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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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Mao Y, Zhang K, Li J, Fu W. Transtibial Versus Anteromedial Portal Technique for Femoral Tunnel Drilling in Primary Single-Bundle Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Level 1 and 2 Evidence of Clinical, Revision, and Radiological Outcomes. Am J Sports Med 2023; 51:250-262. [PMID: 34652233 DOI: 10.1177/03635465211044476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although numerous clinical studies have compared transtibial (TT) and anteromedial portal (AMP) drilling of femoral tunnels during anterior cruciate ligament reconstruction (ACLR), there is no high-quality, evidence-based consensus regarding which technique affords the best outcome. HYPOTHESIS There would be no difference between the TT and AMP techniques in terms of knee stability, patient-reported outcomes, incidence of revision, and radiological results. STUDY DESIGN Meta-analysis; Level of evidence, 2. METHODS The PubMed and EMBASE databases were searched from inception to February 1, 2021. Level 1 and 2 clinical trials that compared TT and AM techniques were included. Data were meta-analyzed for the outcome measures of knee stability, patient-reported functional outcomes, incidence of revision, and radiological results. Dichotomous variables were presented as odds ratios (ORs), and continuous variables were presented as mean differences (MDs) and standard mean differences (SMDs). RESULTS The meta-analysis included 18 clinical studies, level of evidence 1 or 2, that involved 53,888 patients. Pooled data showed that the AMP group had a lower side-to-side difference (SMD, 0.22; 95% CI, 0.06 to 0.39; P = .009), a lower incidence of pivot-shift phenomenon (OR, 3.69; 95% CI, 1.26 to 10.79; P = .02), and a higher postoperative Lysholm score (SMD, -0.26; 95% CI, -0.44 to -0.08; P = .005) than the TT group. However, no statistically significant differences were seen in other outcomes, including subjective International Knee Documentation Committee scores (SMD, -0.11; 95% CI, -0.30 to 0.09; P = .30) or grades (OR, 0.93; 95% CI, 0.35 to 2.49; P = .89), postoperative activity level (MD, -0.14; 95% CI, -0.42 to 0.15; P = .35), and incidence of revision ACLR (OR, 1.04; 95% CI, 0.93 to 1.16; P = .45). The TT technique was more likely to create longer (SMD, 1.05; 95% CI, 0.05 to 2.06; P = .04) and more oblique (SMD, 0.81; 95% CI, 0.51 to 1.11; P < .001) femoral tunnels than the AMP technique, and a higher height ratio of the aperture position was detected with the TT technique (SMD, -3.51; 95% CI, -5.54 to -1.49; P < .001). CONCLUSION The AMP technique for ACLR may be more likely to produce better knee stability and improved clinical outcomes than the TT technique, but no difference was found in the incidence of revision between the 2 groups.
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Affiliation(s)
- Yunhe Mao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Kaibo Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Wang Z, Du Y, Chang Q, Xie Q, Wang L, Xu C. Analysis the Lateral Tunnel Position of the Bone Graft and Regeneration of Femur by CT Tunnel Localization. J BIOMATER TISS ENG 2022. [DOI: 10.1166/jbt.2022.3160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: To analyze, in a retrospective study, the lateral tunnel position of the graft femur by CT after arthroscopic ACL reconstruction via the anteromedial (AM) approach and the tunnel angle shown on X-ray. Methods and Materials: 60 patients undergoing arthroscopic
ACL reconstruction via AM approach with 4 femoral hamstring tendon grafts were investigated from October 2019 to October 2021. Postoperative orthogonal x-rays and computed tomography (CT) scans were obtained, and the position of the femoral tunnel obtained after CT reconstruction was correlated
with the Bernard-Hertel grid. The angle of the resulting femoral tunnel on the orthogonal x-ray was analyzed against the CT tunnel position. Results: In the study, the anterior–posterior orientation was forward (P = 0.001) and the high-low orientation was similar (taken
as 20%, P = 0.066) or slightly higher (taken as 21%, P = 0.025) compared to the AM beam localization in the two-beam reconstruction. Overall, the femoral tunnel angle on non-weight-bearing orthogonal x-ray was negatively correlated with the anterior–posterior (AP) position
of the femoral tunnel centre as shown on CT (P = 0.004, r =−0.368) and positively, but weakly, correlated with the high-low (HL) position (P = 0.049, r = 0.254). Conclusion: Non-weight-bearing orthogonal X-rays only can make approximate predictions
about the distribution of anatomical reconstruction, I.D.E.A.L reconstruction.
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Affiliation(s)
- Zhihui Wang
- Department of Joint Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Yuanliang Du
- Department of Joint Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Qiankun Chang
- Department of Ultrasonography, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Qiang Xie
- Department of Hand and Foot Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Liqing Wang
- Intensive Care Unit, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Cong Xu
- Department of Joint Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
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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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Matava MJ, Koscso J, Melara L, Bogunovic L. Suture Tape Augmentation Improves the Biomechanical Performance of Bone-Patellar Tendon-Bone Grafts Used for Anterior Cruciate Ligament Reconstruction. Arthroscopy 2021; 37:3335-3343. [PMID: 33964381 DOI: 10.1016/j.arthro.2021.04.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate the time-zero biomechanical properties (stiffness, displacement, and load at failure) of bone-patellar tendon-bone (BTB) grafts used for anterior cruciate ligament (ACL) reconstruction with and without suture tape augmentation as a means to determine the potential clinical benefit of this technique. METHODS Eight juvenile porcine knees underwent ACL reconstruction with a human cadaveric BTB graft (control). These were compared to 8 juvenile porcine knees that underwent ACL reconstruction with a BTB graft augmented with suture tape. All knees underwent biomechanical testing utilizing a dynamic tensile testing machine. Cyclic loading between 50-250N was performed for 500 cycles at 1 Hz to simulate in vivo ACL loads during the early rehabilitation phase. The grafts were displaced during load-at-failure tensile testing at 20 mm/min. Differences in graft displacement, stiffness, and load at failure for the control and suture tape augmented groups were compared with the Student t-test with a significance level of P < .05. RESULTS There was no difference in graft displacement between the 2 groups. A 104% higher postcyclic stiffness was noted in the augmented group compared to the controls (augmentation: 261 ± 76 N/mm versus control 128 ± 28 N/mm, P = .002). The mean ultimate load at failure was 57% higher in the augmented group compared to controls (744 ± 219 N vs postcyclic 473 ± 169 N, respectively [P = .015]). There was no difference in mode of failure between the control knees and those augmented with suture tape, with approximately half failing from pull off of the tendon from the bone plug and half with pull out of the bone plug from the tunnel. CONCLUSION Independent suture tape augmentation of a BTB ACL reconstruction grafts was associated with a 104% increase in graft stiffness and a 57% increase in load at failure compared to nonaugmented BTB grafts. CLINICAL RELEVANCE In vivo suture tape augmentation of a BTB ACL reconstruction increases graft construct strength and stiffness, which may reduce graft failure in the clinical setting.
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Affiliation(s)
- Matthew J Matava
- Washington University Department of Orthopedic Surgery, St. Louis, Missouri.
| | - Jonathan Koscso
- Washington University Department of Orthopedic Surgery, St. Louis, Missouri
| | - Lucia Melara
- Arthrex Department of Orthopedic Research, Naples, Florida, U.S.A
| | - Ljiljana Bogunovic
- Washington University Department of Orthopedic Surgery, St. Louis, Missouri
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Bowman EN, Freeman TH, Limpisvasti O, Cole BJ, ElAttrache NS. Anterior cruciate ligament reconstruction femoral tunnel drilling preference among orthopaedic surgeons. Knee 2021; 29:564-570. [PMID: 33774590 DOI: 10.1016/j.knee.2021.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/13/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) technique for femoral tunnel drilling varies substantially, each with advantages and disadvantages. The purpose of this study was to define ACLR femoral tunnel technique predilection among surgeons and to explore factors associated with their preference. METHODS An 11-question survey regarding ACLR femoral tunnel technique was completed by 560 AANA/AOSSM members. Surgeon and practice demographics and residency and fellowship experiences were evaluated with bivariate and multivariable models for association with surgeon preference. RESULTS In current practice, 55% of surgeons prefer anteromedial (AM) portal drilling, 32% retrograde, and 14% transtibial (TT). Sports Medicine fellowship experience was the strongest predictor of current practice (p < 0.001), followed by residency technique (p = 0.014). A significant increase in TT drilling was noted for those practicing >15 years TT (29% vs 3%, p < 0.001), with an inverse relationship for retrograde drilling (38% vs 21%, p < 0.001). Number of ACLRs/year and percent Sports specific practice were significant predictors for AM drilling (p < 0.001). Though less than AM and retrograde, TT was more common for those in private practice (17% vs 8%, p < 0.001), and more prevalent in the Midwest/Southeast (19% vs 10%, p = 0.003). Non-significant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and Certificate of Added Qualifications status. CONCLUSION Surgeon training, practice setting, and years in practice significantly predict preference for femoral tunnel drilling technique. Surgeon comfort and confidence in attaining an anatomic reconstruction should drive choice of technique.
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Affiliation(s)
- Eric N Bowman
- Department of Orthopaedics, Vanderbilt University Medical Center, 1215 21st Avenue South, 4200 Medical Center East, Nashville, TN 37232-8774, United States.
| | - Thomas H Freeman
- Department of Orthopaedics, Vanderbilt University Medical Center, 1215 21st Avenue South, 4200 Medical Center East, Nashville, TN 37232-8774, United States.
| | - Orr Limpisvasti
- Attending Orthopaedic Surgeon, Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA 90045, United States
| | - Brian J Cole
- Department of Orthopaedics, Rush University Medical Center, 1611 W Harrison, Suite 300, Chicago, IL 60612, United States.
| | - Neal S ElAttrache
- Attending Orthopaedic Surgeon, Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA 90045, United States.
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7
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No difference in revision rates between anteromedial portal and transtibial drilling of the femoral graft tunnel in primary anterior cruciate ligament reconstruction: early results from the New Zealand ACL Registry. Knee Surg Sports Traumatol Arthrosc 2020; 28:3631-3638. [PMID: 32239269 DOI: 10.1007/s00167-020-05959-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/23/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The use of an accessory anteromedial portal to drill the femoral graft tunnel in primary anterior cruciate ligament (ACL) reconstruction was introduced in the 2000s in an effort to achieve a more anatomic femoral tunnel position. However, some early studies reported an increase in revision ACL reconstruction compared to the traditional transtibial technique. The aim of this study was to analyse recent data recorded by the New Zealand ACL Registry to compare outcomes of ACL reconstruction performed using the anteromedial portal and transtibial techniques. METHODS Analysis was performed on primary isolated single-bundle ACL reconstructions recorded between 2014 and 2018 by the New Zealand ACL Registry. Patients were categorised into two groups according to whether an anteromedial portal or transtibial technique was used to drill the femoral graft tunnel. The primary outcome was revision ACL reconstruction and was compared between both groups through univariate and multivariate survival analyses. The secondary outcomes that were analysed included subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Marx activity score. RESULTS Six thousand one hundred and eighty-eight primary single-bundle ACL reconstructions were performed using either the anteromedial portal or transtibial drilling techniques. The mean time of follow-up was 23.3 (SD ± 14.0) months. Similar patient characteristics such as mean age (29 years, SD ± 11), sex (males = 58% versus 57%) and time to surgery (median 4 months, IQR 5) were observed between both groups. The rate of revision ACL reconstruction was 2.6% in the anteromedial portal group and 2.2% in the transtibial group (n.s.). The adjusted risk of revision ACL reconstruction was 1.07 (95% CI 0.62-1.84, n.s.). Patients in the anteromedial portal group reported improved scores for subscales of the KOOS and higher Marx activity scores at 1-year post-reconstruction. CONCLUSION There was no difference in the risk of revision ACL reconstruction between the two femoral tunnel drilling techniques at short-term follow-up. We observed minor differences in patient-reported outcomes at 1-year follow-up favouring the anteromedial portal technique, which may not be clinically relevant. Surgeons can achieve good clinical outcomes with either drilling technique. LEVEL OF EVIDENCE III.
