFL reconstruction caused excessive in situ force on the reconstructed graft.

CLINICAL RELEVANCE

This study revealed the effects of initial graft tension during ATFL reconstruction. These data suggest that excessive tension during ATFL reconstruction should be avoided to ensure restoration of normal ankle motion.

Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft. Part 2: Factors related to the tibial tunnel enlargement

BACKGROUND

Factors related to tunnel enlargement after anterior cruciate ligament (ACL) reconstruction should be evaluated by multivariate analysis, because the phenomenon has multifactorial characteristics. The purpose of this study was to elucidate the factors related to the tibial tunnel enlargement rate after anatomic ACL reconstruction with a bone-patellar tendon-bone (BTB) graft using multivariate analysis.

METHODS

Eighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture. The CSA was measured at 3 weeks and 1 year after surgery, and the tunnel enlargement rate at the aperture was calculated. Multiple linear regression analysis was performed to detect the significantly related factors to the tibial tunnel enlargement rate at the aperture among potential factors consisting of preoperative demographic factors and predisposing factors with the tibial tunnel.

RESULTS

The tibial tunnel enlargement rate at the aperture was 21.9 ± 14.1% (mean ± standard deviation). Multiple linear regression analysis detected the tendon length inside the tunnel as a significantly independent factor related to the tibial tunnel enlargement rate at the aperture (standardized β = 0.726, P = 0.008). There was no significant relationship between the tibial tunnel enlargement rate at the aperture and postoperative side-to-side difference (SSD) of the anterior knee laxity or Tegner activity level scale under single linear regression analysis.

CONCLUSION

The greater tendon length inside the tunnel was independently related to the higher tibial tunnel enlargement rate at the aperture 1-year after anatomic ACL reconstruction with a BTB graft under multiple linear regression analysis.

Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft. Part 1: Morphological change in the tibial tunnel

BACKGROUND

Three-dimensional (3D) computed tomography (CT) is reliable and accurate imaging modality for evaluating tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to evaluate the tibial tunnel enlargement including the morphological change after anatomic ACL reconstruction with a bone-patellar tendon-bone (BTB) graft using 3D CT models.

METHODS

Eighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture and 5, 10, and 15-mm distal from the aperture. The CSA was measured at 3 weeks and 1 year after surgery and compared between the two time points. The locations of the center and the anterior, posterior, medial, and lateral edges of the tunnel footprint were also evaluated based on the coordinate system for the tibial plateau and compared between the two time points.

RESULTS

At the aperture, the CSA of the tibial tunnel at 1 year after surgery was significantly larger by 21.9% than that at 3 weeks (P < 0.001). In contrast, the CSA at 1 year was significantly smaller than that at 3 weeks at 10 and 15-mm distal from the aperture (P = 0.041 and < 0.001, respectively). The center of the tunnel footprint significantly shifted postero-laterally with significant posterior shift of the anterior/posterior edges and lateral shift of the lateral edge (P < 0.001).

CONCLUSION

The tibial tunnel enlarged at the aperture by 22% 1-year after anatomic ACL reconstruction with a BTB graft, and the tunnel morphology changed in a postero-lateral direction at the aperture and into conical shape inside the tunnel.

A Randomized Controlled Trial of PEEK Versus Titanium Interference Screws for Anterior Cruciate Ligament Reconstruction With 2-Year Follow-up

BACKGROUND

Graft fixation with interference screws for anterior cruciate ligament (ACL) reconstruction is a highly successful technique. Polyether ether ketone (PEEK) is a novel thermoplastic polymer with high biocompatibility and mechanical properties that mimic native bone, and it can be imaged on computed tomography or magnetic resonance imaging (MRI) without signal flare.

PURPOSE

To compare the clinical performance of ACL reconstruction with PEEK and titanium interference screws at 2 years and to evaluate a novel method of measuring tunnel volume.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 133 patients underwent arthroscopic ACL reconstruction with 4-strand hamstring autografts and were randomized to have titanium or PEEK interference screws for femoral and tibial tunnel fixation. At 2 years, subjective Lysholm and International Knee Documentation Committee scores were assessed and clinical examination performed. At 12 months, MRI was performed to assess graft incorporation and cyst formation, and a novel technique was employed to measure tunnel volumes.

RESULTS

There were no significant differences in graft rerupture rate, contralateral ACL rupture rate, subjective outcomes, or objective outcomes. In the titanium and PEEK groups, MRI demonstrated high overall rates of graft integration (96%-100% and 90%-93%, respectively) and ligamentization (89% and 84%) and low rates of synovitis (22% and 10%) and cyst formation (0%-18% and 13%-15%). There was a higher proportion of patients with incomplete graft integration within the femoral tunnel in the PEEK group as compared with the titanium group (10% vs 0%, P = .03); however, the authors suggest that metal artifact precluded proper assessment of the graft in the titanium group by MRI. Tunnel volumes also appeared to be equivalent in the 2 groups and were measured with a novel technique that was highly reproducible in the PEEK group secondary to the absence of flare.

CONCLUSION

Two-year clinical analysis of PEEK interference screws for femoral and tibial fixation of ACL reconstructions showed equivalent clinical performance to titanium interference screws. Given the excellent mechanical characteristics, biological compatibility, and absence of metal artifact on MRI, PEEK has become our material of choice for interference screw fixation in ACL reconstruction.

Relationship between bone plug position and morphological changes of tunnel aperture in anatomic rectangular tunnel ACL reconstruction

PURPOSE

In animal studies after ACL reconstruction (ACL-R) using the bone-patellar tendon-bone (BTB), the graft-healing pattern was found to depend on the relationship between bone plug and the tunnel wall. This difference of graft-healing pattern could influence the postoperative morphological changes of the tunnel. However, no study has assessed the relationship between bone plug position and the change of tunnel morphology. Therefore, the main purpose of this study was to investigate the relationship between the bone plug position within femoral or tibial tunnel and morphological changes of each tunnel aperture in ACL-R using computed tomography.

