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Borque KA, Laughlin MS, Pinheiro VH, Jones M, Williams A. Rebranding the 'anatomic' ACL reconstruction: Current concepts. J ISAKOS 2023; 8:23-28. [PMID: 36435433 DOI: 10.1016/j.jisako.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022]
Abstract
The anterior cruciate ligament (ACL) is a complex ribbon-like structure, which is approximately 3.5 times larger at the tibial and femoral insertions than at the midpoint. Accordingly, it is impossible to recreate with a single cylindrical graft. However, this has not stopped surgeons from using the term "anatomic" to describe multiple ACL reconstruction techniques inserting at a number of different locations within the original ACL footprint, causing confusion. The term "anatomic" should be discarded and replaced by an anatomic description of the tunnel placements on the tibia and femur. Current ACL reconstruction techniques cite anatomical studies that identified "direct and indirect fibres" of the ACL. The "direct fibres" bear 85-95% of the load and provide the main resistance to both anterior tibial translation and internal rotation/pivot shift. On the femur, these fibres insert in a line just posterior to the intercondylar ridge and comprise the portion of the ACL that surgeons should strive to restore. Placement of the graft just posterior to the intercondylar ridge creates a line of placement options from the anteromedial bundle to the "central" position and finally to the posterolateral bundle position. The authors prefer placing the femoral tunnel in the isometric anteromedial position and addressing a high-grade pivot shift at the IT-band with a lateral extra-articular tenodesis. As with the femoral tunnel, the native ACL footprint on the tibia is much larger than the ACL graft and thus can be placed in multiple "anatomic" locations. The authors prefer placement of the tibial tunnel in the anterior most position of the native footprint that does not cause impingement in the femoral notch. Additional research is needed to determine the ideal tunnel positions on the femur and tibia and validating the technique with patient outcomes. However, this cannot be accomplished without describing tunnel placement with specific anatomical locations so other surgeons can replicate the technique.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Hospital, Houston, TX, 77479, USA.
| | | | | | - Mary Jones
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
| | - Andy Williams
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
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Oshima T, Putnis S, Grasso S, Lim YP, Oshima M, Parker DA. A balance between native footprint coverage and overlap of the anterolateral meniscal root in tibial tunnel positioning during anterior cruciate ligament reconstruction: A 3D MRI study. Knee 2023; 41:106-114. [PMID: 36642034 DOI: 10.1016/j.knee.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/13/2022] [Accepted: 12/08/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Tibial footprint of anterior cruciate ligament (ACL) is situated close to the anterior lateral meniscal root (ALMR) attachment. PURPOSE To investigate the impact of the size and location of the tibial tunnel for ACL reconstruction on the ACL footprint coverage and overlap to the ALMR. STUDY DESIGN Controlled laboratory study. METHODS Twenty knee MRI scans from twenty healthy subjects were recruited, and three-dimensional (3D) tibia models were created to show the tibial attachment sites of ACL and ALMR. Surgical simulation of the tibial tunnel drilling was performed on each 3D model, entering the joint at an angle set at 60 degrees from the tibial plateau plane and 55 degrees from the posterior tibial condylar axis, with analysis for six different drill sizes; 7.5, 8, 8.5, 9, 9.5 and 10 mm; and nine locations; the center of the ACL attachment and eight locations 2% of the tibial width apart surrounding it. The width of the tibial plateau, the distance between ACL and ALMR attachment centers, and the size and location of the potential tibial tunnel were evaluated to determine association with the area of the ACL footprint coverage and ALMR overlap using a linear mixed effects model. RESULTS A large tunnel (p <.001), a central and anterior location (p <.029), and small tibial width (p =.015) were all associated with larger coverage of the ACL footprint. A large tunnel (p <.001), posteriorly and laterally located (p ≤ 0.001), and a small distance between the ACL and ALMR centers (p =.001) were significantly associated with a larger ALMR overlap. The association of the tunnel size to ALMR overlap reduced with a medial tunnel location. CONCLUSIONS The short distance between the centers of the ALMR attachment and native ACL footprint suggests that the ALMR will always be susceptible to overlap when the tibial tunnel is drilled in ACL reconstruction. Small alterations in tunnel location can lead to a statistically significant alteration with the amount of ALMR overlap. To minimize this overlap, whilst maintaining acceptable coverage of the ACL footprint, a tibial tunnel positioned in a medial or anteromedial location from the center of the ACL footprint is recommended.
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Affiliation(s)
- Takeshi Oshima
- Sydney Orthopaedic Research Institute, Chatswood, NSW, Australia; Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
| | - Sven Putnis
- Sydney Orthopaedic Research Institute, Chatswood, NSW, Australia; Bristol Royal Infirmary, University Hospitals Bristol & Weston NHS Foundation Trust, UK
| | - Samuel Grasso
- Sydney Orthopaedic Research Institute, Chatswood, NSW, Australia; The University of Sydney, Sydney, NSW, Australia
| | - Yoong Ping Lim
- Sydney Orthopaedic Research Institute, Chatswood, NSW, Australia; The University of Sydney, Sydney, NSW, Australia.
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - David Anthony Parker
- Sydney Orthopaedic Research Institute, Chatswood, NSW, Australia; The University of Sydney, Sydney, NSW, Australia
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Wang H, Teng Y, Peng B, Jia G, Han H, Xia Y. Surgically adjust tibial tunnel in anatomical anterior cruciate ligament single-bundle reconstruction: A time-zero biomechanical study in vitro. J Orthop Surg (Hong Kong) 2023; 31:10225536221151131. [PMID: 36688346 DOI: 10.1177/10225536221151131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The anatomical positioning of the graft during anterior cruciate ligament reconstruction (ACLR) is of great significance for restoring normal knee kinematics and preventing early joint degeneration. Therefore, the adjustment of the mispositioned guide pin becomes extremely important. Our research aims to test the time-zero biomechanical properties in adjusting inaccurate guide pins to the center of the tibial footprint in anatomical anterior cruciate ligament single-bundle reconstruction. METHODS Porcine tibias and bovine extensor tendons were used to simulate a transtibial ACL reconstruction in vitro. Load-to failure testing was carried out in 4 groups: control group (n = 45): the guide pin was drilled at the center of the ACL footprint; group I, group II and group III (n = 45, respectively): the guide pin was respectively drilled 1 mm, 2 mm and 3 mm away from the center of the ACL footprint. In the experimental groups, a small tunnel with a 4.5 mm reamer is made and the guide pin is shifted to the center of the footprint. All the reamed tibias were scanned by CT to measure the area of the tunnel in the footprint, and time-zero biomechanical properties were recorded. RESULTS All graft-tibia complexes failed because the grafts slipped past the interference screws. Compare to control group, the ultimate load, yield load, and tunnel exit area in group III decreased significantly (p < 0.05). Regarding to the ultimate load, yield load, tensile stiffness, twisting force and tunnel exit area, t-test showed no significant differences between control group and group I, group II respectively (p > 0.05). Pearson test showed that tunnel exit area was negatively correlated with other characteristics (p < 0.05). CONCLUSIONS Surgical adjustment of the guide pin to the center of the tibial footprint may have significant influence in time-zero biomechanical properties in anatomical anterior cruciate ligament single-bundle reconstruction when the adjusted tibial tunnel was significantly enlarged compare to the standard tibial tunnel.
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Affiliation(s)
- Hong Wang
- Department of Orthopaedics, 74713Lanzhou University Second Hospital, Lanzhou, China
- Orthopaedics Key Laboratory of Gansu Province, 74713Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Gansu Intelligent Orthopedics Industry Technology Center, Lanzhou, China
| | - Yuanjun Teng
- Department of Orthopaedics, 74713Lanzhou University Second Hospital, Lanzhou, China
- Orthopaedics Key Laboratory of Gansu Province, 74713Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Gansu Intelligent Orthopedics Industry Technology Center, Lanzhou, China
| | - Bo Peng
- Department of Orthopaedics, 74713Lanzhou University Second Hospital, Lanzhou, China
- Orthopaedics Key Laboratory of Gansu Province, 74713Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Gansu Intelligent Orthopedics Industry Technology Center, Lanzhou, China
| | - Gengxin Jia
- Department of Orthopaedics, 74713Lanzhou University Second Hospital, Lanzhou, China
- Orthopaedics Key Laboratory of Gansu Province, 74713Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Gansu Intelligent Orthopedics Industry Technology Center, Lanzhou, China
| | - Hua Han
- Department of Orthopaedics, 74713Lanzhou University Second Hospital, Lanzhou, China
- Orthopaedics Key Laboratory of Gansu Province, 74713Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Gansu Intelligent Orthopedics Industry Technology Center, Lanzhou, China
| | - Yayi Xia
- Department of Orthopaedics, 74713Lanzhou University Second Hospital, Lanzhou, China
- Orthopaedics Key Laboratory of Gansu Province, 74713Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Gansu Intelligent Orthopedics Industry Technology Center, Lanzhou, China
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Liu A, Ye X, Li C, Yang W, Yan S, Xin Z, Wu H. Preoperative excessive lateral anterior tibial subluxation is related to posterior tibial tunnel insertion with worse sagittal alignment after anterior cruciate ligament reconstructions. Front Surg 2022; 9:965505. [PMID: 36189385 PMCID: PMC9515393 DOI: 10.3389/fsurg.2022.965505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To investigate whether preoperative lateral anterior tibial subluxation (LATS) measured from magnetic resonance imaging (MRI) can influence tibial insertion and postoperative sagittal alignment after anterior cruciate ligament reconstructions (ACLRs). Methods 84 patients who underwent single-bundle ACLRs were retrospectively investigated. Among them, 39 patients (LATS of <6 mm) 23 patients (LATS of ≥6 mm and <10 mm) and 22 patients (excessive LATS of ≥10 mm) were defined as group 1, 2 and 3, respectively. LATS, the position of graft insertion into tibia as ratio of anterior-posterior width (AP ratio) and the sagittal graft angle (SGA) were postoperatively assessed from MRI at 2-year follow-up. Following linear regression analyses were employed. Results The group 3 exhibited the largest preoperative LATS and remained the most postoperative LATS. Moreover, the group 3 possessed the most posteriorly located tunnel insertion with the largest AP ratio and the most vertical graft orientation. Of all included patients, a moderate correlation was demonstrated between pre- and postoperative LATS (r = 0.635). A low correlation was observed between preoperative LATS and AP ratio (r = 0.300) and a moderate correlation was displayed between AP ratio and SGA (r = 0.656). Conclusion For ACL injuries with excessive LATS (≥10 mm), most posteriorly located tibial insertion was found out, and worse sagittal alignment containing high residual LATS was associated with more vertical graft orientation following ACLRs.
