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Gabr A, Khan M, Kini SG, Haddad F. Anteromedial Portal versus Transtibial Drilling Techniques for Femoral Tunnel Placement in Arthroscopic Anterior Cruciate Ligament Reconstruction: Radiographic Evaluation and Functional Outcomes at 2 Years Follow-Up. J Knee Surg 2023; 36:1309-1315. [PMID: 36075229 DOI: 10.1055/s-0042-1755358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to compare the functional and radiographic outcomes of arthroscopic single-bundle anterior cruciate ligament reconstruction (ACLR) using either the anteromedial (AM) portal technique or transtibial (TT) technique. We identified 404 patients who underwent arthroscopic ACLR by a single surgeon between January 2006 and December 2016 at our institution. The TT portal was utilized in femoral tunnel drilling in 202 patients (TT group) while the AM portal was used in 202 patients (AM group). The mean postoperative follow-up duration was 26 months (range: 24-33 months). Postoperative radiographic femoral and tibial tunnel positions were assessed by two independent observers. Functional outcomes were evaluated with Tegner, Lysholm, and Knee Injury and Osteoarthritis Outcome score (KOOS) scores. On the anteroposterior plain radiographs, the mean femoral tunnel position relative to the lateral femoral condyle was 46.8% for the AM group versus 48.6% in the TT group, respectively (p=0.003). The mean graft inclination angle was 31.9° and 22° in the AM and TT groups, respectively (p<0.0001). On the lateral radiographs, the mean femoral tunnel placement across Blumensaat's line in relation to the anterior femoral cortex was 84% in the AM group while it was 78% in the TT group (p<0.0001). At 2 years postoperatively, there were no significant differences in the mean Tegner, Lysholm, and KOOS scores between the two patient groups. The graft failure rate at 2 years follow-up was 4.5% (n=9) in the AM group while it was 2.5% (n=5) in the TT group (p=0.2). Femoral tunnel placement was more anatomical with the AM portal technique compared with the TT technique. However, there was no significant difference in postoperative functional outcomes between the two patient groups. The AM portal technique appears to have a higher graft failure rate. This might be attributed to increased graft loading in an anatomical position.
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Affiliation(s)
- Ayman Gabr
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
| | - Mohsin Khan
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
| | - Sunil G Kini
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
| | - Fares Haddad
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
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Cho JH, Lee HI, Heo JW, Lee SS. Comparison of Clinical and Radiographic Outcomes According to the Presence or Absence of a Posterior Draw Force during Graft Fixation in Anterior Cruciate Ligament Reconstruction. Medicina (B Aires) 2022; 58:medicina58121787. [PMID: 36556989 PMCID: PMC9785038 DOI: 10.3390/medicina58121787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/07/2022] Open
Abstract
Background and Objectives: A reduction forced toward the posterior side during graft fixation may help to lessen anterior tibial translation after ACL reconstruction. The purpose was to compare the clinical and radiological outcomes of graft fixation when a posterior draw was used and when it was not used during anterior cruciate ligament (ACL) reconstruction surgery. Materials and Methods: Of 110 patients who had undergone primary arthroscopic ACL reconstruction between January 2017 and August 2020, in all, 76 patients had been operated on without a posterior draw (non-draw group), and 34 patients had received surgery with a posterior draw (draw group). The results of the Lachman test and the pivot-shift test, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) indexes, the Lysholm scores, the International Knee Documentation Committee (IKDC) subjective scores, and side-to-side difference (STSD) on stress radiography were compared between the two groups. Results: The postoperative WOMAC indexes, Lysholm scores, and IKDC subjective scores were similar across both groups. Postoperative STSD (2.4 ± 2.2 for the non-draw group vs. 2.0 ± 2.2 for the draw group; p = 0.319) and change in STSD (3.5 ± 3.5 for preoperative STSD vs. 4.3 ± 4.4 for postoperative STSD; p = 0.295) were not superior in the draw group. Conclusions: The take-home message is that graft fixation with a posterior draw during ACL reconstruction did not result in significantly better postoperative stability. The postoperative clinical outcomes were similar between both groups.