METHODS

Subjects were 30 consecutive patients (six females and 24 males; mean age, 20.4 ± 5.4 years) who underwent primary ACL-R using BTB. The distance from the tunnel aperture to the tendon-bone junction (TBJ) at 2 weeks postoperatively, and tunnel aperture enlargement and tunnel wall migration from 2 weeks to 6 months postoperatively, were evaluated.

RESULTS

The distance from the femoral tunnel aperture to the TBJ in most cases was less than 2 mm, whereas the TBJ was located within the tibial tunnel. Femoral tunnel aperture was significantly enlarged (17.0 ± 11.7%) distally, and the tibial tunnel aperture was significantly enlarged (19.6 ± 12.5%) posterolaterally. Only the position at distal portion of femoral bone plug was correlated with femoral tunnel aperture enlargement (r = 0.454, p = 0.0015).

CONCLUSION

Both femoral and tibial tunnel aperture were significantly enlarged distally and posterolaterally 6 months postoperatively. Only correlation between the position at distal portion of femoral bone plug and femoral tunnel enlargement were found, suggesting the deep plug position in the tunnel is a risk factor for femoral tunnel enlargement, highlighting the importance of accurately locating the TBJ just at the femoral tunnel aperture. Another option is to deviate the harvest site in the patellar tendon to match the shape of the TBJ and the tunnel aperture.

LEVEL OF EVIDENCE

4 (case series).

Morphological changes in the femoral and tibial bone tunnels after anatomic single-bundle anterior cruciate ligament reconstruction using a calcium phosphate-hybridized tendon graft in 2years of follow-up

INTRODUCTION

A calcium phosphate (CaP)-hybridized tendon graft improves tendon-to-bone healing. The purpose of the study was to evaluate the progression of morphological changes in the femoral and tibial bone tunnels after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction using the CaP-hybridized tendon graft versus an untreated tendon graft during 2 years of follow-up.

HYPOTHESIS

We hypothesized that the CaP-hybridized tendon graft would prevent the progression of bone tunnel enlargement compared with the untreated tendon graft.

PATIENTS AND METHODS

The CaP group comprised 19 patients, while the conventional group comprised 18. Computed tomography was performed at postoperative 1 week, 1 year, and 2 years. The bone tunnel enlargement and tunnel translation at the aperture of the femoral and tibial tunnels were analyzed.

RESULTS

In the CaP group, the femoral bone tunnel did not expand during 2 years of follow-up. In the conventional group, the femoral bone tunnel diameters at postoperative 1 year and 2 years were enlarged compared with postoperative 1 week, and the proximal and distal walls of the femoral bone tunnel shifted proximally and distally, respectively. The femoral bone tunnel in the CaP group was smaller than that in the conventional group at 1 year postoperatively. Although the tibial bone tunnels expanded for up to 1 year postoperatively in both groups, the expanded bone tunnel reduced during 2 years of follow-up only in the CaP group.

DISCUSSION

In anatomic single-bundle ACL reconstruction, the femoral bone tunnel in the CaP group did not expand or progress with time compared with the conventional group, while the tibial bone tunnel in the CaP group expanded for up to 1 year postoperatively and then reduced for up to 2 years postoperatively. The CaP-hybridized tendon can prevent the progression of bone tunnel enlargement.

LEVEL OF EVIDENCE

Level II, Low-powered prospective randomized trial.

A Biomechanical Comparison of Single-, Double-, and Triple-Bundle Anterior Cruciate Ligament Reconstructions Using a Hamstring Tendon Graft

PURPOSE

The first objective of our cadaveric study was to perform a biomechanical comparison of single-bundle (SB), double-bundle (DB), and triple-bundle (TB) anterior cruciate ligament (ACL) reconstructions using a hamstring tendon graft to determine the laxity match pre-tension (LMP) value, which is the tension within the graft required to re-create the same anterior laxity as the ACL-intact knee. The second objective was to determine the anterior laxity and force distribution during the application of both an anterior force and a simulated pivot-shift test.

METHODS

Eleven fresh-frozen cadaveric knees were tested using a robotic/universal force-moment sensor system in the intact state, TB-reconstructed knee, DB-reconstructed knee, and SB-reconstructed knee. The LMP in each reconstruction was recorded. Each reconstructed knee was tested with an external load of 100-N anterior drawer and combined rotatory loads of 10-Nm valgus moment and 5-Nm internal rotation. The anterior tibial translation and tensile forces of each graft bundle were measured.

RESULTS

The LMP values for the TB reconstruction were 1.7 N for the anteromedial-medial graft, 1.7 N for the anteromedial-lateral graft, and 3.4 N for the posterolateral graft (PLG). The LMP value was 5.6 N for the anteromedial graft and PLG in the DB reconstruction. The LMP value was 26.3 N for the whole graft in the SB reconstruction. No statistically significant difference in stability was found between TB and DB reconstructions during the anterior load and the combined rotatory load test. For force distribution, the PLG tension in the TB reconstruction was statistically lower than that in the DB reconstruction.

CONCLUSIONS

Anatomic TB ACL reconstruction with the lowest initial tension on the graft stabilized the knee equally to DB or SB reconstruction, which required greater initial tension.

CLINICAL RELEVANCE

Although SB, DB, and TB ACL reconstructions through the anatomic tunnel position could equally restore stability, the initial tension on the graft required to restore stability was less in the latter 2 multi-tunnel reconstructions.

Editorial Commentary: Triple-Bundle Anterior Cruciate Ligament Reconstruction: More Is More or Less Is More?