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Affiliation(s)
- An Liu
- Department of Orthopedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaojun Ye
- Department of Ultrasound, Hangzhou Women`s Hospital, Hangzhou, China
| | - Congsun Li
- Department of Orthopedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weinan Yang
- Department of Orthopedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shigui Yan
- Department of Orthopedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zengfeng Xin
- Department of Orthopedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Correspondence: Haobo Wu Zengfeng Xin
| | - Haobo Wu
- Department of Orthopedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Correspondence: Haobo Wu Zengfeng Xin
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Moon HS, Song SY, Oh JU, Seo YJ. Effects of modified trans-tibial versus trans-portal technique on stress patterns around the femoral tunnel in anatomical single-bundle ACL reconstruction with different knee flexion angles using finite element analysis. BMC Musculoskelet Disord 2022; 23:759. [PMID: 35941643 PMCID: PMC9361554 DOI: 10.1186/s12891-022-05713-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/27/2022] [Indexed: 12/20/2022] Open
Abstract
Background It is unclear whether different anterior cruciate ligament (ACL) graft trajectories in the distal femur would have different effects on stress generated within the distal femur around the femoral tunnel during knee motion. Thus, the purpose of this study was to determine differences in stress patterns around the femoral tunnel created by trans-portal (TP) vs. modified trans-tibial (TT) technique in anatomical ACL reconstruction at different knee flexion angles. Methods Twelve male subjects’ right knees were scanned with a high-resolution computed tomography (CT) scanner (slice thickness: 1 mm) at four different knee flexion angles (0°, 45°, 90°, and 135°). Three-dimensional (3D) models of these four different flexion angles were created and manipulated with several modelling programs. For the TP group, the virtual femoral tunnelling procedure was performed in a 135° flexion model from the low far anteromedial (AM) portal. For the modified TT group, the same knee models were drilled through the modified TT technique at 90° of flexion separately. Virtual grafts under tension of 40 N were put into corresponding bone tunnel and fixed at the outer aperture of femoral tunnels to simulate the suspensory fixation, followed by fixation of the grafts at the middle of tibial tunnels in the 0° knee flexion models. Finally, the models were exported to a finite element analysis package and analysed using ABAQUS/Explicit code (ABAQUS, USA) to monitor the stress occurring at the node where stress distribution occurred most significantly in the femoral bone around the bone tunnel. Results In general, both groups showed a high stress distribution in bony structures around inner and outer orifices of the femoral tunnel. Mean maximal stresses occurring at the lateral femoral condyle around the inner orifice of the femoral tunnel in the TP group were found to be significantly greater than those in the modified TT group at all flexion angles except 90° of flexion. Mean maximal stresses monitored around the outer orifice of the femoral tunnel in the TP group were also significantly greater than those in the modified TT group at all flexion angles. Conclusions Different tunnelling technologies could yield different stress patterns in the lateral femoral condyle around the femoral tunnel. During knee motion, higher stresses were noticed in the TP group than in the modified TT group, especially around inner and outer orifices of the tunnel. Position of the tunnel after reconstruction with the TP technique can have a greater effect on the stress increase in the femur compared to that with the modified TT technique.
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Affiliation(s)
- Hyun-Soo Moon
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
| | - Si Young Song
- Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, Republic of Korea
| | - Ji Ung Oh
- Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, Republic of Korea
| | - Young-Jin Seo
- Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, Republic of Korea.
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Teng Y, Da L, Jia G, Hu J, Liu Z, Zhang S, Han H, Xia Y. What Is the Maximum Tibial Tunnel Angle for Transtibial PCL Reconstruction? A Comparison Based on Virtual Radiographs, CT Images, and 3D Knee Models. Clin Orthop Relat Res 2022; 480:918-928. [PMID: 35023873 PMCID: PMC9029965 DOI: 10.1097/corr.0000000000002111] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND To minimize the killer turn caused by the sharp margin of the tibial tunnel exit in transtibial PCL reconstruction, surgeons tend to maximize the angle of the tibial tunnel in relation to the tibial plateau. However, to date, no consensus has been reached regarding the maximum angle for the PCL tibial tunnel. QUESTIONS/PURPOSES In this study we sought (1) to determine the maximum tibial tunnel angle for the anteromedial and anterolateral approaches in transtibial PCL reconstruction; (2) to compare the differences in the maximum angle based on three measurement methods: virtual radiographs, CT images, and three-dimensional (3D) knee models; and (3) to conduct a correlation analysis to determine whether patient anthropomorphic factors (age, sex, height, and BMI) are associated with the maximum tibial tunnel angle. METHODS Between January 2018 and December 2020, 625 patients who underwent CT scanning for knee injuries were retrospectively reviewed in our institution. Inclusion criteria were patients 18 to 60 years of age with a Kellgren-Lawrence grade of knee osteoarthritis less than 1 and CT images that clearly showed the PCL tibial attachment. Exclusion criteria were patients with a history of tibial plateau fracture, PCL injuries, tumor, and deformity around the knee. Finally, 104 patients (43 males and 61 females, median age: 38 [range 24 to 56] years, height: 165 ± 9 cm, median BMI: 23 kg/cm2 [range 17 to 31]) were included for analysis. CT data were used to create virtual 3D knee models, and virtual true lateral knee radiographs were obtained by rotating the 3D knee models. Virtual 3D knee models were used as an in vitro standard method to assess the true maximum tibial tunnel angle of anteromedial and anterolateral approaches in transtibial PCL reconstruction. The tibial tunnel's entry was placed 1.5 cm anteromedial and anterolateral to the tibial tubercle for the two approaches. To obtain the maximum angle, a 10-mm- diameter tibial tunnel was simulated by making the tibial tunnel near the posterior tibial cortex. The maximum tibial tunnel angle, tibial tunnel lengths, and perpendicular distances of the tunnel's entry point to the tibial plateau were measured on virtual radiographs, CT images, and virtual 3D knee models. One-way ANOVA was used to compare the differences in the maximum angle among groups, and correlation analysis was performed to identify the relationship of the maximum angle and anthropomorphic factors (age, sex, height, and BMI). RESULTS The maximum angle of the PCL tibial tunnel relative to the tibial plateau was greater in the anteromedial group than the anterolateral group (58° ± 8° versus 50° ± 8°, mean difference 8° [95% CI 6° to 10°]; p < 0.001). The maximum angle of the PCL tibial tunnel was greater in the virtual radiograph group than the CT image (68° ± 6° versus 49° ± 5°, mean difference 19° [95% CI 17° to 21°]; p < 0.001), the anteromedial approach (68° ± 6° versus 58° ± 8°, mean difference 10° [95% CI 8° to 12°]; p < 0.001), and the anterolateral approach (68° ± 6° versus 50° ± 8°, mean difference 18° [95% CI 16° to 20°]; p < 0.001), but no difference was found between the CT image and the anterolateral groups (49° ± 5° versus 50° ± 8°, mean difference -1° [95% CI -4° to 1°]; p = 0.79). We found no patient anthropomorphic characteristics (age, sex, height, and BMI) that were associated with the maximum angle. CONCLUSION Surgeons should note that the mean maximum angle of the tibial tunnel relative to the tibial plateau was greater in the anteromedial than anterolateral approach in PCL reconstruction, and the maximum angle might be overestimated on virtual radiographs and underestimated on CT images. CLINICAL RELEVANCE To perform PCL reconstruction more safely, the findings of this study suggest that the PCL drill system should be set differently for the anteromedial and anterolateral approaches, and the maximum angle measured by intraoperative fluoroscopy should be reduced 10° for the anteromedial approach and 18° for the anterolateral approach. Future clinical or cadaveric studies are needed to validate our findings.
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Affiliation(s)
- Yuanjun Teng
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
| | - Lijun Da
- Department of Oncology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
| | - Gengxin Jia
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
| | - Jie Hu
- The Second Clinical Medical College, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
| | - Zhongcheng Liu
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
| | - Shifeng Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
| | - Hua Han
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People’s Republic of China
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Augmentation of Anterolateral Structures of the Knee Causes Undesirable Tibiofemoral Cartilage Contact in Double-Bundle Anterior Cruciate Ligament Reconstruction-A Randomized In-Vivo Biomechanics Study. Arthroscopy 2022; 38:1224-1236. [PMID: 34509591 DOI: 10.1016/j.arthro.2021.08.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the in vivo tibiofemoral cartilage contact patterns in knees undergoing double-bundle anterior cruciate ligament reconstruction(DB-ACLR) with or without anterolateral structure augmentation (ALSA). METHODS Twenty patients with an ACL-ruptured knee and a healthy contralateral side were included. Nine patients received an isolated DB-ACLR (DB-ACLR group), and 11 patients had a DB-ACLR with ALSA (DB+ALSA group). At 1-year follow-up, a combined computed tomography, magnetic resonance imaging, and dual fluoroscopy imaging system analysis was used to capture a single-legged lunge of both the operated and healthy contralateral side. Tibiofemoral contact points (CPs) of the medial and lateral compartments were compared. CP locations were expressed as anteroposterior (AP, +/-) and medial-lateral (ML, -/+) values according to the tibia. RESULTS In the DB-ACLR knees, no significant differences were found in CPs when compared with the healthy contralateral knees (P ≥ .31). However, in the DB+ALSA knees, the CPs in the lateral compartment had a significantly more anterior (mean AP: operative, -2.8 mm, 95% confidence interval [CI] -5.0 to-0.7 vs healthy, -5.0 mm, 95% CI -6.7 to -3.2; P = .006) and lateral (mean ML: operative, 23.2 mm, 95% CI 21.9-24.5 vs healthy, 21.8 mm, 95% CI 20.2-23.3; P = .013) location. The CPs in the medial compartment were located significantly more posterior (mean AP: operative, -3.4, 95% CI -5.0 to -1.9 vs healthy, -1.3, 95% CI -2.6 to -0.1; P = .006) and lateral (mean ML: operative, -21.3, 95% CI -22.6 to -20.0 vs healthy, -22.6, 95% CI -24.2 to -21.0; P = .021). CONCLUSIONS DB-ACLR restored the tibiofemoral cartilage contact mechanics to near-normal values at 1-year follow-up. Adding the ALSA to the DB-ACLR resulted in significantly altered tibiofemoral cartilage contact locations in both the medial and lateral compartments. CLINICAL RELEVANCE In DB-ACLR knees, the addition of an ALSA may be unfavorable as it caused significantly changed arthrokinematics.