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8
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Akaoka Y, Tensho K, Shimodaira H, Koyama S, Iwaasa T, Horiuchi H, Saito N. Aperture elongation of the femoral tunnel on the lateral cortex in anatomical double-bundle anterior cruciate ligament reconstruction using the outside-in technique. Medicine (Baltimore) 2020; 99:e22053. [PMID: 32957326 PMCID: PMC7505402 DOI: 10.1097/md.0000000000022053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In anatomical anterior cruciate ligament reconstruction surgery using the outside-in technique, the aperture of the femoral lateral cortex may become elliptical.Retrospective cross-sectional studyTo evaluate the extent of elliptical eccentricity in lateral apertures relative to aperture positioning and clinical failure rate in anatomical anterior cruciate ligament double-bundle reconstruction using outside-in technique.In 75 patients, the aperture elongation factor was defined as the ratio of the major axis of the elliptical aperture to the drill size. Using the lateral epicondyle as a reference point, the lateral femur was divided into sections by distance and angle, and the minimum area was evaluated to assess the relationship between the elongation factor and aperture position of the lateral cortex for each bundle. The incidence and associated clinical performance regarding cortical button migration were also investigated.Aperture elongation factors were 120.2 ± 13.3% and 120.0 ± 16.3% on the anteromedial (AM) and posterolateral (PL) sides, respectively. Femoral tunnel elongation was smallest when the entry point axis were both between 30 to 60° and distance was between 10 to 20 mm and 0 to 10 mm on the AM and PL sides, respectively. During the postoperative follow-up period, intra-tunnel migration was confirmed in 4 of 75 cases (5.3%). Fixation failure neither affected clinical scores nor knee laxity.Areas of minimum elongation for each bundle on both AM and PL sides were found anteroproximally to the lateral epicondyle and positioned near each other. Elongation did not directly affect the clinical outcome.Level of evidence grade: prognostic level III.
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Affiliation(s)
| | | | | | | | | | | | - Naoto Saito
- Institute for Biomedical Sciences, Interdisciplinary Cluster for Cutting Edge Research, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Rothrauff BB, Jorge A, de Sa D, Kay J, Fu FH, Musahl V. Anatomic ACL reconstruction reduces risk of post-traumatic osteoarthritis: a systematic review with minimum 10-year follow-up. Knee Surg Sports Traumatol Arthrosc 2020; 28:1072-1084. [PMID: 31471726 DOI: 10.1007/s00167-019-05665-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/05/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To systematically review the literature for radiographic prevalence of osteoarthritis (OA) at a minimum of 10 years following anterior cruciate ligament (ACL) reconstruction (ACLR) with anatomic vs. non-anatomic techniques. It was hypothesized that the incidence of OA at long-term follow-up would be lower following anatomic compared to non-anatomic ACLR. METHODS A systematic review was performed by searching PubMed, MEDLINE, EMBASE, and the Cochrane Library, for studies reporting OA prevalence by radiographic classification scales at a minimum of 10 years following ACLR with autograft. Studies were categorized as anatomic if they met or exceeded a score of 8 according the Anatomic ACL Reconstruction Scoring Checklist (AARSC), while those with a score less than 8 were categorized as non-anatomic/non-specified. Secondary outcomes included graft failure and measures of knee stability (KT-1000, Pivot Shift) and functional outcomes [Lysholm, Tegner, subjective and objective International Knee Documentation Committee (IKDC) scores]. OA prevalence on all radiographic scales was recorded and adapted to a normalized scale. RESULTS Twenty-six studies were included, of which 5 achieved a score of 8 on the AARSC. Using a normalized OA classification scale, 87 of 375 patients (23.2%) had diagnosed OA at a mean follow-up of 15.3 years after anatomic ACLR and 744 of 1696 patients (43.9%) had OA at mean follow-up of 15.9 years after non-anatomic/non-specified ACLR. The AARSC scores were 9.2 ± 1.3 for anatomic ACLR and 5.1 ± 1.1 for non-anatomic/non-specified ACLR. Secondary outcomes were relatively similar between techniques but inconsistently reported. CONCLUSIONS This study showed that anatomic ACLR, defined as an AARSC score ≥ 8, was associated with lower OA prevalence at long-term follow-up. Additional studies reporting long-term outcomes following anatomic ACLR are needed, as high-level studies of anatomic ACLR are lacking. The AARSC is a valuable resource in performing and evaluating anatomic ACLR. Anatomic ACLR, as defined by the AARSC, may reduce the long-term risk of post-traumatic OA following ACL injury to a greater extent than non-anatomic ACLR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Benjamin B Rothrauff
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Ahmed Jorge
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Darren de Sa
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA.
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Saito M, Nakajima A, Sonobe M, Takahashi H, Akatsu Y, Inaoka T, Iwasaki J, Morikawa T, Watanabe A, Aoki Y, Sasho T, Nakagawa K. Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique. Knee Surg Sports Traumatol Arthrosc 2019; 27:2468-2477. [PMID: 30374576 DOI: 10.1007/s00167-018-5240-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel. METHODS Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups. RESULTS There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004). CONCLUSION There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.
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Affiliation(s)
- Masahiko Saito
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan.
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Tsutomu Inaoka
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
| | - Junichi Iwasaki
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Tsuguo Morikawa
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba, 260-8670, Japan
| | - Koichi Nakagawa
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
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11
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Abstract
Background Traditional ACL reconstruction with non-anatomic techniques can demonstrate unsatisfactory long-term outcomes with regards instability and the degenerative knee changes observed with these results. Anatomic ACL reconstruction attempts to closely reproduce the patient's individual anatomic characteristics with the aim of restoring knee kinematics, in order to improve patient short and long-term outcomes. We designed an arthroscopic, patient-specific, ACL femoral tunnel guide to aid anatomical placement of the ACL graft within the femoral tunnel. Methods The guide design was based on MRI scan of the subject's uninjured contralateral knee, identifying the femoral footprint and its anatomical position relative to the borders of the femoral articular cartilage. Image processing software was used to create a 3D computer aided design which was subsequently exported to a 3D-printing service. Results Transparent acrylic based photopolymer, PA220 plastic and 316L stainless steel patient-specific ACL femoral tunnel guides were created; the models produced were accurate with no statistical difference in size and positioning of the center of the ACL femoral footprint guide to MRI (p=0.344, p=0.189, p=0.233 respectively). The guides aim to provide accurate marking of the starting point of the femoral tunnel in arthroscopic ACL reconstruction. Conclusion This study serves as a proof of concept for the accurate creation of 3D-printed patient-specific guides for the anatomical placement of the femoral tunnel during ACL reconstruction.
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Affiliation(s)
- Iain Rankin
- Aberdeen Royal Infirmary - Trauma and Orthopaedic Surgery, Foresterhill Aberdeen AB25 2ZN, United Kingdom of Great Britain and Northern Ireland
| | - Haroon Rehman
- Aberdeen Royal Infirmary - Trauma and Orthopaedic Surgery, Foresterhill Aberdeen AB25 2ZN, United Kingdom of Great Britain and Northern Ireland
| | - Mark Frame
- University Hospital Southampton NHS Foundation Trust Ringgold standard institution - Trauma and Orthopaedic Surgery Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
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Hiramatsu K, Mae T, Tachibana Y, Nakagawa S, Shino K. Contact area between femoral tunnel and interference screw in anatomic rectangular tunnel ACL reconstruction: a comparison of outside-in and trans-portal inside-out techniques. Knee Surg Sports Traumatol Arthrosc 2018; 26:519-525. [PMID: 29058021 DOI: 10.1007/s00167-017-4732-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/25/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE The purpose of this study was to compare the femoral tunnel length, the femoral graft bending angle at the femoral tunnel aperture, and the contact area between the femoral tunnel wall and an interference screw used for fixation in anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction (ART ACLR). METHODS The study included 149 patients with primary ACL injury who underwent ART ACLR. Preoperatively, flexion angle of the index knee was checked under general anaesthesia. Those of less than 130° of passive flexion were assigned to the outside-in (OI) technique (78 patients), while the others to the trans-portal inside-out (TP) technique (71 patients). The patients underwent computed tomography with multiplanar reconstruction at 3-5 weeks post-operatively. Femoral tunnel length, graft bending angle, and contact ratio between the IFS and femoral tunnel were assessed. P < 0.05 was considered statistically significant. RESULTS The femoral tunnel length in the OI technique was significantly longer than that in the TP technique (P < 0.001). The femoral graft bending angle in the OI technique was significantly more acute than that in the TP technique (P < 0.001). The contact ratio in the OI technique was significantly larger than that in the TP technique at every point in the femoral tunnel (P < 0.001). CONCLUSIONS The OI technique resulted in a more acute femoral graft bending angle, longer mean femoral tunnel length, and larger contact ratio than the TP technique after ART ACLR. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Kunihiko Hiramatsu
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yuta Tachibana
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Shigeto Nakagawa
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
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13
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Tashiro Y, Okazaki K, Murakami K, Matsubara H, Osaki K, Iwamoto Y, Nakashima Y. Anterolateral rotatory instability in vivo correlates tunnel position after anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft. World J Orthop 2017; 8:913-921. [PMID: 29312850 PMCID: PMC5745434 DOI: 10.5312/wjo.v8.i12.913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/23/2017] [Accepted: 10/29/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To quantitatively assess rotatory and anterior-posterior instability in vivo after anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BTB) autografts, and to clarify the influence of tunnel positions on the knee stability.
METHODS Single-bundle ACL reconstruction with BTB autograft was performed on 50 patients with a mean age of 28 years using the trans-tibial (TT) (n = 20) and trans-portal (TP) (n = 30) techniques. Femoral and tibial tunnel positions were identified from the high-resolution 3D-CT bone models two weeks after surgery. Anterolateral rotatory translation was examined using a Slocum anterolateral rotatory instability test in open magnetic resonance imaging (MRI) 1.0-1.5 years after surgery, by measuring anterior tibial translation at the medial and lateral compartments on its sagittal images. Anterior-posterior stability was evaluated with a Kneelax3 arthrometer.
RESULTS A total of 40 patients (80%) were finally followed up. Femoral tunnel positions were shallower (P < 0.01) and higher (P < 0.001), and tibial tunnel positions were more posterior (P < 0.05) in the TT group compared with the TP group. Anterolateral rotatory translations in reconstructed knees were significantly correlated with the shallow femoral tunnel positions (R = 0.42, P < 0.01), and the rotatory translations were greater in the TT group (3.2 ± 1.6 mm) than in the TP group (2.0 ± 1.8 mm) (P < 0.05). Side-to-side differences of Kneelax3 arthrometer were 1.5 ± 1.3 mm in the TT, and 1.7 ± 1.6 mm in the TP group (N.S.). Lysholm scores, KOOS subscales and re-injury rate showed no difference between the two groups.
CONCLUSION Anterolateral rotatory instability significantly correlated shallow femoral tunnel positions after ACL reconstruction using BTB autografts. Clinical outcomes, rotatory and anterior-posterior stability were overall satisfactory in both techniques, but the TT technique located femoral tunnels in shallower and higher positions, and tibial tunnels in more posterior positions than the TP technique, thus increased the anterolateral rotation. Anatomic ACL reconstruction with BTB autografts may restore knee function and stability.