We need ambitious pioneers to explore the frontiers of surgical technique, but the surgeons that follow are wise to wait for independent and robust evidence of clinical benefit. Double-bundle anterior cruciate ligament reconstruction has struggled to establish its role, and triple-bundle reconstruction is perhaps even less likely to gain widespread acceptance, given that cadaveric research has shown only a small biomechanical advantage over a double-bundle or even a single-bundle technique and there is no convincing evidence of improved clinical outcomes.

Significant anterior enlargement of femoral tunnel aperture after hamstring ACL reconstruction, compared to bone-patellar tendon-bone graft

PURPOSE

This study aimed to retrospectively compare the enlargement and migration of the femoral tunnel aperture after anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone-patella tendon-bone (BTB) or hamstring tendon (HT) graft using three-dimensional (3-D) computer models.

METHODS

Thirty-two patients who underwent ACL reconstruction and postoperative computed tomography (CT) at 3 weeks and 6 months were included in this study. Of these, 20 patients underwent ACL reconstruction with a BTB graft (BTBR group), and the remaining 12 with an HT graft (HTR group). The area of the femoral tunnel aperture was extracted and measured using a 3-D computer model generated from CT images. Changes in the area and migration direction of the femoral tunnel aperture during this period were compared between the two groups.

RESULTS

In the HTR group, the area of the femoral tunnel aperture was significantly increased at 6 months compared to 3 weeks postoperatively (P < 0.05). The average area of the femoral tunnel aperture at 6 months postoperatively was larger by 16.0 ± 12.4% in the BTBR group and 41.9 ± 22.2% in the HTR group, relative to that measured at 3 weeks postoperatively (P < 0.05). The femoral tunnel aperture migrated in the anteroinferior direction in the HTR group, and only in the inferior direction in the BTBR group.

CONCLUSIONS

The femoral tunnel aperture in the HTR group was significantly more enlarged and more anteriorly located at 6 months after ACL reconstruction, compared to the BTBR group.

LEVEL OF EVIDENCE

IV.

Anatomic single-bundle anterior cruciate ligament reconstruction using a calcium phosphate-hybridized tendon graft: a randomized controlled trial with 2 years of follow-up

BACKGROUND

To improve tendon-to-bone healing in anterior cruciate ligament (ACL) reconstruction, a novel technique via calcium phosphate (CaP)-hybridized tendon graft using an alternate soaking process was developed. The purpose of this study was to evaluate the clinical results of anatomic single-bundle ACL reconstruction using the CaP-hybridized tendon graft with up to 2 years follow-up, and compare the outcome with conventional ACL reconstruction and preoperative data.

METHODS

Ninety patients who required anatomic single-bundle ACL reconstruction were randomized to undergo either the CaP-hybridized tendon graft method (CaP group, n = 45) or the conventional method (conventional group, n = 45). At 1 and 2 years postoperatively, all patients were evaluated using KT-1000 arthrometry, pivot-shift test, International Knee Documentation Committee (IKDC) grade, Lysholm scale, and Tegner scale; at the same timepoints, bone tunnel enlargement was evaluated using computed tomography, and the tendon graft intensity was evaluated on magnetic resonance imaging. Tendon graft appearance was evaluated arthroscopically once after a period of up to 2 years postoperatively. Cases of re-rupture and adverse events were recorded in both groups.

RESULTS

In both groups, the KT-1000 arthrometry, pivot-shift test, IKDC grade, and Lysholm scale results at 1 and 2 years postoperatively were superior to preoperative data; these results did not significantly differ between groups at either timepoint. The rate of increase of the cross-sectional area of the femoral bone tunnel in the CaP group was smaller than that in the conventional group at 1 year postoperatively. The other results did not significantly differ between the two groups at any timepoint. There were two cases of re-rupture in the CaP group, and six cases of re-rupture in the conventional group. There were no adverse events during follow-up in either group.

CONCLUSIONS

Anatomic single-bundle ACL reconstruction using a CaP-hybridized tendon graft was safe, and resulted in improved clinical outcomes at 2 years postoperatively compared with preoperative data; the outcomes were comparable with the conventional method. A longer follow-up is needed to clarify the clinical effects of the CaP-hybridized tendon graft in anatomic single-bundle ACL reconstruction.

TRIAL REGISTRATION

UMIN, UMIN000019788 Registered 14 November 2015-Retrospectively registered.

Femoral tunnel enlargement after anatomic anterior cruciate ligament reconstruction: Bone-patellar tendon-bone /single rectangular tunnel versus hamstring tendon / double tunnels

PURPOSE

This study aimed to prospectively compare the femoral tunnel enlargement at the aperture as well as inside the tunnel after anatomic anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) graft to that with hamstring tendon (HST) graft.

METHODS

This study included 24 patients with unilateral ACL rupture. Twelve patients underwent anatomic rectangular tunnel (ART) ACL reconstruction with BTB graft and the remaining 12 underwent anatomic triple-bundle (ATB) ACL reconstruction with HST graft. Three-dimensional computer models of femur and bone tunnels were reconstructed from computed tomography images obtained at 3 weeks and 1 year postoperatively. The femoral tunnel enlargement from 3 weeks to 1 year was evaluated by comparing the cross-sectional area (CSA), and compared between the two groups.

RESULTS

The CSA in the ART group at 1 year decreased at the aperture as well as inside the tunnel comparing that at 3 weeks. The CSAs of both tunnels in the ATB group at 1 year significantly increased at the aperture in comparison to those at 3 weeks, and gradually decreased toward the inside of the tunnel. The enlargement rate at the aperture in the ART group was -12.9%, which was significantly smaller than that of anteromedial graft (27.9%; P = 0.006) and posterolateral graft (31.3%; P = 0.003) in the ATB group. The tunnel enlargement rate at 5 mm from the aperture in the ART group was also significantly smaller than that in the ATB group. At 10 mm from the aperture, there was no significant difference between the tunnel enlargement rate in the ART group and that of anteromedial tunnel.