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Shao J, Zhang J, Ren S, Liu P, Ma Y, Ao Y. Better Coverage of the ACL Tibial Footprint and Less Injury to the Anterior Root of the Lateral Meniscus Using a Rounded-Rectangular Tibial Tunnel in ACL Reconstruction: A Cadaveric Study. Orthop J Sports Med 2022; 10:23259671221083581. [PMID: 35340730 PMCID: PMC8949746 DOI: 10.1177/23259671221083581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background To better restore the anatomy of the native anterior cruciate ligament (ACL) attachment and fiber arrangement, researchers have developed techniques for changing the shape of the ACL bone tunnel during ACL reconstruction. Purpose To compare the coverage of the ACL tibial footprint and influence on the anterior root of lateral meniscus (ARLM) between a rounded-rectangular tibial tunnel and a conventional round tibial tunnel for ACL reconstruction. Study Design Controlled laboratory study. Methods A total of 16 (8 matched-paired) fresh-frozen human cadaveric knees were distributed randomly into 2 groups: a rounded-rectangular tunnel (RRT) group and a round tunnel (RT) group. One of the knees from each pair was reamed with rounded-rectangular tibial tunnel, whereas the other was reamed with round tibial tunnel. Coverage of the ACL tibial footprint and areas of ARLM attachment before and after reaming were measured using 3-dimensional isotropic magnetic resonance imaging. Results In the RRT group, the average percentage of ACL tibial footprint covered by the tunnel was 70.8% ± 2.5%, which was significantly higher than that in the RT group (48.2% ± 6.4%) (P = .012). As for the ARLM attachment area, in the RT group, there was a significant decrease (22.5% ± 5.9%) in ARLM attachment area after tibial tunnel reaming compared with the intact state (P < .001). Conversely, in the RRT group, the ARLM attachment area was not significantly affected by tibial tunnel reaming. Conclusion Rounded-rectangular tibial tunnel was able to better cover the native ACL tibial footprint and significantly lower the risk of iatrogenic injury to the ARLM attachment than round tibial tunnel during ACL reconstruction.
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Affiliation(s)
- Jiayi Shao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jiahao Zhang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Shuang Ren
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Ping Liu
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yong Ma
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yingfang Ao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures. Sports Med Arthrosc Rev 2022; 30:42-53. [PMID: 35113842 DOI: 10.1097/jsa.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.
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Ikuta Y, Nakamae A, Shimizu R, Ishikawa M, Nakasa T, Ochi M, Adachi N. A Comparison of Central Anatomic Single-Bundle Reconstruction and Anatomic Double-Bundle Reconstruction in Anteroposterior and Rotational Knee Stability: Intraoperative Biomechanical Evaluation. J Knee Surg 2022; 35:273-279. [PMID: 32615614 DOI: 10.1055/s-0040-1713730] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Postoperative anterior and rotational stability are still controversial when compared with single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. This study aimed to compare the central anatomical SB and anatomical DB ACL reconstruction in intraoperative knee kinematics during continuous knee flexion-extension. A total of 34 patients who underwent ACL reconstruction using the hamstring tendon were evaluated intraoperatively before and immediately after ACL reconstruction using OrthoPilot ACL Navigation System Version 3.0. The patients were prospectively randomized into the central anatomical SB (17 knees) and the anatomical DB reconstruction (17 knees) groups. The tibial translation and rotation were continuously measured during knee flexion-extension under conventional knee motion, anterior tibial load (100N), and internal-external torque (3 N·m). The anterior tibial translation and total range of tibial rotation were calculated from the measurement values from 20 to 50 degrees at each 5-degree point. The anterior tibial translation (p = 0.59; two-factor repeated measures analysis of variance; η 2G = 0.0077) and total range of tibial rotation (p = 0.95; η 2G = 0.0001) at each knee flexion angle showed no significant difference between the central anatomical SB and anatomical DB reconstruction groups. It is suggested that the central anatomical SB reconstruction is comparable with the anatomical DB reconstruction in biomechanical anteroposterior and rotational knee stability at time 0.
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Affiliation(s)
- Yasunari Ikuta
- Department of Orthopaedic Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Atsuo Nakamae
- Department of Orthopaedic Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Ryo Shimizu
- Department of Orthopaedic Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Masakazu Ishikawa
- Department of Orthopaedic Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | | | - Nobuo Adachi
- Department of Orthopaedic Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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11
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Yoon KH, Kim YS, Park JY, Kim SG, Lee JH, Choi SH, Kim SJ. Ideal Combination of Anatomic Tibial and Femoral Tunnel Positions for Single-Bundle ACL Reconstruction. Orthop J Sports Med 2022; 10:23259671211069960. [PMID: 35071661 PMCID: PMC8777344 DOI: 10.1177/23259671211069960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/07/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Anatomic anterior cruciate ligament reconstruction (ACLR) is preferred over
nonanatomic ACLR. However, there is no consensus on which point the tunnels
should be positioned among the broad anatomic footprints. Purpose/Hypothesis: To identify the ideal combination of tibial and femoral tunnel positions
according to the femoral and tibial footprints of the anteromedial (AM) and
posterolateral (PL) anterior cruciate ligament bundles. It was hypothesized
that patients with anteromedially positioned tunnels would have better
clinical scores, knee joint stability, and graft signal intensity on
follow-up magnetic resonance imaging (MRI) than those with posterolaterally
positioned tunnels. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 119 patients who underwent isolated single-bundle ACLR with a
hamstring autograft from July 2013 to September 2018 were retrospectively
investigated. Included were patients with clinical scores and knee joint
stability test results at 2-year follow-up and postoperative 3-dimensional
computed tomography and 1-year postoperative MRI findings. The cohort was
divided into 4 groups, named according to the bundle positions in the tibial
and femoral tunnels: AM-AM (n = 33), AM-PL (n = 26), PL-AM (n = 29), and
PL-PL (n = 31). Results: There were no statistically significant differences among the 4 groups in
preoperative demographic data or postoperative clinical scores (Lysholm,
Tegner, and International Knee Documentation Committee subjective scores);
knee joint stability (anterior drawer, Lachman, and pivot-shift tests and
Telos stress radiographic measurement of the side-to-side difference in
anterior tibial translation); graft signal intensity on follow-up MRI; or
graft failure. Conclusion: No significant differences in clinical scores, knee joint stability, or graft
signal intensity on follow-up MRI were identified between the patients with
anteromedially and posterolaterally positioned tunnels.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Yoon-Seok Kim
- Department of Orthopaedic Surgery, Armed Forces Hongcheon Hospital, Hongcheon, Republic of Korea
| | - Jae-Young Park
- Department of Orthopaedic Surgery, Uijeongbu Eulji Medical Center, School of Medicine, Eulji University, Uijeongbu-si, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopaedic Surgery, National Medical Center, Seoul, Republic of Korea
| | - Jong-Hwan Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sun Hwan Choi
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sang Jin Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
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12
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Ding G, Yang G, Zhang J, Huang H, Du J, Ren S, Wang Q, Zhou Z, Zhang X, Ao Y. Feasibility and accuracy of orthopaedic surgical robot system for intraoperative navigation to locate bone tunnel in anterior cruciate ligament reconstruction. Int J Med Robot 2021; 18:e2354. [PMID: 34806824 DOI: 10.1002/rcs.2354] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The combination of navigational system and robotics has the potential to accurately identify and drill bone tunnels in anterior cruciate ligament (ACL) reconstruction. This study explores the feasibility and accuracy of bone tunnel positioning using the TiRobot, an orthopaedic surgical robot. METHODS The experiment was divided into two groups. In group A, the bone tunnels were positioned using the TiRobot surgical robot (n = 8). In group B, handheld locators were used for positioning (n = 8). RESULTS TiRobot can be used for positioning the ACL bone tunnel. The accuracy of positioning the femoral tunnel in group A and B was 1.00 ± 0.20 and 3.10 ± 0.59 mm, respectively (t = -9.49, P < 0.001). As for tibial tunnel, the accuracy was 1.02 ± 0.20 and 2.64 ± 0.14 mm, respectively (t = -18.54, P < 0.001). CONCLUSIONS The bone tunnel drilling precision using TiRobot for ACL reconstruction surgery was more accurate than traditional surgical techniques.