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Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, United States
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka 812-8582, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka 812-8582, Japan
| | - Koji Murakami
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka 812-8582, Japan
| | - Hirokazu Matsubara
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka 812-8582, Japan
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka 812-8582, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka 812-8582, Japan
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Tashiro Y, Sundaram V, Thorhauer E, Gale T, Anderst W, Irrgang JJ, Fu FH, Tashman S. In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament-Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique. Arthroscopy 2017; 33:1393-1402. [PMID: 28343809 PMCID: PMC5495610 DOI: 10.1016/j.arthro.2017.01.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the in vivo dynamic graft bending angle (GBA) in anterior cruciate ligament (ACL)-reconstructed knees, correlate the angle to tunnel positions and tunnel widening, and evaluate the effects of 2 femoral tunnel drilling techniques on GBA. METHODS Patients with an isolated ACL injury undergoing reconstruction from 2011 to 2012 were included. Transportal techniques were used to create femoral tunnels. Tunnel locations were determined by 3-dimensional computed tomography. Tibiofemoral kinematics during treadmill walking and running were assessed by dynamic stereo x-ray analysis 6 months and 2 years postoperatively. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors on each motion frame. The cross-sectional areas of femoral tunnels were measured at 6 months and compared with the initial size to assess tunnel widening. RESULTS A total of 54 patients were included. Use of flexible drills resulted in significantly higher GBAs during walking (80.6° ± 7.8°, P < .001) and running (80.5° ± 9.0°, P = .025) than rigid drills (walking, 67.5° ± 9.3°; running, 74.1° ± 9.6°). Their use led to greater tunnel widening of 113.9% ± 17.6%, as compared with 97.7% ± 17.5% for rigid drills (P = .003). The femoral and tibial apertures were located in similar anatomic positions in both groups, but the femoral tunnel exits were located more anteriorly (P < .001) in the flexible drill group. A higher GBA was highly correlated with anterior location of femoral exits (r = 0.63, P < .001) and moderately correlated with greater tunnel widening (r = 0.48, P < .001). CONCLUSIONS High GBAs were identified during dynamic activities after anatomic ACL reconstruction with a transportal femoral tunnel drilling technique. The GBA was greater when flexible drills were used. The high bending angle resulted from the more anterior location of the femoral tunnel exits, and it correlated with early bone tunnel widening at 6 months. These results suggest that a high GBA may increase stress at the bone-graft interface and contribute to greater tunnel widening after anatomic ACL reconstruction, although the clinical impact should be further investigated. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ysutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Vani Sundaram
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Eric Thorhauer
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - James J. Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Freddie H. Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
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15
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Lee BH, Jangir R, Kim HY, Shin JM, Chang M, Kim K, Wang JH. Comparison of anterior cruciate ligament volume after anatomic double-bundle anterior cruciate ligament reconstruction. Knee 2017; 24:580-587. [PMID: 28408164 DOI: 10.1016/j.knee.2017.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 01/31/2017] [Accepted: 02/24/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUD To determine whether anatomic double-bundle anterior cruciate ligament reconstruction (DB-ACLR) can restore the native ACL volume, and whether the volume change after reconstruction affects clinical outcomes and re-rupture rates following the contemporary techniques. METHODS Eighty patients undergoing anatomic DB-ACLR using transportal or outside-in technique were prospectively evaluated with magnetic resonance imaging (MRI) before and after surgery. The ACL volumes were determined from 3-D models constructed by applying reverse engineering software. In all participants, measured reconstructed ACL volume were compared with the ACL on the opposite uninjured side. Participants were divided into two groups according to the volume of reconstructed graft; larger volume than native ACL of contra-lateral side (Group 1) or smaller (Group 2). RESULTS The mean ACL volume on the reconstructed side (1726.5mm3, 982.1 - 2733.8) was significantly smaller than that on the uninjured opposite side (1857.6mm3, 958.2 - 2871.5) (P<0.001). A total of 31 patients in Group 1 and 49 in Group 2 showed no significant difference of improvement in the clinical outcome scales at the postoperative two-year follow-up (Lysholm knee score, P=0.830, Tegner activity score, P=0.848). Four patients with ACL re-rupture during the two-year follow-up after reconstruction had smaller reconstructed ACL volumes than native ligament on the opposite site. CONCLUSION Anatomic DB-ACLR technique restored the graft volume rather smaller than the volume of the native ACL. Based on the volumetric consideration, graft reconstructed by anatomic DB-ACLR might have increased probability of re-rupture due to its smaller volume related to native ACL on the contralateral side.
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Affiliation(s)
- Byung Hoon Lee
- Department of Orthopedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Seoul, South Korea
| | - Rajat Jangir
- Department of Orthopedics, Mahatma Gandhi Medical College and Hospital, Sitapura, Jaipur, India
| | - Hun Yeong Kim
- Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Jung Min Shin
- Hanyang Medical Center, Hanyang University, Seoul, South Korea
| | - Minho Chang
- School of Mechanical Engineering, Korea University, Seoul, South Korea
| | - Kwon Kim
- Department of Orthopedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Seoul, South Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine; Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University; Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, South Korea.
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16
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Anatomic Femoral and Tibial Tunnel Placement During Anterior Cruciate Ligament Reconstruction: Anteromedial Portal All-Inside and Outside-In Techniques. Arthrosc Tech 2017; 6:e275-e282. [PMID: 28580242 PMCID: PMC5442353 DOI: 10.1016/j.eats.2016.09.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/26/2016] [Indexed: 02/03/2023] Open
Abstract
Tunnel malposition is one of the most common technical reasons for anterior cruciate ligament reconstruction failure. Small changes in tunnel placement can result in significant differences in outcome. More anatomic placement of the tunnels can lead to greater knee stability and a more accurate reproduction of native knee kinematics. This Technical Note describes 2 tibial tunnel-independent methods to obtain anatomic femoral tunnel placement. The all-inside anteromedial portal technique requires only minimal surgical incisions but allows precise femoral tunnel placement. However, hyperflexion of the knee is required, adequate surgical assistance is necessary, and this technique may be susceptible to graft-tunnel mismatch. The outside-in technique may be more beneficial in obese patients, skeletally immature patients, or revision cases. On the downside, it does require an additional 2-cm surgical incision. This article also provides surgical pearls to fine-tune tibial tunnel placement.
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17
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Tashiro Y, Irarrázaval S, Osaki K, Iwamoto Y, Fu FH. Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:129-137. [PMID: 27277192 DOI: 10.1007/s00167-016-4191-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/31/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine graft bending angle (GBA) during knee motion after anatomic anterior cruciate ligament (ACL) reconstruction and to clarify whether surgical techniques affect GBA. Our hypotheses were that the graft bending angle would be highest at knee extension and the difference of surgical techniques would affect the bending steepness. METHODS Eight healthy volunteers with a mean age of 29.3 ± 3.0 years were recruited and 3D MRI knee models were created at three flexion angles (0°, 90° and 130°). Surgical simulation of the tunnel drilling was performed with anatomic tunnel position using each outside-in (OI), trans-portal (TP) and trans-tibial (TT) techniques on the identical cases. The models were matched to other knee positions and the GBA in 3D was measured using computational software. Double-bundle ACL reconstruction was analysed first, and single-bundle reconstruction was also analysed to evaluate its effect to reduce GBA. A repeated-measures ANOVA was used to compare GBA difference at three flexion angles, by three techniques or of three bundles. RESULTS GBA changed substantially with knee motion, and it was highest at full extension (p < 0.001) in each surgical technique. OI technique exhibited highest GBA for anteromedial bundle (94.3° ± 5.2°) at extension, followed by TP (83.1° ± 6.5°) and TT (70.0° ± 5.2°) techniques (p < 0.01). GBA for posterolateral bundle at extension were also high in OI (84.6° ± 7.4°), TP (83.0° ± 6.3°) and TT (77.2° ± 7.0°) techniques (n.s.). Single-bundle grafts did not decrease GBA compared with double-bundle grafts. In OI technique, a more proximal location of the femoral exit reduced GBA of each bundle at extension and 90° flexion. CONCLUSION A significant GBA change with knee motion and considerably steep bending at full extension, especially with OI and TP techniques, were simulated. Although single-bundle technique did not reduce GBA as seen in double-bundle technique, proximal location of femoral exits by OI technique, with tunnels kept in anatomic position, was effective in decreasing GBA at knee extension and flexion. For clinical relevance, high stress on graft and bone interface has been suggested by steep GBA at full extension after anatomic ACL reconstruction. LEVEL OF EVIDENCE Therapeutic study (prospective comparative study), Level II.
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Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA. .,Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Sebastián Irarrázaval
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
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Matsubara H, Okazaki K, Osaki K, Tashiro Y, Mizu-Uchi H, Hamai S, Iwamoto Y. Optimal entry position on the lateral femoral surface for outside-in drilling technique to restore the anatomical footprint of anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2016; 24:2758-2766. [PMID: 25429767 DOI: 10.1007/s00167-014-3460-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 11/20/2014] [Indexed: 01/29/2023]
Abstract
PURPOSE To investigate the optimal starting points for drilling on the lateral femoral condyle for better coverage of the anatomical footprint of the anterior cruciate ligament (ACL) using the outside-in (OI) technique in a single-bundle ACL reconstruction. METHODS Femoral tunnel drilling was simulated on three-dimensional bone models from 40 subjects by connecting the centre of the ACL footprint with various points on the lateral femoral surface. The percentage of the femoral footprint covered by apertures of the virtual tunnel sockets with 9 mm diameter was calculated for each tunnel. RESULTS The mean percentages of the femoral footprint covered by the apertures of the virtual tunnel sockets were significantly higher when drilled at 2 and 3 cm from the lateral epicondyle on a 45° line and a 60° line anterior from the proximal-distal axis than the other points. However, articular cartilage damage was occurred in nine subjects at 3 cm on a 60° line and eight subjects at 3 cm on a 45° line. Posterior wall blowout occurred in five subjects at 3 cm on a 45° line. Thus, OI drilling at 3 cm from the epicondyle has a risk of these complications. CONCLUSION During the OI drilling of the femoral tunnel, connecting the centre of the anatomical footprint of the ACL and the entry drilling point at 2 cm from the lateral epicondyle on between the 45° line and the 60° line anterior from the proximal-distal axis provides an oval-shaped socket aperture that covers and restores the native ACL footprint as nearly as possible. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hirokazu Matsubara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-0054, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-0054, Japan.
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-0054, Japan
| | - Yasutaka Tashiro
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-0054, Japan
| | - Hideki Mizu-Uchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-0054, Japan
| | - Satoshi Hamai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-0054, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-0054, Japan
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19
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Salzler MJ, Harner CD. Tunnel Placement for the ACL During Reconstructive Surgery of the Knee: A Critical Analysis Review. JBJS Rev 2016; 2:01874474-201404000-00003. [PMID: 27490873 DOI: 10.2106/jbjs.rvw.m.00054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Matthew J Salzler
- UPMC Center for Sports Medicine, 3200 South Water Street, Pittsburgh, PA 15203
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20
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Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction? Clin Orthop Relat Res 2016; 474:1679-89. [PMID: 27106125 PMCID: PMC4887379 DOI: 10.1007/s11999-016-4847-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 04/13/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Considerable debate remains over which anterior cruciate ligament (ACL) reconstruction technique can best restore knee stability. Traditionally, femoral tunnel drilling has been done through a previously drilled tibial tunnel; however, potential nonanatomic tunnel placement can produce a vertical graft, which although it would restore sagittal stability, it would not control rotational stability. To address this, some suggest that the femoral tunnel be created independently of the tibial tunnel through the use of an anteromedial (AM) portal, but whether this results in a more anatomic footprint or in stability comparable to that of the intact contralateral knee still remains controversial. QUESTIONS/PURPOSES (1) Does the AM technique achieve footprints closer to anatomic than the transtibial (TT) technique? (2) Does the AM technique result in stability equivalent to that of the intact contralateral knee? (3) Are there differences in patient-reported outcomes between the two techniques? METHODS Twenty male patients who underwent a bone-patellar tendon-bone autograft were recruited for this study, 10 in the TT group and 10 in the AM group. Patients in each group were randomly selected from four surgeons at our institution with both groups demonstrating similar demographics. The type of procedure chosen for each patient was based on the preferred technique of the surgeon. Some surgeons exclusively used the TT technique, whereas other surgeons specifically used the AM technique. Surgeons had no input on which patients were chosen to participate in this study. Mean postoperative time was 13 ± 2.8 and 15 ± 3.2 months for the TT and AM groups, respectively. Patients were identified retrospectively as having either the TT or AM Technique from our institutional database. At followup, clinical outcome scores were gathered as well as the footprint placement and knee stability assessed. To assess the footprint placement and knee stability, three-dimensional surface models of the femur, tibia, and ACL were created from MRI scans. The femoral and tibial footprints of the ACL reconstruction as compared with the intact contralateral ACL were determined. In addition, the AP displacement and rotational displacement of the femur were determined. Lastly, as a secondary measurement of stability, KT-1000 measurements were obtained at the followup visit. An a priori sample size calculation indicated that with 2n = 20 patients, we could detect a difference of 1 mm with 80% power at p < 0.05. A Welch two-sample t-test (p < 0.05) was performed to determine differences in the footprint measurements, AP displacement, rotational displacement, and KT-1000 measurements between the TT and AM groups. We further used the confidence interval approach with 90% confidence intervals on the pairwise mean group differences using a Games-Howell post hoc test to assess equivalence between the TT and AM groups for the previously mentioned measures. RESULTS The AM and TT techniques were the same in terms of footprint except in the distal-proximal location of the femur. The TT for the femoral footprint (DP%D) was 9% ± 6%, whereas the AM was -1% ± 13% (p = 0.04). The TT technique resulted in a more proximal footprint and therefore a more vertical graft compared with intact ACL. The AP displacement and rotation between groups were the same and clinical outcomes did not demonstrate a difference. CONCLUSIONS Although the AM portal drilling may place the femoral footprint in a more anatomic position, clinical stability and outcomes may be similar as long as attempts are made at creating an anatomic position of the graft. LEVEL OF EVIDENCE Level III, therapeutic study.