CONCLUSIONS

The tunnel enlargement rate around the aperture was significantly smaller after the ART procedure than that after the ATB procedure. Thus, BTB graft might be preferable as a graft material to HST graft in the femoral tunnel enlargement.

Effect of Initial Graft Tension During Calcaneofibular Ligament Reconstruction on Ankle Kinematics and Laxity

BACKGROUND

Although a variety of surgical procedures for lateral ankle ligament reconstruction have frequently been reported, little is known about the effects of initial graft tension. Purpose/Hypothesis: The purpose was to investigate the effects of initial graft tension in calcaneofibular ligament (CFL) reconstruction. It was hypothesized that a high degree of initial graft tension would cause abnormal kinematics, laxity, and excessive graft tension.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a 6 degrees of freedom robotic system to apply passive plantarflexion-dorsiflexion motion and multidirectional loads. A repeated-measures experiment was designed with the CFL intact, CFL transected, and CFL reconstructed with 4 initial tension conditions (10, 30, 50, and 70 N). The 3-dimensional path and reconstructed graft tension were simultaneously recorded.

RESULTS

The calcaneus in CFL reconstruction with an initial tension of 70 N had the most eversion relative to the intact condition (mean eversion translations of 1.2, 3.0, 5.0, and 6.2 mm were observed at initial tensions of 10, 30, 50, and 70 N, respectively). The calcaneus also moved more posteriorly with external rotation as the initial tension increased. The reconstructed graft tension tended to increase as the initial tension increased.

CONCLUSION

Ankle kinematic patterns and laxity after CFL reconstruction tended to become more abnormal as the initial graft tension increased at the time of surgery. Moreover, excessive initial graft tension caused excessive tension on the reconstructed graft.

CLINICAL RELEVANCE

This study indicated the importance of initial graft tension during CFL reconstruction. Overtensioning during CFL reconstruction should be avoided to imitate a normal ankle.

Early Structural Results After Anatomic Triple Bundle Anterior Cruciate Ligament Reconstruction Validated by Tunnel Location, Graft Orientation, and Static Anteroposterior Tibia-Femur Relationship

PURPOSE

To elucidate how closely the structural characteristics of the anterior cruciate ligament (ACL) grafts after anatomic triple bundle (ATB) reconstruction resembled those of the normal ACL.

METHODS

From 2012 to 2016, patients who underwent primary ATB ACL reconstruction using hamstring tendon autografts and the same number of healthy control subjects were included. Using magnetic resonance imaging (MRI) taken at 6 months postoperatively, ACL graft orientation was evaluated by the angles against the tibial plateau measured in the sagittal and oblique coronal planes at the anteromedial and posterolateral portions (ACL-tibial plateau angle [ATA]). For factors affecting the graft orientation, the static tibiofemoral relationship was evaluated by anteroposterior tibial translocation (APTT) in the identical MRI using a previously established method, and tunnel locations were evaluated using the quadrant method. To test equivalence, the widely used two one-sided test procedure was performed, with the equivalence margins of 5° and 3 mm for ATA and APTT, respectively.

RESULTS

Thirty-five patients were enrolled for each group. ATAs were not significantly different, and the 95% confidence interval (CI) of these differences was within 5° (sagittal: P = .211 [95% CI, -2.9 to 0.6]; oblique coronal ATA for the anteromedial and posterolateral portions: P = .269 [95% CI, -1.9 to 0.5] and P = .456 [95% CI,-2.1 to 0.9], respectively). The difference in APTT was neither statistically nor clinically significant (P = .114; 95% CI, -2.0 to 0.2).

CONCLUSIONS

These data suggest that ACL grafts using the ATB technique achieved a graft orientation equivalent to that of the normal ACL, with an equivalent postoperative anteroposterior tibiofemoral relationship in the static MRI. Thus, the ATB ACL reconstruction technique with the presented tunnel locations produced grafts that were similar to the native ACL in orientation.

LEVEL OF EVIDENCE

Level III, case-control study.

Stress distribution is deviated around the aperture of the femoral tunnel in the anatomic anterior cruciate ligament reconstruction

PURPOSE

Final tunnel location in the anterior cruciate ligament (ACL) reconstruction is unpredictable due to tunnel widening and/or transposition. The mechanical stress around the tunnel aperture seems to be a major factor but is not fully investigated. The purpose of this study was to measure the stress from the ACL graft around the tunnel aperture when the ACL graft tension reaches its peak.

METHODS

Six cadaveric knees were used. Single-bundle ACL reconstruction was performed using a hamstrings graft. Both femoral and tibial tunnels were created at the centre of the original ACL footprint. A 7-mm-internal-diameter aluminium cylinder with pressure sensors was placed in the femoral tunnel. Hamstrings graft with a microtension sensor was inserted. After fixation, passive extension-flexion was performed while monitoring the tunnel aperture pressure and the graft tension simultaneously. The pressure on the femoral tunnel aperture when the ACL graft tension reach its peak was compared between four directions.

RESULTS

The ACL graft tension peaked (67 ± 49 N) at full extension (-5.8 ± 4.1°). Pressure at the femoral tunnel aperture was different between different directions (p < 0.01). Distal part had significantly larger pressure (1.7 ± 1.3 MPa) than the other directions (p < 0.01). Second largest pressure was carried in the anterior part (0.6 ± 0.5 MPa), followed by proximal and posterior parts (0.4 ± 0.3, 0.2 ± 0.2 MPa respectively).

CONCLUSION

The stress distribution at the femoral tunnel aperture is not equal in different directions, while the distal part dominantly bears the stress from the ACL graft. Surgeons should pay close attention to the distal edge of the femoral tunnel which should be inside the anatomic ACL footprint eventually.