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Affiliation(s)
- Guocheng Ding
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Gang Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jiahao Zhang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Hongjie Huang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jianing Du
- Peking University Health Science Center, Beijing, China
| | - Shuang Ren
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Qining Wang
- Department of Advanced Manufacturing and Robotics, Peking University, Beijing, China.,Institute for Artificial Intelligence, Peking University, Beijing, China
| | - Zhihao Zhou
- Department of Advanced Manufacturing and Robotics, Peking University, Beijing, China.,Institute for Artificial Intelligence, Peking University, Beijing, China
| | - Xin Zhang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yingfang Ao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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13
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[Anterolateral stabilization using the modified ellison technique-Treatment of anterolateral instability and reduction of ACL re-rupture risk]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 34:231-238. [PMID: 34729632 DOI: 10.1007/s00064-021-00741-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/06/2020] [Accepted: 12/10/2020] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The goal of the modified Ellison operation as a supplement to a conventional anterior cruciate ligament (ACL) reconstruction is to decrease anterolateral rotational instability of a knee joint after ACL rupture, to improve the stability and prevent ACL re-rupture. INDICATIONS An ACL rupture with high risk of re-rupture (young age, high-performance sport, hyperlaxity, contralateral ACL rupture in history), increased subjective and objective anterolateral rotational instability of the knee after ACL rupture, ACL re-rupture. CONTRAINDICATIONS Gonarthrosis, additive instabilities (e.g. posterolateral, medial), non-anatomical ACL reconstruction with persistent instability, general contraindications to surgery (e.g. infections), chronic irritation of the knee joint. SURGICAL TECHNIQUE Supine position. Mark the typical landmarks. Incision from Gerdy's tubercle extending proximally along the iliotibial tract (ITT) to the lateral collateral ligament (approx. 5 cm). Incise the ITT in the line of its fibers about 10 mm anterior to its posterior border and continue the incision proximally to 5 mm proximal to the LCL. Make a parallel incision 10-12 mm anterior to the first incision. Use sharp subperiosteal dissection to elevate the strip of the ITT from Gerdy's tubercle. Secure the distal end of the ITT strip with a nonabsorbable suture (e.g. FiberWire No. 2, Arthrex, Naples, USA). Expose the LCL and pass the ITT strip deep to the LCL from proximal to distal and back to Gerdy's tubercle. Reattach the distal end of the strip of the ITT to its original position at Gerdy's tubercle with a bone anchor. The defect in the ITT can be closed with an absorbable suture (e.g. Vicryl, Ethicon, USA) in the proximal part. Layered closure. POSTOPERATIVE MANAGEMENT Knee brace for at least 6 weeks, movement limitation of 0‑0-90° for 6 weeks, 2 weeks 20 kg partial weight bearing. RESULTS A total of 36 patients (mean age 18.9 years) with a high risk of ACL re-rupture have been treated with ACL reconstruction and modified Ellison procedure. Follow-up over 2 years. Of the patients 35 returned to the previous sports level, 1 patient suffered a re-rupture, 2 patients had cyclops resection and 1 patient contralateral ACL rupture.
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14
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de Padua VBC, Saithna A, Chagas EFB, Zutin TLM, Piazzalunga LF, Patriarcha LF, Gelas PJDL, Helito CP. Rate of Tibial Tunnel Malposition Is Not Changed by Drilling Entirely Within the Stump of Preserved Remnants During ACL Reconstruction: A Prospective Comparative 3D-CT Study. Orthop J Sports Med 2021; 9:23259671211037324. [PMID: 34646899 PMCID: PMC8504236 DOI: 10.1177/23259671211037324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Remnant preservation during anterior cruciate ligament (ACL) reconstruction (ACLR) is controversial, and it is unclear whether the stump aids or obscures tibial tunnel positioning. Purpose/Hypothesis: The aim of this study was to determine whether the rate of tibial tunnel malposition is influenced by remnant preservation. The hypothesis was that using a remnant-preserving technique to drill entirely within the tibial stump would result in a significant reduction in tibial tunnel malposition as determined by postoperative 3-dimensional computed tomography (3D-CT). Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing ACLR between October 2018 and December 2019 underwent surgery with a remnant-preserving technique (RP group) if they had a large stump present (>50% of the native ACL length) or if there was no remnant or if it was <50% of the native length of the ACL, they underwent remnant ablation (RA group) and use of standard landmarks for tunnel positioning. The postoperative tunnel location was reported as a percentage of the overall anteroposterior (AP) and mediolateral (ML) dimensions of the tibia on axial 3D-CT. The tunnel was classified as anatomically placed if the center lay between 30% and 55% of the AP length and between 40% and 51% of the ML length. Results: Overall, 52 patients were included in the study (26 in each group). The mean tunnel positions were 36.8% ± 5.5% AP and 46.7% ± 2.9% ML in the RP group and 35.6% ± 4.8% AP and 47.3% ± 2.3% ML in the RA group. There were no significant differences in the mean AP (P = .134) and ML (P = .098) tunnel positions between the groups. Inter- and intraobserver reliability varied between fair to excellent and good to excellent, respectively. There was no significant difference in the rate of malposition between groups (RP group, 7.7%; RA group, 11.5%; P ≥ .999). Conclusion: Drilling entirely within the ACL tibial stump using a remnant-preserving reconstruction technique did not significantly change the rate of tunnel malposition when compared with stump ablation and utilization of standard landmarks.
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Affiliation(s)
| | | | | | | | | | | | | | - Camilo P Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
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15
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Song GY, Ni QK, Zheng T, Feng H, Zhang ZJ, Zhang H. Increased Posterior Tibial Slope Is Associated With Greater Risk of Graft Roof Impingement After Anatomic Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2021; 49:2396-2405. [PMID: 34161178 DOI: 10.1177/03635465211018859] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Increased posterior tibial slope (PTS) has been reported to be associated with irreducible anterior tibial subluxation in extension after anatomic anterior cruciate ligament (ACL) reconstruction (ACLR), which raises concerns about the greater risk of graft roof impingement (GRI) although the tibial tunnel is positioned anatomically. HYPOTHESIS Increased PTS would be associated with greater risk of GRI after anatomic ACLR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Between January 2016 and December 2017, a total of 418 consecutive patients were diagnosed as having noncontact ACL injuries and underwent primary anatomic ACLR. Among them, 26 patients had ≥1 of the following features during the second-look arthroscopy: fractured/guillotined bundles at the tibial insertion or cyclops lesion. These patients were confirmed to have GRI and were allocated to the study group. They were also matched 1:2 to 52 control participants without GRI. PTS was measured on true lateral whole-leg radiographs. Intra-articular ACL graft signal intensity was evaluated on postoperative magnetic resonance imaging scans (mean, 32.8 months; range, 26-38 months) and divided into 3 grades (I, good; II, moderate; III, poor) based on degree of GRI. Moreover, anterior subluxation of the lateral compartment (ASLC) and medial compartment (ASMC) in extension relative to the femoral condyles were measured on postoperative magnetic resonance imaging scans and compared between the groups. In addition, predictors of GRI were evaluated using multivariate logistic regression analysis and included body mass index, PTS, pivot-shift test, KT-1000 side-to-side difference, and concomitant meniscal tears. RESULTS PTS in the study group was significantly higher than that in control group (mean ± SD, 13.8°± 1.5° vs 9.5°± 1.8°; P < .05). In the study group (n = 26), patients with grade III (poor) graft signal intensity (n = 9) showed significantly higher PTS than those with grade II (moderate; n = 17) (16.4°± 1.7° vs 12.4°± 1.3°; P < .05). Moreover, the mean postoperative ASLC and ASMC in extension were significantly larger in the study group than the control group (ASLC, 4.1 ± 1.3 vs 0.8 ± 0.4 mm; ASMC, 4.3 ± 1.5 vs 0.9 ± 0.3 mm; P < .05). Furthermore, the abnormal degree of PTS (≥12°) was determined to be an independent risk factor associated with GRI after anatomic ACLR (odds ratio, 9.0 [95% CI, 3.7-30.2]; P < .001), whereas body mass index, grade of pivot-shift test, KT-1000 side-to-side difference, and concomitant meniscal tears were not. CONCLUSION Increased PTS (≥12°) was associated with greater risk of GRI after anatomic ACLR. This may provide additional information for counseling patients with greater risk of GRI.
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Affiliation(s)
- Guan-Yang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Qian-Kun Ni
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Zhi-Jun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
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16
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Dini F, Tecame A, Ampollini A, Adravanti P. Multiple ACL Revision: Failure Analysis and Clinical Outcomes. J Knee Surg 2021; 34:801-809. [PMID: 31777033 DOI: 10.1055/s-0039-3400741] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Anterior cruciate ligament (ACL) reconstruction represents one of the most successful orthopedic surgical procedures. Nevertheless, ACL revisions are still very frequent, with a small but relevant number of failures. The purpose of this study is to analyze the failure causes and the clinical outcomes of patients who underwent a re-revision ACL reconstruction. Between January 2009 and December 2017, 263 ACL revisions were performed by a single senior surgeon. Seventeen patients (12 males and 5 females) underwent re-revision ACL reconstruction meeting the inclusion criteria. The mean age was 28.4 years (range, 19-41 years). Before the re-revision, the patients were evaluated preoperatively and after a mean follow-up of 29 months (range, 13-58 months). Assessment included subjective and objective evaluations (Lysholm and International Knee Documentation Committee [IKDC]), KT-2000 arthrometer, radiographic study, and preoperative computed tomography scan. Five patients showed a too anterior previous femoral tunnel and seven a too vertical and posterior tibial tunnel; eight meniscal tears were found. Five patients had grade III-IV according to Outerbridge cartilage lesions. IKDC showed a statistically significant improvement (A + B 35%, C + D 65% preop, A + B 82%, C + D 18% postop, odds ratio: 0.1169; p = 0.0083). The mean Lysholm score ranged from 43 ± 9 to 87 ± 7 (p < 0.001). The KT-2000 arthrometer showed a statistically significant improvement from a mean of 5.8 ± 1.4 to 1.5 ± 1.1 (p < 0.001) at last follow-up. Out of 17 patients, only 4 returned to sports activity at the same preinjury levels. Postoperatively at the last follow-up after last revision surgery, no osteoarthritis evolution was observed. This study showed good clinical and radiological results after the last revision ACL surgery in patients with multiple failures of ACL reconstruction but only one-fourth of the patients returned to the same preoperative sport level. Traumatic events, technical errors, and untreated peripheral lesions are the main causes of multiple previous failures; the worst clinical outcomes were found in the patients with high grade of chondral lesions.