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A systematic review of single- versus double-bundle ACL reconstruction using the anatomic anterior cruciate ligament reconstruction scoring checklist. Knee Surg Sports Traumatol Arthrosc 2016; 24:862-72. [PMID: 25344803 DOI: 10.1007/s00167-014-3393-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/15/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this systematic review was to apply the anatomic ACL reconstruction scoring checklist (AARSC) and to evaluate the degree to which clinical studies comparing single-bundle (SB) and double-bundle (DB) ACL reconstructions are anatomic. METHODS A systematic electronic search was performed using the databases PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to January 2014 comparing SB and DB ACL reconstructions with clinical outcome measurements were included. The items from the AARSC were recorded for both the SB and DB groups in each study. RESULTS Eight-thousand nine-hundred and ninety-four studies were analysed, 77 were included. Randomized clinical trials (29; 38%) and prospective comparative studies (29; 38%) were the most frequent study type. Most studies were published in 2011 (19; 25%). The most commonly reported items for both SB and DB groups were as follows: graft type (152; 99%), femoral and tibial fixation method (149; 97% respectively), knee flexion angle during graft tensioning (124; 8%) and placement of the tibial tunnel at the ACL insertion site (101; 66%). The highest level of documentation used for ACL tunnel position for both groups was often one dimensional, e.g. drawing, operative notes or o'clock reference. The DB reconstruction was in general more thoroughly reported. The means for the AARSC were 6.9 ± 2.8 for the SB group and 8.3 ± 2.8 for the DB group. Both means were below a proposed required minimum score of 10 for anatomic ACL reconstruction. CONCLUSIONS There was substantial underreporting of surgical data for both the SB and DB groups in clinical studies. This underreporting creates difficulties when analysing, comparing and pooling results of scientific studies on this subject.
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Pansard E, Klouche S, Vardi G, Greeff E, Hardy P, Ferguson M. How accurate are anatomic landmarks for femoral tunnel positioning in anterior cruciate ligament reconstruction? An in vivo imaging analysis comparing both anteromedial portal and outside-in techniques. Arthroscopy 2015; 31:882-9. [PMID: 25636986 DOI: 10.1016/j.arthro.2014.11.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/07/2014] [Accepted: 11/21/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the ability of 2 independent surgical techniques, an inside-out technique and an outside-in technique, using bony landmarks on the femoral wall, to place the anterior cruciate ligament graft anatomically. METHODS A retrospective single-center study was conducted in 2012 and included patients who underwent anterior cruciate ligament reconstruction. Two techniques were used: The lateral condylar wall was visualized from the anterolateral portal and tunnels were drilled "outside-in" in one group, whereas viewing was performed from the anteromedial portal and retrograde drilling ("inside-out") was performed in the other group. The primary outcome measure was the placement of the tunnel center point on postoperative computed tomography scans with 3-dimensional reconstruction, according to the radiographic quadrant method of Bernard and Hertel. The measurements were compared with optimal placements according to Bird et al. Their reliability was assessed with Spearman (rho) and intraclass correlation coefficients. RESULTS Forty patients were included, with 20 in each group; the mean age was 29.8 ± 9.6 years, and there were 33 men and 7 women. The interobserver reliability and intraobserver reliability of measurements were good, with a Spearman ρ between 0.46 (P = .002) and 0.93 (P < .001) and an intraclass correlation coefficient between 0.44 (P = .001) and 0.86 (P < .001). The femoral tunnel positions of both techniques were close to the previously published anatomic placements, but there was a significant difference between our results and the theoretical position in proximal-distal measurements (P = .01). There was no difference in the anteroposterior measurements. There was no statistical difference in the accuracy of placement of the femoral tunnel center point between these 2 independent techniques. CONCLUSIONS The direct arthroscopic visualization of bony landmarks seems sufficient for accurate positioning of the femoral tunnel whatever the drilling technique. This finding is clinically relevant because the routine use of direct measurement techniques or intraoperative radiographs may not be necessary to obtain anatomic tunnel placement. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Erwan Pansard
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa; Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France; Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France.
| | - Shahnaz Klouche
- Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France; Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France
| | - Glen Vardi
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa
| | - Eugene Greeff
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa
| | - Philippe Hardy
- Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France; Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France
| | - Mark Ferguson
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa
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Lee BH, Bansal S, Park SH, Wang JH. Eccentric graft positioning within the femoral tunnel aperture in anatomic double-bundle anterior cruciate ligament reconstruction using the transportal and outside-in techniques. Am J Sports Med 2015; 43:1180-8. [PMID: 25670836 DOI: 10.1177/0363546514568278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ellipticity of the femoral tunnel aperture, which is considered to better restore the native anterior cruciate ligament (ACL) footprint after ACL reconstruction, is different according to the femoral tunneling technique used. How much of the femoral tunnel aperture is filled with graft in different tunneling techniques has yet to be evaluated. PURPOSE The aim of this study was to evaluate and compare the graft filling area and graft position within the femoral tunnel aperture in ACL reconstruction using the transportal (TP) and outside-in (OI) techniques. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 70 patients were randomized to undergo double-bundle ACL reconstruction using either the TP (n=35) or OI (n=35) technique. The aperture filling was evaluated by calculating the ratio of the cross-sectional area of the graft to that of the femoral tunnel, and the graft center position within the tunnel was assessed using immediate postoperative magnetic resonance imaging. RESULTS The cross-sectional area of the femoral anteromedial (AM) tunnel aperture in the TP group (605.5±112.7 mm2) was larger than that in the OI group (537.9±126.8 mm2). The cross-sectional area of the femoral posterolateral (PL) tunnel aperture in the TP group (369.9±88.3 mm2) did not differ significantly from that of the OI group (387.9±87.0 mm2). The grafts filled only 52.0% of the AM tunnel and 55.3% of the PL tunnel in the TP group, compared with 54.9% of the AM tunnel and 54.4% of the PL tunnel in the OI group, but there was no statistically significant difference (P>.05). The AM graft center was positioned 1.7±0.6 mm from the center of the tunnel aperture in the TP group and 1.6±0.5 mm in the OI group, and the PL graft center was positioned 1.4±0.4 mm from the center in the TP group and 1.3±0.4 mm in the OI group, with no significant intergroup differences (P=.406 and P=.629, respectively). In the OI group, the PL graft center was positioned more perpendicular to the Blumensaat line in relation to the tunnel aperture center (-10.8°±7.6°) compared with the TP group (-4.0°±11.8°) (P=.04). CONCLUSION The grafts did not fill the tunnel aperture area in either group, and the centers of the grafts differed slightly from the centers of the tunnel apertures. The finding of eccentric graft positioning in the tunnel with condensation in a particular direction in each technique might suggest the necessity of an underreamed femoral tunnel for graft. In addition, it may be useful to standardize the starting position of the femoral tunnel according to anatomic landmarks.
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Affiliation(s)
- Byung Hoon Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Samarjit Bansal
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sin Hyung Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abdelkafy A. Anatomic single-bundle anterior cruciate ligament reconstruction using the outside-in femoral tunnel drilling technique: a prospective study and short- to mid-term results. Arch Orthop Trauma Surg 2015; 135:383-92. [PMID: 25631248 DOI: 10.1007/s00402-015-2160-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Anatomic positioning of the femoral and tibial tunnels in the native ACL femoral and tibial footprints requires an independent drilling either via an accessory medial portal (trans-portal drilling) or using an outside-in drilling technique. Conventional trans-tibial drilling (dependant drilling) was found to lack the ability to accurately position the femoral tunnel in the native ACL footprint. The purpose of the current study was to evaluate the functional outcome results of anatomic single-bundle ACLR using the OI femoral tunnel drilling technique. MATERIALS AND METHODS Single surgeon single center prospective case series study. 64 patients having complete ACL tears were included in the current study. Average follow-up was 15.8 months (range 8-25). Objective and subjective IKDC scores, Lysholm knee score, SF-36 score, VAS for patients' satisfaction, VAS for pain and Kellgren and Lawrence (K/L) classification of osteoarthritis were used for follow-up evaluation. RESULTS Objective IKDC score revealed that 60 patients had grade ''A'' and 4 had grade ''B'', while no single patient had neither grade ''C'' nor ''D''. The average Lysholm Score was 92.4, average subjective IKDC was 91.5. Average SF-36 score was 96.7. The average VAS for operation satisfaction was 9.7. Average VAS for pain was 0.3. Forty-nine patients were classified as normal K/L classification, 7 were grade ''1'', 8 were grade ''2''. Comparing pre-operative and follow-up Objective IKDC, Subjective IKDC, Lysholm, SF-36 and VAS for pain scores revealed statistically significant differences (P value <0.05). CONCLUSION Arthroscopic-assisted ACL reconstruction using the outside-in femoral tunnel drilling technique shows a good and satisfactory functional outcome results at short- to mid-term follow-up. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ashraf Abdelkafy
- Orthopaedic Surgery and Traumatology Department, Faculty of Medicine, Suez Canal University, Circular Road, Ismailia, 41522, Egypt,
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Keller TC, Tompkins M, Economopoulos K, Milewski MD, Gaskin C, Brockmeier S, Hart J, Miller MD. Tibial tunnel placement accuracy during anterior cruciate ligament reconstruction: independent femoral versus transtibial femoral tunnel drilling techniques. Arthroscopy 2014; 30:1116-23. [PMID: 24907026 DOI: 10.1016/j.arthro.2014.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 04/04/2014] [Accepted: 04/04/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to compare the accuracy of tibial tunnel placement using independent femoral (IF) versus transtibial (TT) techniques. METHODS Ten matched pairs of cadaveric knees were randomized so that one knee in the pair underwent arthroscopic TT drilling of the femoral tunnel and the other underwent IF drilling through an accessory medial portal. For both techniques, an attempt was made to place the femoral and tibial tunnels as close to the center of the respective anterior cruciate ligament (ACL) footprints as possible. Preoperative and postoperative computed tomography using a technique optimized for ligament evaluation allowed comparison of the anatomic ACL tibial footprint to the tibial tunnel aperture. The percentage of tunnel aperture contained within the native footprint, as well as the distance from the center of the tunnel aperture to the center of the footprint, was measured. Additionally, graft obliquity relative to the tibial plateau was evaluated in the sagittal plane. RESULTS The percentage of tibial tunnel aperture contained within the native footprint averaged 71.6% ± 17.2% versus 52.1% ± 23.4% (P = .04) in the IF and TT groups, respectively. The distance from the center of the footprint to the center of the tibial tunnel aperture was 3.50 ± 1.6 mm and 4.40 ± 1.7 mm (P = .27) in the IF and TT groups, respectively. TT drilling placed 6 of 10 tunnels posterior to the center of the footprint versus 3 of 10 tunnels in IF drilling. The graft obliquity angles were 54.8° in TT specimens and 47.5° in IF specimens (P = .09). CONCLUSIONS This study adds to the literature suggesting that TT drilling with an 8-mm reamer has deleterious effects on tibial tunnel aperture and position. IF drilling, which does not involve repeated reaming of the tibial tunnel, is associated with the placement of a higher percentage of the tunnel aperture within the native tibial footprint. There was not a significant difference between the IF and TT techniques in their ability to place the center of the tibial aperture near the center of the footprint or in graft obliquity. CLINICAL RELEVANCE ACL reconstruction has continued to evolve in an attempt to restore the functional anatomy and biomechanical behavior of the knee. Tibial tunnel characteristics-such as location, aperture topography, and tunnel obliquity-are important factors to consider in ACL reconstruction. This study compares tibial tunnels after IF and TT techniques.