Patient age as a preoperative factor associated with tunnel enlargement following double-bundle anterior cruciate ligament reconstruction using hamstring tendon autografts

PURPOSE

A few studies have detected associations of post-operative tunnel enlargement with sex, age, and the timing of anterior cruciate ligament reconstruction (ACLR). The aim of the present study was to investigate the correlation between post-operative tunnel enlargement following ACLR using hamstring tendon autografts and preoperative factors. The authors hypothesized that tunnel enlargement is associated with age in patients undergoing ACLR.

METHODS

One hundred and six patients (male, n = 57; female, n = 49; mean age, 26.9 years) who underwent double-bundle ACL reconstruction were included in the present study. The time between injury and surgery was 26.3 ± 71.4 weeks. Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months after surgery. The area of the tunnel aperture was measured for the femoral anteromedial tunnel (FAMT), femoral posterolateral tunnel (FPLT), tibial anteromedial tunnel (TAMT), and tibial posterolateral tunnel. The percentage of tunnel area enlargement was defined as the area at 2 weeks after ACLR subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. Spearman's correlation coefficient was calculated for each factor. The patients were divided into two groups based on age. Patients aged <40 and ≥40 years were assigned to Groups A and B, respectively. The differences in the outcomes and characteristics of the two groups were evaluated.

RESULTS

The percentage of enlargement of the FAMT, FPLT, and TAMT was correlated with patient age (r = 0.31, p = 0.001; r = 0.24, p = 0.012; and r = 0.30, p = 0.002, respectively). In total, 87 and 19 knees were classified into Groups A and B, respectively, based on patient age. The percentage of enlargement of the FAMT was significantly higher in Group B than A (78 vs. 60%, respectively; p = 0.01). The percentage of enlargement of the TAMT was significantly higher in Group B than A (53 vs. 36%, respectively; p = 0.03).

CONCLUSION

The percentage of enlargement of the FAMT and TAMT was associated with patient age. These findings suggest the need to consider the possibility of tunnel enlargement when double-bundle ACLR is performed for patients aged >40 years. Age was a preoperative factor associated with tunnel enlargement.

LEVEL OF EVIDENCE

III.

Arthroscopic Viewing Position Affects Anterior Cruciate Ligament Reconstruction Femoral Tunnel Length Measurements

Purpose

To purpose of this study was to compare arthroscopic anterior cruciate ligament (ACL) reconstruction femoral tunnel length measurements from the anterolateral portal between the standard notch view using a 30° arthroscope versus a "top-down" view utilizing a 70° arthroscope to visual the far side of the femoral tunnel aperture.

Methods

Arthroscopic femoral tunnel length measurements using calibrated reamers from the standard notch versus the "top-down" view were obtained and reviewed in 54 skeletally mature patients undergoing ACL reconstruction with no prior bony knee surgery. Patient age, height, weight, sex, and surgery laterality were also recorded. Measurements of femoral tunnel length were repeated using both views for inter-observer and intra-observer correlation.

Results

Inter-observer and intra-observer intra-class correlation coefficients for the standard notch view and "top-down" views were excellent, with higher reliability values appreciated using the "top down" view. Mean overall femoral tunnel length measurements obtained using the standard notch view were significantly longer than measurements from the "top-down" view (p < 0.001).

Conclusions

The standard notch view provides significantly longer femoral tunnel length measurements in comparison to the "top-down" view.

The remnant preservation technique reduces the amount of bone tunnel enlargement following anterior cruciate ligament reconstruction

PURPOSE

The aim of the present study was to investigate the correlation between postoperative tunnel enlargement after ACLR and remnant tissue preservation using the hamstring tendon.

METHODS

One hundred and ninety-two subjects (male, n = 101; female, n = 91; mean age 27.1) who had undergone double-bundle ACL reconstruction were included in the present study. The patients were divided into two groups: the remnant tissue preservation group (Group R) and the non-remnant tissue preservation group (Group N). Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months after surgery. The area of the tunnel aperture for the anteromedial femoral tunnel (FAMT), posterolateral femoral tunnel (FPLT), anteromedial tibial tunnel (TAMT), and posterolateral tibial tunnel (TPLT) was measured. The area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The differences in the outcomes and characteristics of the two groups were evaluated.

RESULTS

Seventy-seven knees were classified into Group R, and 115 knees were classified into Group N. The age, gender, and body mass index did not differ to a statistically significant extent. The percentages of FAMT and TAMT enlargement in Group R were significantly smaller in comparison with Group N (P = 0.003 and P = 0.03, respectively). The percentage of FPLT and TPLT enlargement in the two groups did not differ to a statistically significant extent.

CONCLUSION

The remnant-preserving technique reduces the amount of bone tunnel enlargement. The present findings indicate the advantages of the remnant-preserving ACLR technique, and therefore the remnant-preserving technique should be recommended.

LEVEL OF EVIDENCE

II.

Calcium phosphate-hybridized tendon grafts reduce femoral bone tunnel enlargement in anatomic single-bundle ACL reconstruction

PURPOSE

This study aimed to clarify the effect of calcium phosphate (CaP)-hybridized tendon grafting versus unhybridized tendon grafting on the morphological changes to the bone tunnels at the aperture 1 year after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction.

METHODS

Seventy-three patients were randomized to undergo the CaP (n = 37) or the conventional method (n = 36). All patients underwent computed tomography (CT) evaluation 1 week and 1 year post-operatively. The femoral and tibial tunnels at the aperture were evaluated on reconstructed 3D CT images. Changes in the cross-sectional area (CSA) and diameters of the femur and the tibia, and the translation rate of the tunnel walls and the morphological changes of both tunnels were assessed.