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Affiliation(s)
- Francesco Dini
- Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
| | - Andrea Tecame
- Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
| | - Aldo Ampollini
- Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
| | - Paolo Adravanti
- Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
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17
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Büyükdoğan K, Laidlaw MS, Fox MA, Kew ME, Miller MD. Effect of Tibial Tunnel Placement Using the Lateral Meniscus as a Landmark on Clinical Outcomes of Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2021; 49:1451-1459. [PMID: 33830836 DOI: 10.1177/0363546521999672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It remains unclear if use of the lateral meniscus anterior horn (LMAH) as a landmark will produce consistent tunnel positions in the anteroposterior (AP) distance across the tibial plateau. PURPOSE To evaluate the AP location of anterior cruciate ligament (ACL) reconstruction tibial tunnels utilizing the LMAH as an intra-articular landmark and to examine how tunnel placement affects knee stability and clinical outcomes. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective review was conducted of 98 patients who underwent primary ACL reconstruction with quadrupled hamstring tendon autografts between March 2013 and June 2017. Patients with unilateral ACL injuries and a minimum follow-up of 2 years were included in the study. All guide pins for the tibial tunnel were placed using the posterior border of the LMAH as an intra-articular landmark. Guide pins were evaluated with the Bernard-Hertel grid in the femur and the Stäubli-Rauschning method in the tibia. Patients were divided by the radiographic location of the articular entry point of the guide pin with relation to the anterior 40% of the tibial plateau. Outcomes were evaluated by the Marx Activity Scale and International Knee Documentation Committee (IKDC) form. Anterior knee laxity was evaluated using a KT-1000 arthrometer and graded with the objective portion of the IKDC form. Rotational stability was evaluated using the pivot-shift test. RESULTS A total of 60 patients were available for follow-up at a mean 28.6 months. The overall percentage of AP placement of the tibial tunnel was 39.3% ± 3.8% (mean ± SD; range, 31%-47%). Side-to-side difference of anterior knee laxity was significantly lower in the anterior group than the posterior group (1.2 ± 1.1 mm vs 2.5 ± 1.3 mm; P < .001; r = 0.51). The percentage of AP placement of the tibial tunnel demonstrated a positive medium correlation with side-to-side difference of anterior knee laxity as measured by a KT-1000 arthrometer (r = 0.430; P < .001). The anterior group reported significantly better distribution of IKDC grading as compared with the posterior group (26 grade A and 6 grade B vs 15 grade A and 13 grade B; P = .043; V = 0.297). The pivot-shift test results and outcome scores showed no significant differences between the groups. CONCLUSION Using the posterior border of the LMAH as an intraoperative landmark yields a wide range of tibial tunnel locations along the tibial plateau, with anterior placement of the tibial tunnel leading toward improved anterior knee stability.
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Affiliation(s)
- Kadir Büyükdoğan
- Department of Orthopedic Surgery, Koc University Hospital, Zeytinburnu/Istanbul, Turkey
| | - Michael S Laidlaw
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael A Fox
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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18
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Chen J, Wang C, Xu C, Qiu J, Xu J, Tsai TY, Zhao J. Effects of Anterolateral Structure Augmentation on the In Vivo Kinematics of Anterior Cruciate Ligament-Reconstructed Knees. Am J Sports Med 2021; 49:656-666. [PMID: 33464924 DOI: 10.1177/0363546520981743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Double-bundle anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-known treatment that restores the stability of ACL-deficient knees. However, some isolated ACL-reconstructed knees ultimately show rotatory laxity and develop osteoarthritis. Whether combined ACLR with anterolateral structure (ALS) augmentation (ALSA) can provide better improvement in the in vivo knee rotational kinematics remains unknown. HYPOTHESIS When compared with isolated double-bundle ACLR, combined double-bundle ACLR with ALSA can improve knee in vivo rotational kinematics and provide better restoration of knee kinematics. STUDY DESIGN Controlled laboratory study. METHODS Sixteen patients with unilateral ACL injury were randomly divided into 2 groups to receive either combined double-bundle ACLR and ALSA (ALSA group) or isolated double-bundle ACLR (ACLR group). All patients performed a single-leg lunge using the operative and nonoperative/contralateral legs under dual-fluoroscopic imaging system surveillance during a hospital visit at a minimum 1 year (12-13 months) of follow-up to assess the 6 degrees of freedom knee kinematics. Functional evaluation using the Lysholm and Marx rating scales and clinical examinations were also performed. RESULTS From full extension to approximately 90° of knee flexion at 5° intervals, the mean ± SD internal rotation of the reconstructed knees in the ALSA group (1.5°± 0.9°) was significantly smaller than that of the contralateral knees (8.2°± 1.9°; P = .008). The ALSA group knees also showed significantly (P = .045) more medial translation than the contralateral knees. In the ACLR group, the mean internal rotation of the reconstructed knee (6.0°± 2.1°) was significantly smaller than that of the contralateral knees (8.9°± 0.6°; P < .001). At full extension, the tibia was significantly more externally rotated than that of the contralateral legs (0.5°± 7.4° vs 7.6°± 3.4°, P = .049). CONCLUSION When compared with isolated double-bundle ACLR, double-bundle ACLR augmented with ALS reconstruction resulted in anterolateral rotatory overconstraint during the lunge motion. CLINICAL RELEVANCE Additional ALSA of double-bundle ACL-reconstructed knees overconstrained rotatory stability. Therefore, the use of ALSA for ACL-reconstructed knees should be considered with caution for patients with ACL deficiency and anterolateral rotatory instability. Longer-term follow-up to evaluate long-term outcomes and altered kinematics over time is recommended.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cong Wang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China.,Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiayu Qiu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China.,Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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19
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Influence of selected plane on the evaluation of tibial tunnel locations using a three-dimensional bone model in double-bundle anterior cruciate ligament reconstruction. Knee 2021; 29:298-304. [PMID: 33677154 DOI: 10.1016/j.knee.2021.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/22/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the influence of a selected plane on the evaluation of tibial tunnel locations following anterior cruciate ligament reconstruction (ACLR) between two planes: the plane parallel to the tibial plateau (Plane A) and the plane perpendicular to the proximal tibial shaft axis (Plane B). METHODS Thirty-four patients who underwent double-bundle ACLR were included. Three-dimensional model of tibia was created using computed tomography images 2 weeks postoperatively, and tibial tunnels of the anteromedial bundle (AMB) and posterolateral bundle (PLB) were extracted. To evaluate tibial tunnel locations, two planes (Planes A and B) were created. The locations of the tibial tunnel apertures of each bundle were evaluated using a grid method and compared between Planes A and B. The difference in coronal alignment between Planes A and B were also assessed. RESULTS The AMB and PLB tunnel apertures in Plane A were significantly more laterally located than in Plane B (mean difference; AMB, 1.5%; PLB, 1.7%, P < 0.01). There were no significant differences in the anteroposterior direction between the planes. Coronal alignment difference between the planes was 16.8 ± 2.2°; Plane B was more valgus than Plane A. CONCLUSION Although tibial tunnel locations were not significantly influenced by the selected planes in the AP direction, subtle but statistically significant differences were found in the ML direction between the Planes A and B in double-bundle anterior cruciate ligament reconstruction. The findings suggest that both Planes A and B can be used in the assessment of tibial tunnel locations after anterior cruciate ligament reconstruction.
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Ziegler CG, DePhillipo NN, Kennedy MI, Dekker TJ, Dornan GJ, LaPrade RF. Beighton Score, Tibial Slope, Tibial Subluxation, Quadriceps Circumference Difference, and Family History Are Risk Factors for Anterior Cruciate Ligament Graft Failure: A Retrospective Comparison of Primary and Revision Anterior Cruciate Ligament Reconstructions. Arthroscopy 2021; 37:195-205. [PMID: 32911007 DOI: 10.1016/j.arthro.2020.08.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 08/23/2020] [Accepted: 08/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess patient history, physical examination findings, magnetic resonance imaging (MRI) and 3-dimensional computed tomographic (3D CT) measurements of those with anterior cruciate ligament (ACL) graft failure compared with primary ACL tear patients to better discern risk factors for ACL graft failure. METHODS We performed a retrospective review comparing patients who underwent revision ACL reconstruction (ACLR) with a primary ACLR group with minimum 1-year follow-up. Preoperative history, examination, and imaging data were collected and compared. Measurements were made on MRI, plain radiographs, and 3D CT. Inclusion criteria were patients who underwent primary ACLR by a single surgeon at a single center with minimum 1-year follow-up or ACL graft failure with revision ACLR performed by the same surgeon. RESULTS A total of 109 primary ACLR patients, mean age 33.7 years (range 15 to 71), enrolled between July 2016 and July 2018 and 90 revision ACLR patients, mean age 32.9 years (range 16 to 65), were included. The revision ACLR group had increased Beighton score (4 versus 0; P < .001) and greater side-to-side differences in quadricep circumference (2 versus 0 cm; P < .001) compared with the primary ACLR group. A family history of ACL tear was significantly more likely in the revision group (47.8% versus 16.5%; P < .001). The revision group exhibited significantly increased lateral posterior tibial slope (7.9° versus 6.2°), anterolateral tibial subluxation (7.1 versus 4.9 mm), and anteromedial tibia subluxation (2.7 versus 0.5 mm; all P < .005). In the revision group, femoral tunnel malposition occurred in 66.7% in the deep-shallow position and 33.3% in the high-low position. The rate of tibial tunnel malposition was 9.7% from medial to lateral and 54.2% from anterior to posterior. Fifty-six patients (77.8%) had tunnel malposition in ≥2 positions. Allograft tissue was used for the index ACLR in 28% in the revision group compared with 14.7% in the primary group. CONCLUSION Beighton score, quadriceps circumference side-to-side difference, family history of ACL tear, lateral posterior tibial slope, anterolateral tibial subluxation, and anteromedial tibia subluxation were all significantly different between primary and revision ACLR groups. In addition, there was a high rate of tunnel malposition in the revision ACLR group.