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Affiliation(s)
- Thomas C Keller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Marc Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | | | | | - Cree Gaskin
- Department of Musculoskeletal Radiology, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Stephen Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Joseph Hart
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Anatomic single-bundle ACL surgery: consequences of tibial tunnel diameter and drill-guide angle on tibial footprint coverage. Knee Surg Sports Traumatol Arthrosc 2014; 22:1030-9. [PMID: 23370987 DOI: 10.1007/s00167-013-2416-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 01/17/2013] [Indexed: 01/15/2023]
Abstract
PURPOSE To investigate the consequences of differences in drill-guide angle and tibial tunnel diameter on the amount of tibial anatomical anterior cruciate ligament (ACL) footprint coverage and the risk of overhang of the tibial tunnel aperture over the edges of the native tibial ACL footprint. METHODS Twenty fresh-frozen adult human knee specimens with a median age of 46 years were used for this study. Digital templates mimicking the ellipsoid aperture of tibial tunnels with a different drill-guide angle and a different diameter were designed. The centres of these templates were positioned over the geometric centre of the tibial ACL footprint. The amount of tibial ACL footprint coverage and overhang was calculated. Risk factors for overhang were determined. Footprint coverage and the risk of overhang were also compared between a lateral tibial tunnel and a classic antero-medial tibial tunnel. RESULTS A larger tibial tunnel diameter and a smaller drill-guide angle both will create significant more footprint coverage and overhang. In 45% of the knees, an overhang was created with a 10-mm diameter tibial tunnel with drill-guide angle 45°. Furthermore, a lateral tibial tunnel was found not to be at increased risk of overhang. CONCLUSION A larger tibial tunnel diameter and a smaller drill-guide angle both will increase the amount of footprint coverage. Inversely, larger tibial tunnel diameters and smaller drill-guide angles will increase the risk of overhang of the tibial tunnel aperture over the edges of the native tibial ACL footprint. A lateral tibial tunnel does not increase the risk of overhang.
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Tashiro Y, Okazaki K, Uemura M, Toyoda K, Osaki K, Matsubara H, Hashizume M, Iwamoto Y. Comparison of transtibial and transportal techniques in drilling femoral tunnels during anterior cruciate ligament reconstruction using 3D-CAD models. Open Access J Sports Med 2014; 5:65-72. [PMID: 24744615 PMCID: PMC3983023 DOI: 10.2147/oajsm.s59297] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose The purpose of this study was to assess the differences in bone tunnel apertures between the trans-accessory medial portal (trans-AMP) technique and the transtibial (TT) technique in double-bundle anterior cruciate ligament reconstruction. The extent of ovalization and the frequency of overlap of the two tunnel apertures were compared. Methods The simulation of femoral tunnel drilling with the TT and the trans-AMP techniques was performed using three-dimensional computer aided design models from two volunteers. The incidence angle of drilling against the intercondylar wall, the femoral tunnel position, the ovalization, and the overlap were analyzed. The aperture and location of the tunnels were also examined in real anterior cruciate ligament reconstruction cases (n=36). Results The surgical simulation showed that a lower drill incident angle induced by the TT technique made the apertures of two tunnels more ovalized, located anteromedial tunnels in a shallower position to prevent posterior wall blow out, and led to a higher frequency of tunnel overlap. The trans-AMP group had tunnel places within the footprint and had less ovalization and overlap. The results of analysis for tunnels in the clinical cases were consistent with results from the surgical simulation. Conclusion In the TT technique, the shallow anteromedial tunnel location and more ovalized tunnel aperture can lead to a higher frequency of tunnel overlap. Compared with the TT technique, the trans-AMP technique was more useful in preparing femoral tunnels anatomically and avoiding tunnel ovalization and overlapping in double-bundle anterior cruciate ligament reconstruction.
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Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Munenori Uemura
- Department of Advanced Medical Initiatives, Kyushu University Hospital, Fukuoka, Japan
| | - Kazutaka Toyoda
- Department of Advanced Medical Initiatives, Kyushu University Hospital, Fukuoka, Japan
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Hirokazu Matsubara
- Department of Orthopaedic Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Makoto Hashizume
- Department of Advanced Medical Initiatives, Kyushu University Hospital, Fukuoka, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Kyushu University Hospital, Fukuoka, Japan
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Trentacosta N, Fillar AL, Liefeld CP, Hossack MD, Levy IM. Avoiding Complications and Technical Variability During Arthroscopically Assisted Transtibial ACL Reconstructions by Using a C-Arm With Image Intensifier. Orthop J Sports Med 2014; 2:2325967114530075. [PMID: 26535320 PMCID: PMC4555598 DOI: 10.1177/2325967114530075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Surgical reconstruction of the anterior cruciate ligament (ACL) can be complicated by incorrect and variable tunnel placement, graft tunnel mismatch, cortical breaches, and inadequate fixation due to screw divergence. This is the first report describing the use of a C-arm with image intensifier employed for the sole purpose of eliminating those complications during transtibial ACL reconstruction. PURPOSE To determine if the use of a C-arm with image intensifier during arthroscopically assisted transtibial ACL reconstruction (IIAA-TACLR) eliminated common complications associated with bone-patellar tendon-bone ACL reconstruction, including screw divergence, cortical breaches, graft-tunnel mismatch, and improper positioning of the femoral and tibial tunnels. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 110 consecutive patients (112 reconstructed knees) underwent identical IIAA-TACLR using a bone-patellar tendon-bone autograft performed by a single surgeon. Intra- and postoperative radiographic images and operative reports were evaluated for each patient looking for evidence of cortical breeching and screw divergence. Precision of femoral tunnel placement was evaluated using a sector map modified from Bernard et al. Graft recession distance and tibial α angles were recorded. RESULTS There were no femoral or tibial cortical breaches noted intraoperatively or on postoperative images. There were no instances of loss of fixation screw major thread engagement. There were no instances of graft-tunnel mismatch. The positions of the femoral tunnels were accurate and precise, falling into the desired sector of our location map (sector 1). Tibial α angles and graft recession distances varied widely. CONCLUSION The use of the C-arm with image intensifier enabled accurate and precise tunnel placement and completely eliminated cortical breach, graft-tunnel mismatch, and screw divergence during IIAA-TACLR by allowing incremental adjustment of the tibial tunnel and knee flexion angle. Incremental adjustment was essential to accomplish this. Importantly, a C-arm with image intensifier can be used with any ACL reconstruction that incorporates tunnels in the technique, with the expectation of increase in accuracy and precision and the elimination of common complications. CLINICAL RELEVANCE The use of an image intensifier during transtibial ACL reconstruction will substantially reduce the common complications associated with the procedure and improve both accuracy and precision of tibial and femoral tunnel placement. Use of an image intensifier unit is generalizable to an individual surgeon's preferences for graft choices and drilling techniques and will be especially valuable when the intercondylar architecture is altered from injury, time, or prior surgery.
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Affiliation(s)
- Natasha Trentacosta
- Department of Orthopaedics, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Allison Liefeld Fillar
- Department of Orthopaedics, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Cynthia Pierce Liefeld
- Department of Orthopaedics, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Michael D. Hossack
- Department of Orthopaedics, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - I. Martin Levy
- Department of Orthopaedics, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
- I. Martin Levy, MD, Department of Orthopaedics, Montefiore Medical Center/Albert Einstein College of Medicine, 1250 Waters Place, Floor 11, New York, NY 10461, USA (e-mail: )
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Knight JR, Condie D, Querry R, Robertson WJ. The use of a mono-fluted reamer results in decreased enlargement of the tibial tunnel when using a transtibial ACL reconstruction technique. Knee Surg Sports Traumatol Arthrosc 2014; 22:357-62. [PMID: 23471528 DOI: 10.1007/s00167-013-2455-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 02/20/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate whether femoral tunnel preparation using a mono-fluted reamer rather than an acorn reamer would result in less tibial tunnel deformation when using a transtibial technique for anterior cruciate ligament reconstruction. METHODS Tibial and femoral tunnel preparation was performed in four matched pairs of cadaveric knees. The tibial tunnel was drilled using a standard acorn reamer. The femoral tunnel was prepared using a transtibial technique with a mono-fluted reamer, and then, the same femoral tunnel was re-reamed using an acorn reamer. The anterior-posterior (AP) and medial-lateral (ML) dimensions of the tibial tunnel were recorded after each reamer. We then compared the measurements following the use of each reamer using a paired two-sample t test. RESULTS There was a significantly larger degree of tibial tunnel deformation following femoral tunnel preparation with the acorn reamer when compared with the mono-fluted reamer. The initial tibial tunnel measured 10.5 and 10.1 mm in the AP and ML dimensions, respectively. The resultant AP diameter of the tibial tunnel after femoral reaming was 16.7 mm (p < 0.001) for the acorn reamer compared with 11.6 mm (p < 0.001) for the mono-fluted reamer. The ML diameters were 11.3 mm (p = 0.003) versus 10.2 mm (p = 0.07) for the acorn and mono-fluted reamer, respectively. CONCLUSION The use of a mono-fluted reamer for femoral tunnel preparation results in less tibial tunnel deformation during transtibial reaming.
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Affiliation(s)
- Justin R Knight
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX, 75390-8883, USA,
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The influence of femoral tunnel position in single-bundle ACL reconstruction on functional outcomes and return to sports. Knee Surg Sports Traumatol Arthrosc 2014; 22:97-103. [PMID: 23132410 DOI: 10.1007/s00167-012-2288-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 10/26/2012] [Indexed: 12/28/2022]
Abstract
PURPOSE The purpose of this study was to radiographically investigate the influence of femoral tunnel placement in ACL reconstruction on early outcomes and return to sports due to anatomic and nonanatomic positioning. METHODS A prospective study was conducted from 2008 to 2010, with 86 athletes who underwent ACL reconstruction between anteromedial (AM) footprint and high AM position. Knee functional outcomes (IKDC objective and subjective, Tegner score, and Lysholm scale) return to sports and complications were analyzed at 6- and 12-month follow-up. RESULTS At follow-up, it was observed that tunnel projection along Blumensaat's line was correlated with functional outcomes on Tegner scale (at 6 and 12 months) and IKDC subjective (at 12 months). There was a significant difference in mean tunnel projection along Blumensaat's line when analyzing return to sports (73 ± 1.4 and 79 ± 1.7 %, respectively, for projections on return vs. no return to sports, p = 0.02) and complications (73 ± 1.3 vs. 78 ± 1.6 %, respectively, for projections on no complications vs. complications, p = 0.03). No differences were stated on coronal view. These correlations between tunnel positioning on functional outcomes could not be explained by demographic or baseline characteristics. CONCLUSION The clinical relevance of this study is that tunnel positioning along AM footprint and high AM position represented by tunnel projection along Blumensaat's line is associated with early return to sports on previous Tegner level and better functional outcome in athletes.