RESULTS

There was a significant reduction in the increase in the CSA and the anterior-posterior and proximal-distal tunnel diameters on the femoral side in the CaP group as compared with the conventional group. On the femoral side, the translation rate of the posterior wall was significantly larger in the CaP group than in the conventional group, whereas the translation rate of the distal wall was significantly smaller in the CaP group than in the conventional group.

CONCLUSIONS

As compared with the conventional method, the CaP-hybridized tendon graft reduced bone tunnel enlargement on the femoral side 1 year after anatomic single-bundle ACL reconstruction due to an anterior shift of the posterior wall and reduced distal shift in the femoral bone tunnel. Clinically, the CaP-hybridized tendon grafts can prevent femoral bone tunnel enlargement in anatomic single-bundle ACL reconstruction.

LEVEL OF EVIDENCE

I.

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

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.

Bone tunnel change develops within two weeks of double-bundle anterior cruciate ligament reconstruction using hamstring autograft: A comparison of different postoperative immobilization periods using computed tomography

BACKGROUND

The purpose of this study was to evaluate bone tunnel changes following anterior cruciate ligament (ACL) reconstruction during the early postoperative period using computed tomography (CT), and to understand the impact of postoperative immobilization on these changes.

METHODS

Twenty patients who underwent double-bundle ACL reconstruction using hamstring tendon autografts were included. We subcategorized patients into two groups: patients who underwent isolated ACL reconstruction and had three days of knee immobilization (Group A, n=10); and patients with concomitant meniscus injuries who underwent ACL reconstruction and meniscus repair simultaneously (Group B, n=10) had their knees immobilized for two weeks after surgery. Bone tunnel enlargement was evaluated using CT imaging at one to three days, two weeks, one month, three months and six months after surgery. The cross-sectional area of the femoral and tibial tunnels was measured, and enlargement rate was calculated. The tunnel center location at two weeks after surgery was also evaluated.

RESULTS

The mean cross-sectional area adjacent to the joint space of the femoral and tibial tunnels significantly increased immediately after surgery, especially in the first month (P<0.01). However, after one to six months they were not increased (P>0.01). There was no significant difference in tunnel enlargement rate between group A and B. Tunnel center location changed even in the first two weeks.

CONCLUSIONS

Bone tunnel enlargement following double-bundle ACL reconstruction occurred at an earlier time point after surgery than anticipated. Postoperative immobilization could not prevent bone tunnel enlargement, but might prevent tunnel migration.

How to evaluate bone tunnel widening after ACL reconstruction - a critical review

Background

Comparing different imaging modalities and methods for assessment tunnel widening after ACL reconstruction and providing a detailed evidence-based literature overview.

Methods

PubMed was searched from 1970 to 2016 using the terms "ACL reconstruction" and "tunnel" and "imaging" or "CT" or "computerized tomography" or "MRI" or "magnetic resonance imaging" or "radiographs". 647 studies were found. 575 articles were excluded due to absence of specific radiological measurement methods of tunnel widening and 40 due to repetition of a previously published radiological measurement method. 32 articles were included reporting interand intraobserver reliabilities of tunnel measurement methods after ACL reconstruction.

Results

A variety of different algorithms and measurement methods using radiographs, magnetic resonance imaging, computed tomography or SPECT/CT evaluating tunnel position and bone tunnel enlargement have been described. Tunnel delination restricts an exact analysis using X-ray. Measurements using CT or MR were mostly obtained perpendicular to the tunnel axis or using specialized software for tunnel volume calculation in 3D.Based on the review the width of the femoral and tibial tunnels should be assessed perpendicular to the tunnel axis at different levels in relation to the joint. At least one measurement should be performed at the tunnel entrance, exit and midpoint of the tunnel.

Conclusion

CT should be considered the gold standard assessing tunnel widening in patients after ACL reconstruction. If specialized software is available calculating the tunnel volume, measurements should be preferably performed in 3D CT.

Level of evidence

II.

Morphological changes in tibial tunnels after anatomic anterior cruciate ligament reconstruction with hamstring tendon graft

Background

Three-dimensional (3D) reconstructed computed tomography (CT) is crucial for the reliable and accurate evaluation of tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purposes of this study were to evaluate the tibial tunnel enlargement at the tunnel aperture and inside the tunnel and to clarify the morphological change at the tunnel footprint 1 year after the anatomic triple-bundle (ATB) ACL reconstruction using 3D CT models.

Methods

Eighteen patients with unilateral ACL rupture were evaluated. The ATB ACL reconstruction with a semitendinosus tendon autograft was performed. 3D computer models of the tibia and the three tibial tunnels were reconstructed from CT data obtained 3 weeks and 1 year after surgery. The cross-sectional areas (CSAs) of the two anterior and the one posterior tunnels were measured at the tunnel aperture and 5 and 10 mm distal from the aperture and compared between the two periods. The locations of the center and the anterior, posterior, medial, and lateral edges of each tunnel footprint were also measured and compared between the two periods.

Results

The CSA of the posterior tunnel was significantly enlarged at the aperture by 40.4%, whereas that of the anterior tunnels did not change significantly, although the enlargement rate was 6.1%. On the other hand, the CSA was significantly reduced at 10 mm distal from the aperture in the anterior tunnels. The enlargement rate in the posterior tunnel was significantly greater than that in the anterior tunnels at the aperture. The center of the posterior tunnel footprint significantly shifted postero-laterally. The anterior and posterior edges of the posterior tunnel footprint demonstrated a significant posterior shift, while the lateral edge significantly shifted laterally. There was no significant shift of the center or all the edges of the anterior tunnels footprint.