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Affiliation(s)
- Connor G Ziegler
- Steadman Clinic Vail, Colorado, U.S.A.; New England Orthopedic Surgeons, Springfield, Massachusetts, U.S.A
| | - Nicholas N DePhillipo
- Steadman Clinic Vail, Colorado, U.S.A.; Twin Cities Orthopedics, Edina, Minnesota, U.S.A
| | | | | | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
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Liu D, Li Y, Li T, Yu Y, Cai G, Yang G, Wang G. The use of a 3D-printed individualized navigation template to assist in the anatomical reconstruction surgery of the anterior cruciate ligament. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1656. [PMID: 33490168 PMCID: PMC7812217 DOI: 10.21037/atm-20-7515] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background To explore the location accuracy and early clinical outcomes of using a 3D-printed individualized navigation template to assist in the reconstruction of the anterior cruciate ligament (ACL). Methods A single center randomized control study was conducted. Patients with ACL injury were treated with a conventional operation or an operation assisted by a 3D-printed individualized navigation template (the 3D group). The primary endpoint was the accuracy of the actual reconstruction compared with the planned position. Results There were 20 and 23 participants in the conventional group and the 3D group, respectively. There were no differences in the bone tunnel position between the actual postoperative position and the preoperative design in the 3D group (P>0.05). Compared with the 3D group, the positioning of the femoral tunnel was more inferior and shallower in the conventional group (P<0.05). The position of the tibia tunnel was closer to the anterior and medial edge of the tibial platform in the conventional group compared to the 3D group (P<0.05). The intraoperative positioning time was shorter in the 3D group than in the conventional group (3.3±1.0 vs. 5.9±1.8 minutes, P<0.001). The Lysholm and International Knee Documentation Committee scores did not differ between the two groups (P>0.05 for both), and all patients improved after surgery (P<0.001). Conclusions The 3D-printed individualized navigation template showed good location accuracy and resulted in reduced intraoperative positioning time compared to the traditional method for ACL reconstruction.
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Affiliation(s)
- Dejian Liu
- Department of Sports Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanlin Li
- Department of Sports Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Tao Li
- Department of Trauma Surgery, Affiliated Hospital of Yunnan University, Kunming, China
| | - Yang Yu
- Department of Sports Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Guofeng Cai
- Department of Sports Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Guiran Yang
- Department of Sports Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Guoliang Wang
- Department of Sports Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
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Cremer P, Peltier A, Maubisson L, Neyret P, Lustig S, Servien E. Positioning of the Tibial Tunnel After Single-Bundle ACL Primary Reconstruction on 3D CT scans: A New Method. Arthrosc Sports Med Rehabil 2020; 2:e615-e622. [PMID: 33135002 PMCID: PMC7588642 DOI: 10.1016/j.asmr.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 07/16/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To assess intra-articular tunnel aperture positioning after primary anterior cruciate ligament (ACL) reconstruction with either the reference standard method or the intercondylar area method in a single center using 3-dimensional (3D) computed tomography (CT) scans and to evaluate the intra-articular position of the tibial tunnel relative to the ACL footprint. Methods 3D CT scans were performed after 120 single-bundle primary ACL reconstruction cases. The center of the tibial tunnel aperture and the center of the ACL footprint were referenced on axial views of the tibial plateau in the anteroposterior (AP) and mediolateral (ML) planes according to a centimetric grid system including the whole plateau (reference standard). This was compared with a grid system based on intercondylar area bony anatomy. The posterior aspect of intertubercular fossa, anterior aspect of the tibial plateau, medial intercondylar ridge, and crossing point between lateral intercondylar ridge and posterior margin were used as landmarks to define the grid. Results According to the reference standard method, the center of the tibial tunnel aperture was positioned 0.57 ± 2.62 mm more posterior and 0.67 ± 1.55 mm more medial than the center of the footprint. According to the intercondylar area method, the center of the tibial tunnel aperture was positioned 1.32 ± 2.74 mm more posterior and 0.66 ± 1.56 mm more medial than the center of the footprint. The position difference between the center of the tunnel aperture and the center of the footprint were statistically correlated for both grids, with r = –0.887, P < .001 for AP positioning and r = 0.615, P < .001 for ML positioning. Conclusion This intercondylar area method using arthroscopic landmarks can be used to assess tunnel placement on 3D CT scans after ACL reconstruction. Level of Evidence III, retrospective comparative study.
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Affiliation(s)
| | | | | | - Philippe Neyret
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
| | | | - Elvire Servien
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
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Oshima T, Nakase J, Ohashi Y, Shimozaki K, Asai K, Tsuchiya H. Intraoperative fluoroscopy shows better agreement and interchangeability in tibial tunnel location during single bundle anterior cruciate ligament reconstruction with postoperative three-dimensional computed tomography compared with an intraoperative image-free navigation system. Knee 2020; 27:809-816. [PMID: 32178971 DOI: 10.1016/j.knee.2020.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/30/2020] [Accepted: 02/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fluoroscopy and navigation systems provide an accurate and reproducible method of guiding anatomical tunnel positioning during anterior cruciate ligament reconstruction (ACLR). The aim was to evaluate the differences in tibial tunnel location assessed by both an intraoperative navigation system and fluoroscopy, validated using a one-week postoperative three-dimensional computed tomography (3DCT). METHODS The tibial tunnel location in a consecutive series of 35 patients who received a single-bundle ACLR was evaluated by intraoperative navigation system, fluoroscopic image and compared with postoperative 3DCT position. The location to the anterior-posterior (AP) and medial-lateral (ML) direction were compared between all three methods. RESULTS The tibial tunnel locations were 46.7 ± 4.5%, 44.5 ± 1.9%, and 43.6 ± 2.4% in ML direction, and 42.8 ± 7.6%, 37.9 ± 3.8%, and 37.9 ± 3.7% in AP direction using an intraoperative navigation system, fluoroscopic image and postoperative 3DCT, respectively. Significant differences between the navigation system and fluoroscopic image (ML, P = 0.001; AP, P = 0.006), and the navigation system and 3DCT (ML, P = 0.001; AP, P < 0.001) were seen. However, there was no significant difference between fluoroscopy and 3DCT (ML, P = 0.315; AP, P = 0.999). There was a significant lack of agreement for analyses measured using a navigation system and 3DCT. Fluoroscopy and 3DCT demonstrated an acceptable agreement (ML, rpt = -0.21, P = 0.232; AP, rpt = 0.04, P = 0.826). CONCLUSIONS A tibial tunnel location assessed by intraoperative fluoroscopy shows better agreement and interchangeability with one-week postoperative 3DCT validation during single-bundle ACLR compared with an intraoperative image-free navigation system.
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Affiliation(s)
- Takeshi Oshima
- Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Ishikawa, Japan.
| | - Yoshinori Ohashi
- Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Kengo Shimozaki
- Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Kazuki Asai
- Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Ishikawa, Japan
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Marwan Y, Böttcher J, Laverdière C, Jaffer R, Burman M, Boily M, Martineau PA. Three-Dimensional Magnetic Resonance Imaging for Guiding Tibial and Femoral Tunnel Position in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study. Orthop J Sports Med 2020; 8:2325967120909913. [PMID: 32284939 PMCID: PMC7137122 DOI: 10.1177/2325967120909913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Femoral and tibial tunnel malposition for anterior cruciate ligament (ACL) reconstruction (ACLR) is correlated with higher failure rate. Regardless of the surgical technique used to create ACL tunnels, significant mismatches between the native and reconstructed footprints exist. Purpose: To compare the position of tunnels created by a standard technique with the ones created based on preoperative 3-dimensional magnetic resonance imaging (3D MRI) measurements of the ACL anatomic footprint. Study Design: Controlled laboratory study. Methods: Using 3D MRI, the native ACL footprints were identified. Tunnels were created on 16 knees (8 cadavers) arthroscopically. On one knee of a matched pair, the tunnels were created based on 3D MRI measurements that were provided to the surgeon (roadmapped technique), while on the contralateral knee, the tunnels were created based on a standard anatomic ACLR technique. The technique was randomly assigned per set of knees. Postoperatively, the positions of the tunnels were measured using 3D MRI. Results: On the tibial side, the median distance between the center of the native and reconstructed ACL footprints in relation to the root of the anterior horn of the lateral meniscus medially was 1.7 ± 2.2 mm and 1.9 ± 2.8 mm for the standard and roadmapped techniques, respectively (P = .442), while the median anteroposterior distance was 3.4 ± 2.4 mm and 2.5 ± 2.5 mm for the standard and roadmapped techniques, respectively (P = .161). On the femoral side, the median distance in relation to the apex of the deep cartilage (ADC) distally was 0.9 ± 2.8 mm and 1.3 ± 2.1 mm for the standard and roadmapped techniques, respectively (P = .195), while the median distance anteriorly from the ADC was 1.2 ± 1.3 mm and 4.6 ± 4.5 mm for the standard and roadmapped techniques, respectively (P = .007). Conclusion: Providing precise radiological measurements of the ACL footprints does not improve the surgeon’s ability to position the tunnels. Future studies should continue to attempt to provide tools to improve the tunnel position in ACLR. Clinical Relevance: This cadaveric study indicates that despite the use of 3D MRI in understanding the ACL anatomy, re-creating the native ACL footprints remains a challenge.
