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Mueller MM, Tenfelde O, Hinz N, Pagenstert G, Frosch KH, Hoeher J, Akoto R. App-based analysis of the femoral tunnel position in ACL reconstruction using the quadrant method. Arch Orthop Trauma Surg 2024; 144:3137-3144. [PMID: 38795188 DOI: 10.1007/s00402-024-05380-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/09/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE The purpose of this study was to examine the intra- and interobserver variability of an app-based analysis of the femoral tunnel position using the quadrant method in primary anterior cruciate ligament reconstruction. MATERIALS AND METHODS Between 12/2020 und 12/2021 50 patients who underwent primary anterior cruciate ligament reconstruction were included in this retrospective study. Intraoperative strictly lateral fluoroscopic images of the knee with marked femoral tunnel were analyzed by four observers using the quadrant method. For retest reliability analysis, measurements were repeated once by 2 observers after 4 weeks. RESULTS The femoral tunnel position of all included patients averaged 27.86% in the depth relation and 15.61% in the height relation. Statistical analysis showed an almost perfect intra- and interobserver reliability in the depth and height relation. The ICC was 0.92 in the depth relation and 0.84 in the height relation. The Pearson's correlation coefficient in the depth and height relation of observer 1 (0.94/0.81) was only slightly different from the Pearson's correlation coefficient of observer 2 (0.92/0.85). The app-based tunnel analysis took on average 59 ± 16 s per measurement. CONCLUSION The femoral tunnel analysis with the app-based quadrant method has an almost perfect intra- and interobserver reliability. By smartphone camera, a fast and highly accurate, if necessary also intraoperative, control of the tunnel position can be performed. LEVEL OF EVIDENCE Level 3-diagnostic retrospective cohort study.
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Affiliation(s)
- Maximilian M Mueller
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany.
| | - Oliver Tenfelde
- Department of Orthopaedic Surgery, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
- Sportsclinic Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Nico Hinz
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
| | - Geert Pagenstert
- Clarahof Clinic of Orthopaedic Surgery, University of Basel, Clarahofweg 19a, 4058, Basel, Switzerland
| | - Karl-Heinz Frosch
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Juergen Hoeher
- Department of Orthopaedic Surgery, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
- Sportsclinic Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Ralph Akoto
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
- Department of Orthopaedic Surgery, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
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Hoeher J, Tenfelde O, Wagener B, Fink M, Mauri-Moeller A, Balke M. App-Based Analysis of Fluoroscopic Images According to Bernard-Hertel Method for the Determination of Femoral Tunnel Positioning in Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2024; 13:102863. [PMID: 38435250 PMCID: PMC10907940 DOI: 10.1016/j.eats.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/08/2023] [Indexed: 03/05/2024] Open
Abstract
The accurate positioning of the femoral tunnel is crucial for the success of anterior cruciate ligament reconstruction. Malpositioning of the tunnel is believed to be one of the most important reasons for graft failure. While use of anatomic landmarks and industry-supplied aiming devices aid the surgeon in placing the drill pin in the correct position, fluoroscopic imaging is an additional tool used intraoperatively to verify pin placement. While interpretation of fluoroscopic imaging is frequently based on eyeball measurement, a more accurate analysis of a lateral image uses the quadrant method by Bernard-Hertel. This method has been primarily used for scientific research due to its complexity and has not been integrated into clinical routine yet. We present a digital app-based approach to easily quantify the femoral pin position based on the quadrant method. This approach is mobile and easy to use. Quantification of pin position of femoral bone tunnel on a lateral fluoroscopic image may be used for quality control and teaching purposes or may provide the surgeon with additional information during ACL reconstruction.
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Affiliation(s)
- Juergen Hoeher
- Address correspondence to Juergen Hoeher, M.D., Ph.D., SPORTSCLINIC COLOGNE, Ringsstr. 20-22, 50996 Cologne, Germany.