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Nakayama H, Yamaguchi M, Yoshiya S. Comparison of transportal inside-out and outside-in femoral drilling techniques in anatomic ACL reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol 2014. [DOI: 10.1016/j.asmart.2013.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Ahldén M, Sernert N, Karlsson J, Kartus J. A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction. Am J Sports Med 2013; 41:2484-91. [PMID: 23921339 DOI: 10.1177/0363546513497926] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of the study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using either the double-bundle or single-bundle technique with hamstring tendon autografts in an unselected group of patients. HYPOTHESIS Double-bundle ACL reconstruction will render a better outcome on the pivot-shift test. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A randomized series of 103 patients (33 women, 70 men; median age, 27 years; range, 18-52 years) with a unilateral ACL rupture underwent anatomic ACL reconstruction. The double-bundle technique was used in 53 patients, and the single-bundle technique was used in 50 patients. The ACL footprint was visualized, and the femoral tunnel was drilled through the anteromedial portal; interference screw fixation was used at both ends. The patients were examined preoperatively and at a median of 26 months (range, 22-42 months) after the reconstruction by a blinded observer. The primary variable was the pivot-shift test. RESULTS At 2-year follow-up, 98 patients (93%) were examined. Clinical assessments at follow-up revealed no significant differences between the double-bundle and single-bundle groups in terms of the pivot-shift test, KT-1000 arthrometer laxity measurements, manual Lachman test, range of motion, Lysholm knee scoring scale, Tegner activity scale, Knee Injury and Osteoarthritis and Outcome Score (KOOS), 1-legged hop test, and square hop test. A significant improvement was seen in both groups compared with the preoperative values in terms of most clinical assessments. CONCLUSION In this prospective randomized study, the primary variable, the pivot-shift test, and other subjective and objective outcome variables revealed no significant differences between the double-bundle and single-bundle techniques at 2 years after ACL reconstruction in an unselected group of patients.
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Affiliation(s)
- Mattias Ahldén
- Mattias Ahldén, Department of Orthopaedics, Sahlgrenska University Hospital/Mölndal, SE-431 80, Mölndal, Sweden.
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Kim JG, Chang MH, Lim HC, Bae JH, Ahn JH, Wang JH. Computed tomography analysis of the femoral tunnel position and aperture shape of transportal and outside-in ACL reconstruction: do different anatomic reconstruction techniques create similar femoral tunnels? Am J Sports Med 2013; 41:2512-20. [PMID: 23982402 DOI: 10.1177/0363546513500626] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The desire to perform independent femoral drilling in anterior cruciate ligament (ACL) reconstruction has prompted interest in both the transportal (TP) and outside-in (OI) techniques. However, there have been no in vivo studies on the differences in femoral aperture shape between the 2 techniques. PURPOSE To evaluate the femoral tunnel aperture shape and femoral tunnel position between ACL reconstruction using the TP and OI techniques. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 80 patients were randomized to undergo double-bundle ACL reconstruction using either the TP (n = 40) or OI (n = 40) technique. The femoral tunnel aperture shape (height/width ratio), aperture axis angle (angle between the aperture axis and femoral shaft axis), and femoral tunnel position were assessed by computed tomography. RESULTS The mean height/width ratio of the anteromedial (AM) femoral tunnels in the TP group (1.35 ± 0.16) was significantly more ellipsoidal than that in the OI group (1.22 ± 0.16) (P = .008). There was no difference between the 2 groups in the posterolateral (PL) tunnels (TP, 1.32 ± 0.23; OI, 1.35 ± 0.29; P = .99). The mean aperture axis angle of the PL femoral tunnels in the OI group was significantly more perpendicular to the femoral shaft axis and had a more variable range than that in the TP group (P = .007). The mean PL femoral tunnel position in the OI group was significantly shallower and a little higher than that in the TP group (P = .006). CONCLUSION The TP technique revealed a more ellipsoidal AM femoral tunnel aperture than the OI technique. The mean PL femoral tunnel position in the OI group was significantly shallower than that in the TP group, with a more variable and more perpendicular aperture axis angle to the femoral shaft axis. CLINICAL RELEVANCE The TP technique might be more advantageous than the OI technique in terms of graft coverage, with a more ellipsoidal AM femoral tunnel and more horizontal and consistent PL aperture axis angle. In addition, it may be useful to consider the shallower PL femoral tunnel positions created with the OI technique.
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Affiliation(s)
- Jae Gyoon Kim
- Joon Ho Wang, Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-dong #50, Kangnam-gu, Seoul, 135-710, Korea.
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van Eck CF, Gravare-Silbernagel K, Samuelsson K, Musahl V, van Dijk CN, Karlsson J, Irrgang JJ, Fu FH. Evidence to support the interpretation and use of the Anatomic Anterior Cruciate Ligament Reconstruction Checklist. J Bone Joint Surg Am 2013; 95:e153. [PMID: 24132368 DOI: 10.2106/jbjs.l.01437] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Published papers on anatomic anterior cruciate ligament (ACL) reconstruction often lack details in the description of the surgical procedure, and there are large variations in anatomic ACL reconstruction techniques. We aimed to develop a validated checklist to be used for anatomic ACL reconstruction. First, a list of all potential items that could be used in the checklist was generated. Thirty-four ACL experts were selected to participate in an anonymous online survey to rate the importance of these items on a scale of 1 to 4 (with a score of 4 having the most importance). The results were verified by surveying a large sample of 959 orthopaedic specialists who are peer reviewers for four major orthopaedic journals. Items were included in the final checklist if they received an importance score of 3 or 4 from at least 75% of the survey takers. The survey response rate was 79% (twenty-seven of thirty-four) of the ACL experts and 40% (379 of 959) of the peer reviewers. The final Anatomic ACL Reconstruction Checklist includes seventeen items with a maximum score of 19 points. The final checklist underwent preliminary testing for internal consistency, intertester reliability, and validity. Cronbach's alpha for internal consistency was 0.82, and the intraclass correlation coefficient (ICC) for intertester reliability was 0.65. This large survey-based study on anatomic ACL reconstruction resulted in the development of the Anatomic ACL Reconstruction Checklist; preliminary evidence for interpretation of the scores is provided.
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Affiliation(s)
- Carola F van Eck
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh PA 15213. E-mail address for F.H. Fu:
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Robert HE, Bouguennec N, Vogeli D, Berton E, Bowen M. Coverage of the anterior cruciate ligament femoral footprint using 3 different approaches in single-bundle reconstruction: a cadaveric study analyzed by 3-dimensional computed tomography. Am J Sports Med 2013; 41:2375-83. [PMID: 23940205 DOI: 10.1177/0363546513498989] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Performing a single-bundle anterior cruciate ligament (ACL) reconstruction within the femoral footprint is important to obtain a functional graft and a stable knee. HYPOTHESIS There will be a significant difference in the ability of 3 ACL reconstruction techniques to reach and cover the native femoral footprint. STUDY DESIGN Controlled laboratory study. METHODS The percentage of the ACL footprint covered by the femoral tunnel was compared after 3 different techniques to target the footprint: transtibial (TT), inside-out/anteromedial (IO), and outside-in/transfemoral (OI). Fourteen cadaveric knee specimens with a mean age of 67.5 years were used. For each knee, the TT technique utilized a 7.5-mm offset guide, the IO technique was performed through an accessory anteromedial portal, and the OI technique was carried out through the femur from the external wall of the lateral condyle. Entry points in the footprint were spotted with markers, and orientations (sagittal and frontal) of each drill guide were noted. The distal femurs were sawed and scanned, and 3-dimensional image reconstructions were analyzed. The virtual drilled area (reamer diameter, 8 mm) depending on the entry point and the sagittal/frontal orientation of the drill guide was calculated and reported for each of the 3 techniques. The distance from the tunnel center to the ACL center, percentage of the femoral tunnel within the ACL footprint, and percentage of the ACL footprint covered by the tunnel were calculated and statistically compared (analysis of variance and t test). RESULTS The average distance to the native femoral footprint center was 6.8 ± 2.68 mm for the TT, 2.84 ± 1.26 mm for the IO, and 2.56 ± 1.39 mm for the OI techniques. Average percentages of the femoral tunnel within the ACL footprint were 32%, 76%, and 78%, and average percentages of the ACL footprint covered by the tunnel were 35%, 54%, and 47%, for the TT, IO, and OI techniques, respectively. No significant difference was observed between the IO and OI techniques (P = .11). The TT approach gave less satisfactory coverage on all testing criteria. CONCLUSION The IO and OI techniques allowed for creation of a tunnel closest to the ACL femoral footprint center. Despite this fact and even if the average percentage of the drilled area included in the femoral footprint was close to 80% for these 2 techniques, the average percentage of the ACL footprint covered by the tunnels was <55% for all 3 techniques. Coverage of the ACL footprint depended on the entry point, orientation, and diameter of the drilling but also on the size of the footprint. CLINICAL RELEVANCE To improve the coverage of the native femoral footprint with a single-bundle graft, in addition to the entry point it may also be necessary to consider the orientation of the drilling to increase the dimensions of the area while respecting the anatomic constraints of the femoral bone and graft geometry.
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Affiliation(s)
- Henri E Robert
- Henri E. Robert, Orthopedic Department, North Mayenne Hospital, 229 Bd Paul Lintier, 53100 Mayenne, France.
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Yau WP, Fok AWM, Yee DKH. Tunnel positions in transportal versus transtibial anterior cruciate ligament reconstruction: a case-control magnetic resonance imaging study. Arthroscopy 2013; 29:1047-52. [PMID: 23591379 DOI: 10.1016/j.arthro.2013.02.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 02/09/2013] [Accepted: 02/12/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to examine the difference in the position of bone tunnels prepared by the transportal technique versus the transtibial technique in anterior cruciate ligament (ACL) reconstruction. METHODS A consecutive series of 42 patients receiving single-bundle ACL reconstructions were recruited between July 1, 2007, and December 31, 2008. The preparations of the femoral tunnel were performed by the transtibial technique in the first 21 cases and by the transportal technique in the subsequent 21 cases. Magnetic resonance imaging examination was performed in 39 patients (93%) 1 year after the index operation (20 transtibial and 19 transportal). Optimal tunnel position was defined as a lateralized femoral tunnel at a position of less than 11 o'clock for a right knee or more than 1 o'clock for a left knee, an adequate posteriorized femoral tunnel in the fourth quadrant of the modified Bernard line, and a tibial tunnel located in the second quadrant of the modified Amis line. RESULTS The average clock position was 10:18 in the transportal group and 10:54 in the transtibial group (P < .001). Five outliers were found in the transtibial group but none in the transportal group. Concerning the femoral tunnel position on the sagittal-cut magnetic resonance imaging scan, the average position along the modified Bernard line was 74% in the transportal group and 69% in the transtibial group (P = .029). Concerning the tibial tunnel position, the average tibial tunnel positions along the modified Amis line were 47% and 52%, respectively (P = .019). CONCLUSIONS The adoption of the transportal technique in single-bundle ACL reconstruction produced improved positions in both the femoral and tibial tunnels when compared with the transtibial technique. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- W P Yau
- Division of Sports and Arthroscopic Surgery, Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
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Lubowitz JH, Akhavan S, Waterman BR, Aalami-Harandi A, Konicek J. Technique for creating the anterior cruciate ligament femoral socket: optimizing femoral footprint anatomic restoration using outside-in drilling. Arthroscopy 2013; 29:522-8. [PMID: 23332371 DOI: 10.1016/j.arthro.2012.10.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 09/02/2012] [Accepted: 10/07/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate and optimize anterior cruciate ligament (ACL) femoral outside-in drilling technique with a goal of anatomic restoration of the footprint morphologic length, width, area, and angular orientation. METHODS Ex vivo, computer navigation was used to create virtual 3-dimensional maps of femoral bone tunnels for ACL drill guide pin insertion paths on small, medium, and large models of averaged femora considering various pin insertion angles to the femur. We then determined which pin insertion angle resulted in an ACL femoral footprint optimally matching normal human anatomic length, width, area, and angular orientation of the footprint long axis. RESULTS During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of 60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin entrance angle of 20° to the transepicondylar axis, results in the closest approximation of the gold standard of normal anatomic morphology of the human knee ACL femoral footprint length, width, area, and angular orientation. CONCLUSIONS During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of 60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin entrance angle of 20° to the transepicondylar axis, results in optimal reconstruction of the normal human anatomic ACL femoral footprint length, width, area, and angular orientation. CLINICAL RELEVANCE We describe arthroscopic landmarks for anatomic ACL femoral socket creation that may be considered by practicing arthroscopic surgeons in the operating room, without open dissection or fluoroscopy and unaffected by type of drill guide or variations in the thickness of the femoral soft-tissue envelope.