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Affiliation(s)
- Yousef Marwan
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Jens Böttcher
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Carl Laverdière
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Rehana Jaffer
- Department of Radiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Mark Burman
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Mathieu Boily
- Department of Radiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Paul A Martineau
- Division of Orthopaedic Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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Yoon KH, Kim JH, Kwon YB, Kim EJ, Lee SH, Kim SG. A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2020; 140:383-390. [PMID: 31970504 DOI: 10.1007/s00402-020-03343-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Indexed: 01/14/2023]
Abstract
INTRODUCTION A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry. METHODS This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2 days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes. RESULTS The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5 mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%). CONCLUSIONS The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR. LEVEL OF EVIDENCE Retrospective case series; level of evidence, 4.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Jae Ho Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Yoo Beom Kwon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Eung Ju Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang Hyeon Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, South Korea.
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Moon HS, Choi CH, Jung M, Lee DY, Chang H, Kim SH. Do Rotation and Measurement Methods Affect Reliability of Anterior Cruciate Ligament Tunnel Position on 3D Reconstructed Computed Tomography? Orthop J Sports Med 2019; 7:2325967119885882. [PMID: 31840029 PMCID: PMC6902393 DOI: 10.1177/2325967119885882] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: The literature has seldom investigated the anterior cruciate ligament (ACL) tunnel position while considering the effect of rotation of 3-dimensional computed tomography (3D-CT) images during measurements. Hypothesis: We hypothesized that (1) measurement of the ACL tunnel position in the femur and tibia through use of 3D-CT is considerably influenced by rotation of the 3D model and (2) there exists a reliable measurement method for ACL tunnel position least affected by rotation. Study Design: Controlled laboratory study. Methods: The 3D-CT images of 30 randomly selected patients who underwent single-bundle ACL reconstruction were retrospectively reviewed. For femoral tunnel assessments, rectangular reference frames were used that involved the highest point of the intercondylar notch and outer margins of the lateral femoral condyle (method 1), the highest point of the intercondylar notch and outer margins of the lateral wall of the intercondylar notch (method 2), and the lowest point of the intercondylar notch and outer margins of the lateral femoral condyle (method 3). For tibial tunnel assessments, rectangular reference frames with the cortical outline at the articular surface of the tibia (method A) and the cortical outline of the proximal tibia (method B) were used. For both femoral and tibial assessments, the tunnel positions at 5°, 10°, and 15° of rotation of the 3D model were compared with that at a neutral position. Results: The values measured by methods 1 and 3 showed significant differences at greater than 5° of rotation compared with the value at the neutral position, whereas method 2 showed relatively consistent results. However, the values measured with both methods A and B showed significant differences at greater than 5° of rotation compared with the value at the neutral position. Conclusion: The tunnel position on 3D-CT images was significantly influenced by rotation during measurements. For femoral tunnel position, measurement with a reference frame using the lateral wall of the intercondylar notch (method 2) was the least affected by rotation, with relatively consistent results. Clinical Relevance: This study demonstrates that measurement using the lateral wall of the intercondylar notch might be a consistent and reliable method for evaluating the ACL femoral tunnel position considering the effect of 3D-CT image rotation during measurements. However, both methods to measure tibial tunnel position described in this study were similarly affected by rotation.
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Affiliation(s)
- Hyun-Soo Moon
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chong-Hyuk Choi
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae-Young Lee
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Saegil Hospital, Seoul, Republic of Korea
| | - Hsienhao Chang
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Pedneault C, Laverdière C, Hart A, Boily M, Burman M, Martineau PA. Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2019; 47:3187-3194. [PMID: 31513428 DOI: 10.1177/0363546519873633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic anterior cruciate ligament (ACL) reconstruction improves knee kinematics and joint stability in symptomatic patients who have ACL deficiency. Despite a concerted effort to place the graft within the ACL's native attachment sites, the accuracy of tunnel placement using contemporary techniques is not well established. PURPOSE To use 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate the accuracy of tibial tunnel placement after anatomic ACL reconstruction. STUDY DESIGN Case series; Level of evidence, 4. METHODS Forty patients with symptomatic, ACL-deficient knees were prospectively enrolled in the study and underwent 3D MRI of both their injured and uninjured knees before and after surgery through use of a validated imaging protocol. The root ligament of the anterior horn of the lateral meniscus was used as a radiographic reference, and the center of the reconstructed graft was compared with that of the contralateral normal knee. The tunnel angles and intra-articular graft angles were also measured, as was the percentage overlap between the native tibial footprint and tibial tunnel. RESULTS The reconstructed tibial footprint was placed at a mean ± SD of 2.14 ± 2.45 mm (P < .001) medial and 5.11 ± 3.57 mm (P < .001) posterior to the native ACL footprint. The mean distance between the center of the native and reconstructed ACL at the tibial attachment site was 6.24 mm. Of the 40 patients, 18 patients had a tibial tunnel that overlapped more than 50% of the native footprint, and 10 patients had maximal (100%) overlap. Further, 22 of the 40 patients had less than 50% overlap with the native footprint, and in 12 patients the footprint was missing completely. CONCLUSION Despite the use of contemporary surgical techniques to perform anatomic ACL reconstruction, a significant positioning error in tibial tunnel placement remains.
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Affiliation(s)
- Christopher Pedneault
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | | | - Adam Hart
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | - Mathieu Boily
- Department of Musculoskeletal Radiology, McGill University Health Center, Montreal, Québec, Canada
| | - Mark Burman
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
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Parkar AP, Adriaensen MEAPM, Giil LM, Solheim E. Computed Tomography Assessment of Anatomic Graft Placement After ACL Reconstruction: A Comparative Study of Grid and Angle Measurements. Orthop J Sports Med 2019; 7:2325967119832594. [PMID: 30915380 PMCID: PMC6429657 DOI: 10.1177/2325967119832594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The anatomic placement of anterior cruciate ligament (ACL) grafts is often assessed with postoperative imaging. In clinical practice, graft angles are measured to indicate anatomic placement on magnetic resonance imaging, whereas grid measurements are performed on computed tomography (CT). Recently, a study indicated that graft angle measurements could also be assessed on CT. No consensus has yet been reached on which measurement method is best suited to assess anatomic graft placement. Purpose: To compare the ability of grid measurements and angle measurements to identify anatomic versus nonanatomic tunnel placement on CT performed in patients undergoing ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A total of 100 knees undergoing primary reconstruction with a hamstring graft (HAM group), 91 undergoing reconstruction with a bone–patellar tendon–bone graft (BPTB group), and 117 undergoing revision ACL reconstruction (REV group) were assessed with CT. Grid measurements of the femoral and tibial tunnels and angle measurements of grafts were performed. Graft placement, rated as anatomic or nonanatomic, was assessed with both methods. Pearson chi-square, analysis of variance, Kruskal-Wallis, and weighted kappa tests were performed as appropriate. Results: The grid assessment classified 10% of the HAM group, 4% of the BPTB group, and 17% of the REV group as nonanatomic (P < .001). The angle assessment classified 37% of the HAM group, 54% of the BPTB group, and 47% of the REV group as nonanatomic. The weighted kappa between angle measurements and grid measurements was low in all groups (HAM: 0.009; BPTB: 0.065; REV: 0.041). Conclusion: The agreement between grid measurements and angle measurements was very low. The angle measurements seemed to overestimate nonanatomic tunnel placement. Grid measurements were better in identifying malpositioned grafts.
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Affiliation(s)
- Anagha P Parkar
- Department of Radiology, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | | | - Lasse M Giil
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Eirik Solheim
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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Wurm M, Herbst E, Forkel P, Imhoff AB, Herbort M. [Anterolateral stabilization using the modified Lemaire technique for ACL deficiency]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 31:36-44. [PMID: 30478634 DOI: 10.1007/s00064-018-0579-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/11/2018] [Accepted: 07/12/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Treatment of persistent anterolateral knee instability. INDICATIONS Subjective/objective (rotational) instability of the knee after anatomic anterior cruciate ligament (ACL) reconstruction. ACL re-rupture including special demands (e.g., high-performance athletes, hyperlaxity) RELATIVE CONTRAINDICATIONS: Osteoarthritis, additional instability of the knee, which should be treated independently; non-anatomic ACL reconstruction with persisting instability should be treated first with anatomic ACL reconstruction. ABSOLUTE CONTRAINDICATIONS General contraindications for surgery (e. g. septic arthritis), acute irritation of the affected knee. SURGICAL TECHNIQUE Supine position. Incision along the proximal lateral femoral epicondyle. Marking of the needed width and length of the iliotibial band (ITB) graft. Passing the ITB graft underneath the lateral collateral ligament. Find and mark the isometric point for fixation next to the lateral femoral epicondyle. Fixation of the ITB graft. Layered wound closure. POSTOPERATIVE MANAGEMENT Knee brace for at least 6 weeks. Range of motion (RoM): from postoperative day 1: flexion-extension 90-0-0°; first 2 weeks after surgery: partial weight bearing (20 kg). RESULTS An anterolateral extra-articular reconstruction may reduce a persistent anterolateral rotatory instability as well as the re-rupture rate following ACL reconstruction with good patient-reported short-term outcomes. Based on current (biomechanical) data, anterolateral tenodesis seems to be superior to a reconstruction of the anterolateral ligament. If a tenodesis is performed, the graft should be fixed in an isometric position, with neutral rotation of the knee and low graft tension to avoid extraphysiologic load within the lateral compartment. Indications for such a procedure may include a high-grade pivot shift or revision ACL reconstruction as well as a persistent anterolateral rotatory instability following anatomic ACL reconstruction.