Conclusions

The posterior tibial tunnel was significantly enlarged at the aperture by 40% with the morphological change in the postero-lateral direction reflected by the ACL fiber orientation 1 year after the ATB ACL reconstruction. The proper tibial tunnel location in the ACL reconstruction should be determined considering the tunnel enlargement in postero-lateral direction after surgery.

Effects of initial graft tension on femoral tunnel widening after anatomic anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft

INTRODUCTION

The effects of initial graft tension upon tunnel widening (TW) following anatomic anterior cruciate ligament (ACL) reconstruction have not been elucidated. The purpose of this study was to retrospectively investigate the effect of two different graft-tensioning protocols upon femoral TW following anatomic ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft and a three-dimensional (3D) computed tomography (CT) model.

METHODS

Forty-three patients who underwent isolated ACL reconstruction using BPTB grafts were included in this study. In 18 out of the 43 patients, the graft was fixed at full knee extension with manual maximum pull (Group H). These patients were compared with 25 patients in whom the BPTB graft was fixed at full knee extension with 80-N pull (Group L). Tunnel aperture area was measured using 3D CT 1 week and 1 year postoperatively, thus enabling us to calculate the percentage change in the area of femoral tunnel aperture. Clinical assessment was performed 1 year postoperatively, corresponding to the time period of CT assessment, and involved the evaluation of Lysholm score, anterior knee stability using a KneeLax3 arthrometer, and the pivot-shift test.

RESULTS

When measured at 1 year postoperatively, the mean area of the femoral tunnel aperture had increased by 78.6 ± 36.8% in Group H when compared with at 1 week postoperatively, whereas that of Group L had increased by 27.7 ± 32.3%. Furthermore, TW (%) in Group H was significantly greater than that of Group L (P < 0.001). No significant differences were detected between the two groups with regard to any of the clinical outcomes evaluated.

CONCLUSION

High levels of initial graft tension resulted in greater TW of the femoral tunnel aperture following anatomical ACL reconstruction using BPTB grafts. However, such levels of graft tension did not affect clinical outcome.

Is the Grafted Tendon Shifted Anteriorly in the Femoral Tunnel at the Postremodeling Phase After Anterior Cruciate Ligament Reconstruction? A Clinical MRI Study

BACKGROUND

Based on previous in vitro studies, it has been commonly believed that during anterior cruciate ligament (ACL) reconstruction with hamstring tendon, the grafted tendon is shifted anteriorly in the tunnel permanently after the graft is anchored to the tunnel wall. However, this has not been proven by in vivo studies.

HYPOTHESIS

At 1 year after anatomic double-bundle ACL reconstruction, the grafted tendons may not be shifted anteriorly in the femoral tunnel but anchored to the bony wall at the center of the tunnel.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Participants consisted of 40 patients who underwent anatomic double-bundle ACL reconstruction. The grafted tendons located in the femoral tunnel were examined 1 year after surgery using 2 different magnetic resonance imaging (MRI) protocols. In the first substudy, with 20 patients, the grafted tendon location was evaluated on an inclined sagittal multiplanar reconstruction (MPR) image taken using a standard T2-weighted protocol. In the second substudy with the remaining 20 patients, tendon location was evaluated on a pure axial MPR image taken using a VISTA (volume isotropic turbo spin echo acquisition) protocol.

RESULTS

On the inclined sagittal T2-weighted images of the anteromedial (AM) graft, the anterior width of the newly formed fibrous tissue, which surrounded the tendon graft, was significantly greater than the posterior width (P = .001). The center of the grafted tendon was slightly (mean, 2.5% of the tunnel diameter) but significantly (P = .0310) shifted posteriorly from the tunnel center. On the axial T2-VISTA images, the center of the AM graft was slightly but significantly shifted posteriorly (3.9%; P = .022) and medially (5.5%; P = .002) from the tunnel center. The center of the posterolateral (PL) graft was not significantly shifted to any direction from the center of the tunnel.

CONCLUSION

The grafted tendons were not shifted anteriorly in the femoral tunnel 1 year after anatomic double-bundle ACL reconstruction. The PL graft was located approximately at the center of the tunnel outlet, while the AM graft was slightly but significantly shifted posteriorly and proximally.

3D Computed Tomography Evaluation of Morphological Changes in the Femoral Tunnel After Medial Patellofemoral Ligament Reconstruction With Hamstring Tendon Graft for Recurrent Patellar Dislocation

BACKGROUND

Reconstruction of the medial patellofemoral ligament (MPFL) for recurrent lateral patellar dislocation is gaining popularity. However, the morphological changes in the femoral tunnel after MPFL reconstruction are still not fully documented.

PURPOSE

This study used 3-dimensional (3D) computed tomography to evaluate morphological changes in the femoral tunnel after MPFL reconstruction with hamstring tendon graft to investigate factors affecting the phenomenon and to elucidate whether it is associated with clinical outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-three patients with recurrent patellar dislocation were prospectively enrolled in this study. The patients included 6 males and 17 females with a mean age of 24 years (range, 14-53). The MPFL was reconstructed by creating 2 patellar bone sockets and 1 femoral bone socket anatomically under X-ray control, and the semitendinosus autograft was fixed with cortical suspension devices. Computed tomography scans obtained 3 weeks and 1 year after surgery were reconstructed into 3D constructs with a volume analyzer. Cross-sectional areas (CSAs) of the aperture and inside the femoral tunnel were compared between the 2 time points. Likewise, the location of tunnel walls and center of the femoral tunnel footprint were evaluated. Relationships were assessed between femoral tunnel morphological changes and potential risk factors-such as age, body mass index, sex, femoral tunnel positioning, patellar height, sulcus angle, congruence angle, lateral tilt angle, degree of trochlear dysplasia, lateral deviation of the tibial tubercle, and Kujala score.