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Affiliation(s)
- James H Lubowitz
- Taos Orthopaedic Institute Research Foundation, Taos, New Mexico, USA.
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Tompkins M, Milewski MD, Carson EW, Brockmeier SF, Hamann JC, Hart JM, Miller MD. Femoral tunnel length in primary anterior cruciate ligament reconstruction using an accessory medial portal. Arthroscopy 2013; 29:238-43. [PMID: 23270787 DOI: 10.1016/j.arthro.2012.08.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 08/16/2012] [Accepted: 08/17/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate tunnel length during independent femoral tunnel drilling using an accessory medial portal with the knee in maximal hyperflexion, and correlate the tunnel length and flexion angle with anthropometric data. METHODS During a 1-year period, 106 consecutive patients undergoing primary anterior cruciate ligament (ACL) reconstruction were included in the study. All patients underwent independent femoral tunnel drilling using an accessory medial portal with maximal knee hyperflexion. Tunnel length and maximal intraoperative knee flexion angles were measured. Additionally, height, weight, and body mass index (BMI), plus the width and depth of the lateral femoral condyle (LFC), were recorded to correlate with tunnel length and knee flexion angles. RESULTS Average tunnel length was 37.0 ± 3.3 mm (range, 26 to 45), with all but one tunnel greater than 30 mm. Average knee flexion angle was 134.4 ± 5.0° (range, 122° to 147°). Height (r = 0.5, P < .001) and weight (r = 0.33, P = .001), but not BMI (r = 0.14, P = .17), correlated positively with tunnel length. Width (r = 0.46, P < .001) and depth (r = 0.38, P < .001) of the LFC also correlated positively with tunnel length. Knee flexion angle was not correlated with tunnel length (r = -0.09, P = .39) or width (r = -0.04, P = .7) and depth (r = -0.01, P = .91) of the LFC. Knee flexion angle was negatively correlated with weight (r = -0.44, P < .001) and BMI (r = -0.46, P < .001). CONCLUSIONS Using an accessory medial portal for independent femoral tunnel drilling, with maximal knee hyperflexion, in ACL reconstruction consistently produced tunnel lengths greater than 30 mm with no posterior wall fractures. Tunnel lengths tend to be longer with increasing patient height, mass, and larger LFC dimensions. Maximum knee flexion angle achieved intraoperatively tends to be less for patients with increasing weight and BMI. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Marc Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota 55454, USA.
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Yao J, Wen C, Cheung JTM, Zhang M, Hu Y, Yan C, Chiu KYP, Lu WW, Fan Y. Deterioration of stress distribution due to tunnel creation in single-bundle and double-bundle anterior cruciate ligament reconstructions. Ann Biomed Eng 2012; 40:1554-67. [PMID: 22302321 DOI: 10.1007/s10439-012-0517-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 01/16/2012] [Indexed: 11/24/2022]
Abstract
Bone tunnel enlargement is a common effect associated with knee laxity after anterior cruciate ligament(ACL) reconstruction. Nevertheless, its exact pathomechanism remains controversial. One of the possible reasons could be bone remodeling due to tunnel creation, which changes the stress environment in the joint. The present study aims to characterize the deteriorated stress distribution on the articular surface, which is due to tunnel creation after single-bundle or double-bundle ACL reconstruction. The stress distributions in the knee following ACL reconstruction under the compression, rotation, and valgus torques were calculated using a validated three-dimensional finite element(FE) model. The results indicate that, (a) under compression,von Mises stress is decreased at lateral and posteromedial regions of single/anteromedial (AM) tunnel, whereas it is increased at anterior region of single/AM tunnel in tibial subchondral bone; (b) the concentration of tensile stress is transferred from the articular surface to the location of graft fixation, and tensile stress in subchondral plate is decreased after ACL reconstruction; (c) severe stress concentration occurs between AM and posterolateral tunnels following the double-bundle reconstruction, which may contribute to the tunnel communication after surgery. In summary, the present study affirms that the deterioration of stress distribution occurs near the articular surface, which may cause the collapse of the tunnel wall, and lead to tunnel enlargement.The present study provides an insight into the effect of tunnel creation on articular stress deterioration after single-bundle or double-bundle ACL reconstruction. These findings provide knowledge on the effect of tunnel enlargement after ACL reconstruction in the long term.
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Affiliation(s)
- Jie Yao
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 37 Xueyuan Road, Haidian District, Beijing 100191, China
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Driscoll MD, Isabell GP, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR. Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy 2012; 28:1481-9. [PMID: 22796141 DOI: 10.1016/j.arthro.2012.03.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 03/13/2012] [Accepted: 03/14/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate knee stability after anterior cruciate ligament (ACL) reconstruction using 2 modern clinically relevant single-bundle constructs. METHODS Two arthroscopic ACL reconstructions were performed on 6 fresh-frozen human cadaveric knees using bone-patellar tendon-bone autografts. The tibial tunnel was centered in the anatomic tibial footprint. The femoral tunnel was reamed through the anteromedial (AM) portal and centered alternately in either the AM portion of the femoral footprint (center-AM) or the center of the femoral footprint (center-center). Two external loading conditions were applied: (1) a 134-N anterior tibial load and (2) a 10-Nm valgus load combined with a 5-Nm internal tibial torque. Resulting kinematics were determined under 4 conditions: (1) ACL intact, (2) ACL deficient, (3) center-AM reconstruction, and (4) center-center reconstruction. RESULTS In response to anterior tibial loading, anterior translation was similar in the ACL-intact knee and the 2 reconstructions at 0° to 60° of flexion but was greater in the reconstructed specimens at 90°. In response to the complex rotatory load, internal tibial rotation (ITR) at 30° of flexion was slightly greater in center-AM knees compared with ACL-intact knees (11.0° ± 0.6° v 10.5° ± 0.6°, P = .03). At other angles tested, ITR in both reconstructions was similar to the ACL-intact knee (P > .05). When we compared the 2 reconstruction alternatives, however, center-center knees exhibited greater resistance to ITR at all angles (P < .05). CONCLUSION Anatomic single-bundle ACL reconstruction performed with the femoral tunnel placed through the AM portal restores translational and rotational knee stability to an extent that closely approximates the ACL-intact condition. When compared with the AM femoral tunnel position, a femoral tunnel positioned in the anatomic center of the femoral origin of the ACL may further improve rotatory stability without sacrificing anterior stability. CLINICAL RELEVANCE This study provides additional biomechanical evidence in support of anatomic single-bundle ACL reconstruction with tunnels positioned in the center of the femoral and tibial footprints.
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George MS. Femoral tunnel drilling from the anteromedial portal using the figure-4 position in ACL reconstruction. Orthopedics 2012; 35:674-7. [PMID: 22868588 DOI: 10.3928/01477447-20120725-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Creation of the femoral tunnel in anterior cruciate ligament (ACL) reconstruction via the anteromedial portal can reproducibly achieve femoral tunnel positioning at the center of the femoral ACL footprint. Anteromedial portal drilling requires knee hyperflexion, which is awkward to perform. Knee hyperflexion to 120° can easily be achieved in the figure-4 position for femoral tunnel drilling via the anteromedial portal. The leg is hyperflexed in the figure-4 position on a Mayo stand. The offset femoral guide, guidewire, and drill are placed at the femoral ACL footprint via the anteromedial portal to create the femoral tunnel.
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Getgood A, Spalding T. The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop J 2012; 6:287-94. [PMID: 22905073 PMCID: PMC3415664 DOI: 10.2174/1874325001206010287] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 03/02/2012] [Accepted: 03/10/2012] [Indexed: 02/08/2023] Open
Abstract
Anterior cruciate ligament reconstruction has evolved significantly since the early 1900's, back when an emphasis was placed on repair and not reconstruction. Over the past century, the technique has evolved from intra-articular non anatomic reconstruction, to extra articular reconstruction, back to intra articular (performed arthroscopically), to now, the advent of anatomic insertion site restoration. This review will aim to illustrate the changes that have occurred, describing the rational for this process, based upon anatomical, radiological, biomechanical and clinical studies, all of which have aimed to improve patient function following ACL injury.
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Affiliation(s)
- Alan Getgood
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
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Tompkins M, Milewski MD, Brockmeier SF, Gaskin CM, Hart JM, Miller MD. Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling. Am J Sports Med 2012; 40:1313-21. [PMID: 22523370 DOI: 10.1177/0363546512443047] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND During anatomic anterior cruciate ligament (ACL) reconstruction, we have found that the femoral footprint can best be visualized from the anteromedial portal. Independent femoral tunnel drilling can then be performed through an accessory medial portal, medial and inferior to the standard anteromedial portal. PURPOSE To compare the accuracy of independent femoral tunnel placement relative to the ACL footprint using an accessory medial portal versus tunnel placement with a traditional transtibial technique. STUDY DESIGN Controlled laboratory study. METHODS Ten matched pairs of cadaveric knees were randomized such that within each pair, one knee underwent arthroscopic transtibial (TT) drilling, and the other underwent drilling through an accessory medial portal (AM). All knees underwent computed tomography (CT) both preoperatively and postoperatively with a technique optimized for ligament evaluation (80 keV with maximum mAs). Computed tomography was performed with a dual-energy scanner. Commercially available third-party software was used to fuse the preoperative and postoperative CT scans, allowing anatomic comparison of the ACL footprint to the drilled tunnel. The ACL footprint was marked in consensus by an orthopaedic surgeon and a musculoskeletal radiologist and then compared with the tunnel aperture after drilling. The percentage of tunnel aperture contained within the native footprint as well as the distance from the center of the tunnel aperture to the center of the footprint was measured. RESULTS The AM technique placed 97.7% ± 5% of the tunnel within the native femoral footprint, significantly more than 61.2% ± 24% for the TT technique (P = .001). The AM technique placed the center of the femoral tunnel 3.6 ± 1.2 mm from the center of the native footprint, significantly closer than 6.0 ± 1.9 mm for the TT technique (P = .003). CONCLUSION This study demonstrates that use of an accessory medial portal will facilitate more accurate placement of the femoral tunnel in the native ACL femoral footprint. CLINICAL RELEVANCE More accurate placement of the femoral tunnel in the native ACL femoral footprint should improve the ability to achieve more anatomic positioning of the ACL graft.