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Affiliation(s)
- M Wurm
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81679, München, Deutschland
| | - E Herbst
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81679, München, Deutschland
| | - P Forkel
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81679, München, Deutschland
| | - A B Imhoff
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81679, München, Deutschland.
| | - M Herbort
- Klinik für Unfall‑, Hand und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
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Ni J, Li D, Mao M, Dang X, Wang K, He J, Shi Z. A Method of Accurate Bone Tunnel Placement for Anterior Cruciate Ligament Reconstruction Based on 3-Dimensional Printing Technology: A Cadaveric Study. Arthroscopy 2018; 34:546-556. [PMID: 29122434 DOI: 10.1016/j.arthro.2017.08.288] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To explore a method of bone tunnel placement for anterior cruciate ligament (ACL) reconstruction based on 3-dimensional (3D) printing technology and to assess its accuracy. METHODS Twenty human cadaveric knees were scanned by thin-layer computed tomography (CT). To obtain data on bones used to establish a knee joint model by computer software, customized bone anchors were installed before CT. The reference point was determined at the femoral and tibial footprint areas of the ACL. The site and direction of the bone tunnels of the femur and tibia were designed and calibrated on the knee joint model according to the reference point. The resin template was designed and printed by 3D printing. Placement of the bone tunnels was accomplished by use of templates, and the cadaveric knees were scanned again to compare the concordance of the internal opening of the bone tunnels and reference points. RESULTS The twenty 3D printing templates were designed and printed successfully. CT data analysis between the planned and actual drilled tunnel positions showed mean deviations of 0.57 mm (range, 0-1.5 mm; standard deviation, 0.42 mm) at the femur and 0.58 mm (range, 0-1.5 mm; standard deviation, 0.47 mm) at the tibia. CONCLUSIONS The accuracy of bone tunnel placement for ACL reconstruction in cadaveric adult knees based on 3D printing technology is high. CLINICAL RELEVANCE This method can improve the accuracy of bone tunnel placement for ACL reconstruction in clinical sports medicine.
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Affiliation(s)
- Jianlong Ni
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Dichen Li
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Mao Mao
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Xiaoqian Dang
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Kunzheng Wang
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiankang He
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Zhibin Shi
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Fujii M, Furumatsu T, Miyazawa S, Kodama Y, Hino T, Kamatsuki Y, Ozaki T. Bony landmark between the attachment of the medial meniscus posterior root and the posterior cruciate ligament: CT and MR imaging assessment. Skeletal Radiol 2017; 46:1041-1045. [PMID: 28314900 DOI: 10.1007/s00256-017-2625-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/27/2017] [Accepted: 03/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES (1) To reveal the prevalence of the bony recess (posterior dimple) and (2) to determine the position of the posterior dimple on the tibial plateau using three-dimensional computed tomography (3DCT). MATERIALS AND METHODS In this study, a retrospective review of 112 patients was performed to identify the posterior dimple and to evaluate its position on 3DCT. Magnetic resonance images (MRIs) were also used to determine the positional relationship among the posterior cruciate ligament (PCL), medial meniscus posterior insertion (MMPI), and posterior dimple. RESULTS The posterior dimple was observed in 100 of 112 knees (89.3%) on 3DCT. The center of the posterior dimple was 13.6 ± 0.8 mm from the medial tibial eminence apex. MRI showed that the posterior dimple separated the tibial attachment of the PCL and MMPI. CONCLUSION This is the first study to discuss the prevalence and position of the bony recess in the posterior intercondylar fossa.
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Affiliation(s)
- Masataka Fujii
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Shinichi Miyazawa
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yuya Kodama
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Tomohito Hino
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yusuke Kamatsuki
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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Parkar AP, Adriaensen MEAPM, Vindfeld S, Solheim E. The Anatomic Centers of the Femoral and Tibial Insertions of the Anterior Cruciate Ligament: A Systematic Review of Imaging and Cadaveric Studies Reporting Normal Center Locations. Am J Sports Med 2017; 45:2180-2188. [PMID: 27899355 DOI: 10.1177/0363546516673984] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The anterior cruciate ligament (ACL) is regularly reconstructed if knee joint function is impaired. Anatomic graft tunnel placement, often assessed with varying measurement methods, in the femur and tibia is considered important for an optimal clinical outcome. A consensus on the exact location of the femoral and tibial footprint centers is lacking. PURPOSE To systematically review the literature regarding anatomic centers of the femoral and tibial ACL footprints and assess the mean, median, and percentiles of normal centers. STUDY DESIGN Systematic review. METHODS A systematic literature search was performed in the PubMed/Medline database in November 2015. Search terms were the following: "ACL" and "insertion anatomy" or "anatomic footprint" or "radiographic landmarks" or "quadrant methods" or "tunnel placement" or "cadaveric femoral" or "cadaveric tibial." English-language articles that reported the location of the ACL footprint according to the Bernard and Hertel grid in the femur and the Stäubli and Rauschning method in the tibia were included. Weighted means, weighted medians, and weighted 5th and 95th percentiles were calculated. RESULTS The initial search yielded 1393 articles. After applying the inclusion and exclusion criteria, 16 studies with measurements on cadaveric specimens or a healthy population were reviewed. The weighted mean of the femoral insertion center based on measurements in 218 knees was 29% in the deep-shallow (DS) direction and 35% in the high-low (HL) direction. The weighted median was 26% for DS and 34% for HL. The weighted 5th and 95th percentiles for DS were 24% and 37%, respectively, and for HL were 28% and 43%, respectively. The weighted mean of the tibial insertion center in the anterior-posterior direction based on measurements in 300 knees was 42%, and the weighted median was 44%; the 5th and 95th percentiles were 39% and 46%, respectively. CONCLUSION Our results show slight differences between the weighted means and medians in the femoral and tibial insertion centers. We recommend the use of the 5th and 95th percentiles when considering postoperative placement to be "in or out of the anatomic range."
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Affiliation(s)
- Anagha P Parkar
- Radiology Department, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | | | - Søren Vindfeld
- Surgical Department, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Eirik Solheim
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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Parkinson B, Robb C, Thomas M, Thompson P, Spalding T. Factors That Predict Failure in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2017; 45:1529-1536. [PMID: 28296429 DOI: 10.1177/0363546517691961] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [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 placement in anterior cruciate ligament (ACL) reconstruction has become the preferred technique for many surgeons. The predictive factors for graft failure in anatomic single-bundle ACL reconstruction are relatively unknown. PURPOSE To determine the risk factors for graft failure and the relative importance of those factors in anatomic single-bundle ACL reconstruction. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS All primary anatomic ACL reconstructions undertaken at a single institution over a 2-year period were evaluated for subjective and objective measures of graft failure. Risk factors evaluated included time since ACL rupture, age, sex, body mass index, intact or deficient medial and lateral meniscus, meniscal repair, hamstring graft size, and femoral and tibial tunnel position as assessed by 3D computed tomography (CT) scan. The significant factors predicting failure and the relative importance of those factors were determined. RESULTS At a median follow-up of 26 months, 123 patients were available for analysis. Ninety-seven patients underwent postoperative 3D CT for tunnel positions, including all 20 cases with graft failure. The significant predictors of graft failure were medial meniscal deficiency (hazard ratio [HR] 15.1; 95% CI, 4.7-48.5; P < .001), lateral meniscal deficiency (HR 9.9; 95% CI, 3-33; P < .001), shallow nonanatomic femoral tunnel positioning (HR 4.3; 95% CI, 1.6-11.6; P = .004), and younger patient age (HR 0.9; 95% CI, 0.9-1; P = .008). CONCLUSION Meniscal deficiency is the most significant factor to predict graft failure in single-bundle anatomic ACL reconstruction. Shallow nonanatomic femoral tunnel positioning and younger patient age are additional risk factors for failure, but their relative importance is less.
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Affiliation(s)
- Ben Parkinson
- Department of Orthopaedics, Cairns Hospital, Cairns, Queensland, Australia
| | - Curtis Robb
- Warrington and Halton NHS Trust, Warrington, UK
| | - Michael Thomas
- University Hospitals Coventry and Warwickshire (UHCW), Coventry, UK
| | - Peter Thompson
- University Hospitals Coventry and Warwickshire (UHCW), Coventry, UK
| | - Tim Spalding
- University Hospitals Coventry and Warwickshire (UHCW), Coventry, UK
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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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Iio K, Tsuda E, Tsukada H, Yamamoto Y, Maeda S, Naraoka T, Kimura Y, Ishibashi Y. Characteristics of elongated and ruptured anterior cruciate ligament grafts: An analysis of 21 consecutive revision cases. Asia Pac J Sports Med Arthrosc Rehabil Technol 2017; 8:1-7. [PMID: 29264272 PMCID: PMC5721916 DOI: 10.1016/j.asmart.2016.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND/OBJECTIVE Anterior cruciate ligament (ACL) reconstructions often fail without graft rupture. The purpose of this study was to compare the characteristics of patients with elongated and ruptured bone-patellar tendon-bone (BTB) grafts that required revision surgery. METHODS Twenty one patients who required revisions of a BTB-reconstructed ACL between 2010 and 2015 were enrolled in this study. All patients were evaluated for bone tunnel position using computed tomography. Tunnel angle was calculated with radiographs. Stability under anaesthesia, and meniscus and cartilage condition were evaluated during the revision surgery. Age at primary surgery, time between primary and revision surgery, activity level, original tunnel position of the graft, and meniscus and cartilage condition were compared between elongated and ruptured grafts. RESULTS Age at primary surgery was not significantly different between the two groups (p = 0.528). Time between primary and revision surgery as well as activity level were also not significantly different between the two groups (p = 0.010 and p = 0.307, respectively). Femoral bone tunnel position was more proximal (p = 0.003), and radiographic tunnel angle was not significantly different between the two groups (p = 0.029). The rupture group was significantly more unstable on the pivot shift (p < 0.003). Meniscus degeneration, meniscus tear, and cartilage damage were not significantly different between the two groups (p = 0.030, p = 0.311, and p = 0.505, respectively). CONCLUSION The location of the original femoral tunnel was more proximal in patients with elongated grafts than in those with ruptured grafts. Different bone tunnel position from native ACL might lead to graft elongation.
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Affiliation(s)
- Kohei Iio
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
- Department of Orthopaedic Surgery, National Hospital Hospital Organization Hirosaki National Hospital, Aomori, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Harehiko Tsukada
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Shugo Maeda
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Takuya Naraoka
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
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