| | - Oliver Tenfelde
- SPORTSCLINIC COLOGNE, Cologne, Germany
- University of Witten-Herdecke, Witten, Germany
- Cologne Merheim Medical Center, Cologne, Germany
| | - Ben Wagener
- SPORTSCLINIC COLOGNE, Cologne, Germany
- University of Witten-Herdecke, Witten, Germany
- Cologne Merheim Medical Center, Cologne, Germany
| | - Markus Fink
- SPORTSCLINIC COLOGNE, Cologne, Germany
- University of Witten-Herdecke, Witten, Germany
- Cologne Merheim Medical Center, Cologne, Germany
| | - Alejandro Mauri-Moeller
- SPORTSCLINIC COLOGNE, Cologne, Germany
- University of Witten-Herdecke, Witten, Germany
- Cologne Merheim Medical Center, Cologne, Germany
| | - Maurice Balke
- SPORTSCLINIC COLOGNE, Cologne, Germany
- University of Witten-Herdecke, Witten, Germany
- Cologne Merheim Medical Center, Cologne, Germany
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Pehlivanoglu G, Yildiz KI. Freehand vs. Medial Portal Offset Aimer Technique for Accurate Femoral Tunnel Placement in Arthroscopic ACL Reconstruction. Indian J Orthop 2023; 57:1219-1225. [PMID: 37525732 PMCID: PMC10387000 DOI: 10.1007/s43465-023-00929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 06/05/2023] [Indexed: 08/02/2023]
Abstract
Purpose In this study, our aim was to reveal the effect of the medial femoral offset aimer usage through the femoral tunnel entry and exit points and the tunnel length during femoral tunnel drilling in arthroscopic anterior cruciate ligament (ACL) reconstruction. Methods One hundred patients who underwent arthroscopic single-bundle ACL reconstruction were included in the study. Group 1 consisted of 50 patients who underwent femoral tunnel drilling using a medial portal offset aimer device, while Group 2 consisted of 50 patients who were operated on using the freehand technique. Both groups were compared in terms of femoral tunnel and graft tunnel lengths, femoral tunnel angle in the coronal plane, and the location of the femoral tunnel entry and exit points. Results The mean femoral tunnel and graft tunnel lengths were significantly longer in Group 2 (p = 0.000). There was no significant difference in terms of localization of the femoral tunnel entry point in both the axial and sagittal planes. The tunnel exit point was located significantly more posterior in Group 1 in the axial plane (p = 0.028). There was no significant difference in terms of the coronal plane femoral tunnel angle between the two groups. Conclusion In arthroscopic ACL reconstructions, more successful results may be obtained with the freehand technique compared to drilling with a femoral offset aimer. For an experienced orthopedic surgeon, using a medial portal offset aimer device during femoral tunnel drilling does not seem necessary. Supplementary Information The online version contains supplementary material available at 10.1007/s43465-023-00929-z.
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Affiliation(s)
- Gokhan Pehlivanoglu
- Orthopaedics and Traumatology Department, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Kadir Ilker Yildiz
- Orthopaedics and Traumatology Department, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Hisar St. No: 56, Sariyer, Istanbul, Turkey
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Pandey V, Madi S, Thonse C, Joseph C, Rajan D, Varughese J, Thilak J, Jayaprasad PS, Acharya K, Ramamurthy KG, Reddy R, Amravathi R, Rao S, Gangavarapu S, Srinivas M, Jose S, Sundararjan SR. Trends in Primary Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Practice in Adult Patients Prevalent Among Arthroscopy Surgeons of Six Southern States of India. Indian J Orthop 2022; 56:1703-1716. [PMID: 36187588 PMCID: PMC9485326 DOI: 10.1007/s43465-022-00719-z] [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: 01/20/2022] [Accepted: 08/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although guidelines from multiple scientific studies decide the general trend in ACLR practice, there is often a variation between scientific guidelines and actual practice. METHODS A 17-member committee comprised of sports surgeons with experience of a minimum of 10 years of arthroscopy surgery finalized a survey questionnaire consisting of concepts in ACL tear management and perioperative trends, intraoperative and post-operative practices regarding single-bundle anatomic ACLR. The survey questionnaire was mailed to 584 registered sports surgeons in six states of south India. A single, non-modifiable response was collected from each member and analyzed. RESULTS 324 responses were received out of 584 members. A strong consensus was present regarding Hamstring tendons preference for ACLR, graft diameter ≥ 7.5 mm, viewing femoral footprint through the anterolateral portal, drilling femoral tunnel from anteromedial portal guided by ridges and remnants of femoral footprint using a freehand technique, suspensory devices to fix the graft in femur and interference screw in the tibia and post-operative bracing. A broad consensus was achieved in using a brace to minimize symptoms of instability of an ACL tear and antibiotic soaking of graft. There was no consensus regarding the timing of ACLR, preferred graft in athletes, pre-tensioning, extra-articular procedure, and return to sports. There was disagreement over hybrid tibial fixation and suture tapes to augment graft. CONCLUSION Diverse practices continue to prevail in the management of ACL injuries. However, some of the consensuses reached in this survey match global practices. Contrasting or inconclusive practices should be explored for potential future research.