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Affiliation(s)
- Marc Tompkins
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Piefer JW, Pflugner TR, Hwang MD, Lubowitz JH. Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature. Arthroscopy 2012; 28:872-81. [PMID: 22301358 DOI: 10.1016/j.arthro.2011.11.026] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 11/16/2011] [Accepted: 11/20/2011] [Indexed: 02/09/2023]
Abstract
PURPOSE The purpose of our study was to systematically review current arthroscopic and related literature and to characterize the anatomic centrum of the anterior cruciate ligament (ACL) femoral footprint. METHODS On June 2, 2011, 2 independent reviewers performed a Medline search using the terms "anterior cruciate ligament" or "ACL," "femur" or "femoral," and "anatomy" or "origin" or "footprint." We included anatomic, cadaveric, and radiographic studies of adult, human, ACL femoral anatomy. Studies not published in the English language, studies published before January 1, 2000, and review articles were excluded. References of included articles were also searched according to our inclusion/exclusion criteria. Included studies were subjectively and quantitatively synthesized to define the anatomic centrum of the ACL femoral footprint. RESULTS The Medline search produced 533 articles. After application of inclusion and exclusion criteria and reference search, 20 articles were included and systematically reviewed. With regard to arthroscopically measurable landmarks, the anatomic centrum of the ACL femoral footprint is, on average, (1) in the sagittal plane, 43% of the distance from the proximal articular margin (arthroscopically visualized osteochondral junction) to the distal articular margin on the lateral wall of the intercondylar notch, and (2) in the axial plane, socket radius plus 2.5 mm anterior to the posterior articular margin, with a 2.5-mm rim of bone between the posterior ACL fibers and the posterior articular cartilage margin. CONCLUSIONS Our results show that the anatomic centrum of the ACL femoral footprint is 43% of the proximal-to-distal length of lateral, femoral intercondylar notch wall and femoral socket radius plus 2.5 mm anterior to the posterior articular margin. CLINICAL RELEVANCE This systematic review of basic science studies may have clinical relevance for surgeons who believe that anatomic ACL reconstruction can result in improved outcomes.
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Affiliation(s)
- Jason W Piefer
- Woodlands Sports Medicine Centre, The Woodlands, Texas, U.S.A
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Otani M, Nozaki M, Kobayashi M, Goto H, Tawada K, Waguri-Nagaya Y, Okamoto H, Iguchi H, Watanabe N, Otsuka T. Comparative risk of common peroneal nerve injury in far anteromedial portal drilling and transtibial drilling in anatomical double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2012; 20:838-43. [PMID: 21830114 DOI: 10.1007/s00167-011-1632-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Accepted: 07/18/2011] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to investigate the risk of common peroneal nerve injury in FM drilling as compared to transtibial drilling in anatomical double-bundle ACL reconstruction. METHODS Ten cadaveric knees without ligament injury or significant arthritis were used for this study. Knees were secured at 90° and 120° of flexion. In transtibial drilling groups, a guide pin was drilled through either the anteromedial bundle (AMB) or posterolateral bundle (PLB) tibial insertion site to either the AMB or PLB femoral insertion site (tibial insertion site-femoral insertion site: AM-AM, PL-PL, PL-AM and AM-PL). In FM drilling groups (FM-AM and FM-PL),the pin was drilled at the AMB or PLB femoral insertion site through the FM. We measured the shortest distance between the point at which the pin ran through the lateral cortex of the femur and the ipsilateral common peroneal nerve at a knee flexion of 90° and 120°. RESULTS At a knee flexion of 90°, the shortest mean distance to the common peroneal nerve was 15.3 mm in the FM-PL group, 13.4 mm in the FM-AM group, 27.9 mm in the PL-PL group, 30.8 mm in the AM-AM group, 37.8 mm in the PL-AM group and 29.5 mm in the AM-PL group. At a knee of flexion 120°, the mean distance was 17.3 mm in the FM-PL group, 18.1 mm in the FM-AM group, 32.2 mm in the PL-PL group, 36.6 mm in the AM-AM group, 38.0 mm in the PL-AM group and 35.2 mm in the AM-PL group. Significant differences were observed between 90° and 120° of knee flexion in the FM-AM, PL-PL, AM-AM and AM-PL groups (P < 0.05). Significant differences were observed at flex 90° between the FM-AM group and AM-AM group, and between the FM-AM group and PL-AM group. Significant differences were observed at flex 120° between the FM-AM group and AM-AM group, between the FM-AM group and PL-AM group and between the FM-PL group and AM-PL group. CONCLUSION The distance to the peroneal nerve in FM drilling was significantly longer at 120° than at 90° of knee flexion. Therefore, the risk of peroneal injury using FM drilling should decrease at a higher angle of knee flexion.
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Affiliation(s)
- M Otani
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
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Lubowitz JH, Provencher MT, Poehling GG. Do large-diameter hamstring grafts in young patients prevent knee osteoarthritis after ACL reconstruction? Arthroscopy 2012; 28:447-8. [PMID: 22464287 DOI: 10.1016/j.arthro.2012.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/02/2012] [Indexed: 02/02/2023]
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Musahl V, Kopf S, Rabuck S, Becker R, van der Merwe W, Zaffagnini S, Fu FH, Karlsson J. Rotatory knee laxity tests and the pivot shift as tools for ACL treatment algorithm. Knee Surg Sports Traumatol Arthrosc 2012; 20:793-800. [PMID: 22207028 DOI: 10.1007/s00167-011-1857-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 12/19/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED The goal of anterior cruciate ligament (ACL) reconstruction surgery is to eliminate the pivot shift phenomenon. Different injury mechanisms and injury patterns may lead to specific knee laxity patterns. Computer navigation is helpful for the surgeon during examination under anesthesia. Surgical treatment may have to be altered if high-grade laxity is detected preoperatively for example by utilizing a computer navigation that is a helpful adjunct for surgeons during examination under anesthesia. A typical case for revision ACL reconstruction is presented. This article describes several techniques of laxity assessments. Based on the type and degree of pathologic laxity, a treatment algorithm has been developed. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA.
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Fernandes TL, Protta TR, Fregni F, Neto RB, Pedrinelli A, Camanho GL, Hernandez AJ. Isokinetic muscle strength and knee function associated with double femoral pin fixation and fixation with interference screw in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2012; 20:275-80. [PMID: 21710112 DOI: 10.1007/s00167-011-1585-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 06/14/2011] [Indexed: 01/10/2023]
Abstract
PURPOSE Intensive scheduling in sports requires athletes to resume physical activity shortly after injury. The purpose of this study was to investigate early isokinetic muscle strength and knee function on bone-patellar tendon-bone (BPTB) ACL reconstruction with double femoral pin fixation or interference screw technique. METHODS A prospective study was conducted from 2008 to 2009, with 48 athletes who received femoral BPTB fixation with interference screw (n = 26) or double pin (n = 22). Clinical (IKDC objective score and hop test) and isokinetic muscle strength (peak torque (PT), PT/body weight and flexion/extension rate (F/E) in 60 and 240°/s) were analyzed at 6 months of follow-up. RESULTS Analysis at baseline showed no differences between groups before surgery related to age, gender, associated injury, Tegner or Lysholm score; thus showing that groups were similar. During follow-up, however, there were significant differences between the two groups in some of the isokinetic muscle strength: PT/BW 60°/s (Double Pin = 200% ± 13% vs. Interference Screw = 253% ± 16%*, *P = 0.01); F/E 60°/s (Double Pin = 89% ± 29%* vs. Interference Screw = 74% ± 12%, *P = 0.04). No statistical differences between groups were observed on IKDC objective score, hop test and complications. CONCLUSION The significant muscle strength outcome of the interference screw group found in this study gives initial evidence that this fixation technique is useful for athletes that may need accelerated rehabilitation. Early return to sports ability signaled by isokinetic muscle strength is of clinical relevance as it is one of the main goals for athletes' rehabilitation.
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Affiliation(s)
- Tiago Lazzaretti Fernandes
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, School of Medicine, FIFA Medical Centre of Excellence, University of São Paulo, 333 Dr. Ovídio Pires de Campos, São Paulo, Brazil.
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49
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Celentano U, Cardoso MPA, Martins CAQ, Ramirez CP, van Eck CF, Smolinski P, Fu FH. Use of transtibial aimer via the accessory anteromedial portal to identify the center of the ACL footprint. Knee Surg Sports Traumatol Arthrosc 2012; 20:69-74. [PMID: 21695468 PMCID: PMC3249156 DOI: 10.1007/s00167-011-1574-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 06/03/2011] [Indexed: 01/30/2023]
Abstract
PURPOSE To assess the ability of a transtibial aimer with a 7-mm off-set in a standardized position to reach the center of the ACL footprint on the femur through the AM portal. METHODS Nineteen cadaveric knees were dissected, and the perimeter of the femoral ACL footprint was marked. The aimer was placed just superior to the medial joint line close to the medial condyle through the AM portal. The guide was rested upon the posterior cortex and placed in three different positions: (A) at zero degrees in frontal plane and 60° in axial plane, (B) at 45° in frontal and 45° in axial, and (C) at the center of the ACL insertion site under direct visualization. A digital camera was used to take pictures on the axial plane, and Image J software was used for angle measurement. Aluminum beads were used to mark the three positions indicated by the aimer, and CT scans were performed. The distances from the true center of the ACL to each point were determined. RESULTS Position A resulted in femoral tunnel placement furthest from the center of the ACL footprint (8.6 mm). Position B was at a distance of 3.2 mm, and position C was the most accurate, with an average distance of 2.0 mm. The angles required by Position C varied with an average of 54° ± 11° in the frontal plane and an average of 44° ± 6° in the axial plane. CONCLUSION The 7-mm transtibial aimer was unable to reach the center of ACL footprint at a fixed orientation.
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Affiliation(s)
- Umberto Celentano
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Bldg Ste 1011, 3471 Fifth Ave, Pittsburgh, PA 15213-3221 USA ,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA USA
| | - Marcos P. A. Cardoso
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Bldg Ste 1011, 3471 Fifth Ave, Pittsburgh, PA 15213-3221 USA ,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA USA
| | - Cesar A. Q. Martins
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Bldg Ste 1011, 3471 Fifth Ave, Pittsburgh, PA 15213-3221 USA ,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA USA
| | | | - Carola F. van Eck
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Bldg Ste 1011, 3471 Fifth Ave, Pittsburgh, PA 15213-3221 USA ,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Bldg Ste 1011, 3471 Fifth Ave, Pittsburgh, PA 15213-3221 USA ,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA USA
| | - Freddie H. Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Bldg Ste 1011, 3471 Fifth Ave, Pittsburgh, PA 15213-3221 USA ,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA USA
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Ochi M, Abouheif MM, Kongcharoensombat W, Nakamae A, Adachi N, Deie M. Double bundle arthroscopic Anterior Cruciate Ligament reconstruction with remnant preserving technique using a hamstring autograft. Sports Med Arthrosc Rehabil Ther Technol 2011; 3:30. [PMID: 22141394 PMCID: PMC3284875 DOI: 10.1186/1758-2555-3-30] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 12/05/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Preservation of the Anterior Cruciate Ligament (ACL) remnant is important from the biological point of view as it enhances revascularization, and preserves the proprioceptive function of the graft construct. Additionally, it may have a useful biomechanical function. Double bundle ACL reconstruction has been shown to better replicate the native ACL anatomy and results in better restoration of the rotational stability than single bundle reconstruction. METHODS We used the far anteromedial (FAM) portal for creation of the femoral tunnels, with a special technique for its preoperative localization using three dimensional (3D) CT. The central anteromedial (AM) portal was used to make a longitudinal slit in the ACL remnant to allow visualization of the tips of the guide pins during anatomical creation of the tibial tunnels within the native ACL tibial foot print. The use of curved hemostat allow retrieval of the wire loop from the apertures of the femoral tunnels through the longitudinal slit in the ACL remnant thereby, guarding against impingement of the reconstruction graft against the ACL remnant as well as the roof of the intercondylar notch. CONCLUSION Our technique allows for anatomical double bundle reconstruction of the ACL while maximally preserving the ACL remnant without the use of intra-operative image intensifier.
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Affiliation(s)
- Mitsuo Ochi
- Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
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