RESULTS

No patient reported recurrence of patellar dislocation during the follow-up period. The CSA of the femoral tunnel aperture enlarged by 41.1% ± 34.7% ( P < .01). The center, anterior border, and proximal border of the femoral tunnel significantly shifted in the anterior direction ( P < .01). The distal border significantly shifted in both anterior and distal directions ( P < .01). Patella alta was associated with distal migration of the tunnel center ( P < .05). Morphological changes were not associated with other risk factors or Kujala score.

CONCLUSION

The CSA of the femoral tunnel aperture enlarged, and the tunnel aperture migrated anteriorly with time after MPFL reconstruction. Risk factors for patellar dislocation other than patella alta did not influence morphological changes of the femoral tunnel.

The cross-sectional shape of the fourfold semitendinosus tendon is oval, not round

BACKGROUND

The looped side of the semitendinosus tendon (ST) graft (i.e., the side inserted into the femoral tunnel during anterior cruciate ligament reconstruction) appears to be oval rather than round. The purpose of this study was to investigate the cross section of the fourfold semitendinosus tendon graft and, more specifically, the differences in pressure exerted by a rounded rectangular tunnel versus a round femoral tunnel.

METHODS

Seven STs were harvested from cadaveric knees and a fourfold ST graft was made. Aluminum cubes with round or rectangular tunnels containing four-way pressure-sensitive conductive sensors (vertically and bilaterally) were used. The area of both cubes was the same. The graft was inserted into the tunnels 15 mm from the looped edge. After measuring pressure, the graft was fixed using ultraviolet-curing acrylic resin and was cut at 7.5 mm and 15 mm from the lapel edge. The area, axes for the best fitting ellipse of the cross-section, and ellipticity of the axes were measured.

RESULTS

In the round tunnel, the mean contact pressure was 287.0 ± 136.7 gf at the bilateral sensor; there was no contact pressure detected by the vertical sensor. In the rounded rectangular tunnel, the mean contact pressure was 260.9 ± 186.4 gf at the bilateral sensor and 352.9 ± 49.5 gf at the vertical sensor. Ellipticity was 1.25 ± 0.13 at 7.5 mm, and 1.17 ± 0.07 at 15 mm from the lapel edge of the graft.

CONCLUSIONS

The cross-sectional shape of the fourfold ST graft was not round, but oval. Moreover, the rounded rectangular tunnel was more fitted to the graft than the round tunnel.

Evaluation of the semitendinosus tendon graft shift in the bone tunnel: an experimental study

PURPOSE

The purpose of this study was to measure the semitendinosus tendon graft shift at the tunnel aperture with graft bending using a simulated femoral bone tunnel.

METHODS

Eight semitendinosus tendon grafts were used in this study. The median age of the specimen was 53 years (range 46-63). After stripping excess soft tissue, the semitendinosus tendon was doubled over the loop of the EndoButton CL (Smith and Nephew Inc.). The diameter of the graft was measured using a graft-sizing tube (Smith and Nephew Inc.) and verified to be 7.0 mm. A custom-made aluminium fixture, the size was 40.0 mm(3), with 7.0-mm-diameter hole was used as a simulated femoral bone tunnel. The graft was inserted to the tunnel, and EndoButton was positioned to the outside of the tunnel on the fixture. The distal end of the graft was tensioned with 30 N at an angle of 15°, 30°, 45°, 60°, 75° that reproduced the graft bending angle during knee range of motion. The photograph of the tunnel aperture was taken at each graft bending angle using a digital camera, and the graft shift amount in the simulated tunnel was analysed using the computer software (ImageJ).

RESULTS

The amount of the graft shift significantly increased when the graft bending angle was increased (P < 0.05). The biggest shift was observed when the graft bending angle was 75° in all specimens, and the value was 1.10 mm ± 0.12.

CONCLUSION

The present study suggests that even if the femoral tunnel was created in the centre of the ACL insertion site, the graft shifted within the tunnel in the direction of the tension applied to the graft during knee range of motion. Surgeons may have to consider the graft shift within the bone tunnel as well as the tunnel position in the restoration of the native ACL anatomy.

Anatomic ACL reconstruction: rectangular tunnel/bone-patellar tendon-bone or triple-bundle/semitendinosus tendon grafting

Anatomic ACL reconstruction is the reasonable approach to restore stability without loss of motion after ACL tear. To mimic the normal ACL like a ribbon, our preferred procedures is the anatomic rectangular tunnel (ART) technique with a bone-patellar tendon-bone (BTB) graft or the anatomic triple bundle (ATB) procedure with a hamstring (HS) tendon graft. It is important to create tunnel apertures inside the attachment areas to lessen the tunnel widening. To identify the crescent-shaped ACL femoral attachment area, the upper cartilage margin, the posterior cartilage margin and the resident's ridge are used as landmarks. To delineate the C-shaped tibial insertion, medial intercondylar ridge, Parson's knob and anterior horn of the lateral meniscus are helpful. In ART-BTB procedure which is suitable for male patients engaged in contact sports, the parallelepiped tunnels with rectangular apertures are made within the femoral and tibial attachment areas. In ATB-HS technique which is mainly applied to female athletes engaged in non-contact sports including skiing or basketball, 2 femoral and 3 tibial round tunnels are created inside the attachment areas. These techniques make it possible for the grafts to run as the native ACL without impingement to the notch or PCL. After femoral fixation with an interference screw or cortical fixation devices including Endobutton, the graft is pretensioned in situ by repetitive manual pulls at 15-20° of flexion, monitoring the graft tension with tensioners on a tensioning boot installed on the calf. Tibial fixation with pullout sutures is achieved using Double Spike Plate and a screw at the pre-determined amount of tension of 10-20N. While better outcomes with less failure rate are being obtained compared to those in the past, higher graft tear rate remains a problem. Improved preventive training may be required to avoid secondary ACL injuries.