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Affiliation(s)
- Vivek Pandey
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Sandesh Madi
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Chirag Thonse
- Vikram Hospital, Millers Road, Bangalore, 560052 India
| | - Clement Joseph
- Arthroscopy and Sports Medicine, SRM Institute for Medical Sciences, Vadapalani, Chennai, Tamil Nadu 600 026 India
| | - David Rajan
- Ortho-One Orthopaedic Speciality Centre, Trichy Road, Singanallur, Coimbatore, Tamil Nadu 641005 India
| | | | - Jai Thilak
- Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala 682 041 India
| | - P. S. Jayaprasad
- Kamineni Hospitals, L.B. Nagar, Bahadurguda, Hyderabad, Telangana 500068 India
| | - Kiran Acharya
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | | | - Raghuveer Reddy
- Krishna Institute of Medical Sciences Secunderabad, Hyderabad, India ,Care Hospitals in Banjara Hills, Hyderabad, India ,Sai Institute of Sports Injury and Arthroscopy in Banjara Hills, Hyderabad, 500 004 India
| | - Rajkumar Amravathi
- St John’s Medical College Hospital, Sarjapur Road, Bangalore, 560034 India
| | - Sharath Rao
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Sridhar Gangavarapu
- Department of Orthopaedics, Medicover Hospitals, Gokhale Rd, Krishna Nagar, Maharani Peta, Visakhapatnam, Andhra Pradesh 530002 India
| | - Moparthi Srinivas
- Nandan Hospital, Suryarao Pet, Vijayawada, Andhra Pradesh 520002 India
| | - Sujit Jose
- Institute of Advanced Orthopaedics at MOSC Hospital and Medical College, Kolenchery, Ernakulam, Kerala 682311 India
| | - S. R. Sundararjan
- Arthroscopy and Sports Medicine, Ganga Hospital, Coimbatore, 641 043 India
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The posterior horn of the lateral meniscus is a reliable novel landmark for femoral tunnel placement in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:1384-1391. [PMID: 29063153 DOI: 10.1007/s00167-017-4759-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Femoral tunnel placement is essential for good outcome in anterior cruciate ligament (ACL) reconstruction. In the past, several attempts have been made to optimize femoral tunnel placement. It was observed that the posterior horn of the lateral meniscus was always located directly below to the desired femoral ACL tunnel position, when the knee was brought to deep flexion (> 120°). The goal of the present study was to verify the hypothesis that the posterior horn of the lateral meniscus can be used as a landmark for femoral tunnel placement. METHODS Out of a consecutive series of ACL reconstructions done by a single surgeon, 55 lateral radiographs were evaluated according to the quadrant method by Bernard and Hertel. Additionally, on anterior-posterior radiographs the femoral tunnel angle was determined. RESULTS In the present case series the posterior horn of the lateral meniscus could be identified and used as a landmark for femoral tunnel placement in all cases. The mean tunnel depth was 24 ± 5.1% and the mean tunnel height was 31.3 ± 5.7%. The mean femoral tunnel angle was 41 ± 4.9° using the anatomical axis as a reference. Compared to previous cadaver studies the data of the present study were within their anatomical range of the native ACL insertion site. CONCLUSION The suggested technique using the posterior horn of the lateral meniscus as a landmark for femoral tunnel placement showed reproducible results and matches the native ACL insertion site compared to previous cadaveric studies. In particular, non-experienced ACL surgeons will benefit from this apparent landmark and the corresponding easy-to-use ACL reconstruction method. LEVEL OF EVIDENCE IV.
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Achtnich A, Ranuccio F, Willinger L, Pogorzelski J, Imhoff AB, Braun S, Herbst E. High incidence of partially anatomic tunnel placement in primary single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:462-467. [PMID: 28439635 DOI: 10.1007/s00167-017-4555-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/19/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate tunnel position and width in failed primary single-bundle (SB) anterior cruciate ligament (ACL) reconstructions. It was hypothesized that both femoral and tibial bone tunnels are frequently malplaced in terms of a partially anatomic position in the setting of failed SB ACL reconstruction. METHODS Patients with recurrent instability following isolated SB ACL reconstruction using hamstring tendon autografts, undergoing revision ACL surgery, were retrospectively included. Further inclusion criteria were age >18 years and availability of preoperative computed tomography (CT) scans and radiographs of the affected knee. Patients with multiligamentous instabilities as well as incomplete or poor radiographs were excluded. Tunnel position was evaluated according to the method described by Harner et al. and Stäubli and Rauschning. Tunnel width was determined on CT scans perpendicular to the bone tunnel axis at three different heights of each bone tunnel. RESULTS Eighty-two patients met the inclusion criteria and were considered for radiological analysis. Femoral tunnels were graded as anatomic in 60% (49 of 82) of all cases. In the remaining 40% (33/82), 27% of the tunnels were placed partially anatomic and 13% were graded as non-anatomic. Tibial tunnel placement was found to be anatomic in 54% (44/82) of all cases, partially anatomic in 45% and non-anatomic in 1% of the cases. No statistically significant difference between anatomic or partially anatomic tunnel position and tunnel diameter, neither for the femoral nor for the tibial side, was observed (n.s.). CONCLUSION The present study demonstrates that there is a high incidence of partially anatomic placed tunnels in failed SB ACL reconstruction. Tunnel width was not associated with tunnel position. Clinically, partially anatomic bone tunnels frequently require a staged procedure with bone grafting and subsequent ACL revision surgery. Thus, surgeons should carefully analyse tunnel position and width preoperatively to properly plan ACL revision surgery.
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Affiliation(s)
- Andrea Achtnich
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Francesco Ranuccio
- Department of Orthopaedic and Trauma Surgery, Policlinico San Pietro, Ponte St. Pietro, Italy
| | - Lukas Willinger
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jonas Pogorzelski
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Sepp Braun
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Elmar Herbst
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Suruga M, Horaguchi T, Iriuchishima T, Yahagi Y, Iwama G, Tokuhashi Y, Aizawa S. Morphological size evaluation of the mid-substance insertion areas and the fan-like extension fibers in the femoral ACL footprint. Arch Orthop Trauma Surg 2017; 137:1107-1113. [PMID: 28593582 DOI: 10.1007/s00402-017-2726-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the detailed anatomy of the femoral anterior cruciate ligament (ACL) insertion site, with special attention given to the morphology of the mid-substance insertion areas and the fan-like extension fibers. METHODS Twenty-three non-paired human cadaver knees were used (7 Males, 16 Females, median age 83, range 69-96). All soft tissues around the knee were resected except the ligaments. The ACL was divided into antero-medial (AM) and postero-lateral (PL) bundles according to the difference in macroscopic tension patterns. The ACL was carefully dissected and two outlines were made of the periphery of each bundle insertion site: those which included and those which excluded the fan-like extension fibers. An accurate lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area of each bundle, including and excluding the fan-like extension fibers, was measured with Image J software (National Institution of Health). The width and length of the mid-substance insertion sites were also evaluated using same image. RESULTS The femoral ACL footprint was divided into four regions (mid-substance insertion sites of the AM and PL bundles, and fan-like extensions of the AM and PL bundles). The measured areas of the mid-substance insertion sites of the AM and PL bundles were 35.5 ± 12.5, and 32.4 ± 13.8 mm2, respectively. Whole width and length of the mid-substance insertion sites were 5.3 ± 1.4, and 15.5 ± 2.9 mm, respectively. The measured areas of the fan-like extensions of the AM and PL bundles were 27 ± 11.5, and 29.5 ± 12.4 mm2, respectively. CONCLUSION The femoral ACL footprint was divided into quarters of approximately equal size (mid-substance insertion sites of the AM and PL bundles, and fan-like extensions of the AM and PL bundles). For clinical relevance, to perform highly reproducible anatomical ACL reconstruction, the presence of the fan-like extension fibers should be taken into consideration.
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Affiliation(s)
- Makoto Suruga
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Takashi Horaguchi
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Takanori Iriuchishima
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan. .,Department of Orthopedic Surgery, Kamimoku Hot Springs Hospital, Minakami, Japan.
| | - Yoshiyuki Yahagi
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Genki Iwama
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Yasuaki Tokuhashi
- Department of Orthopedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shin Aizawa
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
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