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Takahashi T, Saito T, Kubo T, Hirata K, Sawamura H, Suzuki T, Takeshita K. Evaluation of Tibial Tunnel Location with the Femoral Tunnel Created Behind the Resident's Ridge in Transtibial Anterior Cruciate Ligament Reconstruction. J Knee Surg 2022; 35:1132-1137. [PMID: 33482675 DOI: 10.1055/s-0040-1722568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Few studies have determined whether a femoral bone tunnel could be created behind the resident's ridge by using a transtibial (TT) technique-single bundle (SB)-anterior cruciate ligament (ACL) reconstruction. The aim of this study was to clarify (1) whether it is possible to create a femoral bone tunnel behind the resident's ridge by using the TT technique with SB ACL reconstruction, (2) to define the mean tibial and femoral tunnel angles during anatomic SB ACL reconstruction, and (3) to clarify the tibial tunnel inlet location when the femoral tunnel is created behind resident's ridge. Arthroscopic TT-SB ACL reconstruction was performed on 36 patients with ACL injuries. The point where 2.4-mm guide pin was inserted was confirmed, via anteromedial portal, to consider a location behind the resident's ridge. Then, an 8-mm diameter femoral tunnel with a 4.5-mm socket was created. Tunnel positions were evaluated by using three-dimensional computed tomography (3D-CT) 1 week postoperatively. Quadrant method and the resident's ridge on 3D-CT were evaluated to determine whether femoral tunnel position was anatomical. Radiological evaluations of tunnel positions yielded mean ( ± standard deviation) X- and Y-axis values for the tunnel centers: femoral tunnel, 25.2% ± 5.1% and 41.6% ± 10.2%; tibial tunnel, 49.2% ± 3.5%, and 31.5% ± 7.7%. The bone tunnels were anatomically positioned in all cases. The femoral tunnel angle relative to femoral axis was 29.4 ± 5.5 degrees in the coronal view and 43.5 ± 8.0 degrees in the sagittal view. The tibial tunnel angle relative to tibial axis was 25.5 ± 5.3 degrees in the coronal view and 52.3 ± 4.6 degrees in the sagittal view. The created tibial bone tunnel inlet had an average distance of 13.4 ± 2.7 mm from the medial tibial joint line and 9.7 ± 1.7 mm medial from the axis of the tibia. Femoral bone tunnel could be created behind the resident's ridge with TT-SB ACL reconstruction. The tibial bone tunnel inlet averaged 13.4 mm from the medial tibial joint line and 9.7 mm medial from the tibia axis.
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Affiliation(s)
- Tsuneari Takahashi
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Tomohiro Saito
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Tatsuya Kubo
- Department of Orthopaedic Surgery, Haga Red Cross Hospital, Moka, Japan
| | - Ko Hirata
- Department of Sports and Health Science, Tochigi Medical Center Shimotsuga, Tochigi, Japan
| | - Hideaki Sawamura
- Department of Orthopaedic Surgery, Shin Oyama Municipal Hospital, Oyama, Japan
| | - Takahiro Suzuki
- Department of Orthopaedic Surgery, Ishibashi General Hospital, Shimotsuke, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Japan
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Vadlamudi A, Kale A, Sharma J, Patil V, Pai M. Comparison of Inside-Out and Outside-In Methods of Femoral Tunnel Preparation in Anterior Cruciate Ligament (ACL) Reconstruction Using 3D-CT. Cureus 2022; 14:e23367. [PMID: 35475087 PMCID: PMC9020750 DOI: 10.7759/cureus.23367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Anterior cruciate ligament (ACL) reconstruction techniques continue to evolve and the need to address the more anatomical femoral tunnel placement of the graft is critical, and in our study, we assessed the placement of femoral tunnel via transportal and retrograde drilling techniques. Material and methods Sixty patients where n=31 for retrograde, n=29 for transportal were assessed via CT knee for the femoral tunnel aperture on the intercondylar ridge via high low and deep shallow direction ratio and interpreted accordingly. Results In our study, the femoral tunnel done via transportal method (n=29) has a deep shallow ratio range of 22%-47% and mean of 31.9±6.5, and graft is anatomical in 79%. The femoral tunnel done via the retrograde method (n=31) has a deep shallow depth ratio range of 11%-41% with a mean of 27.5±6.5 and graft is anatomical in 77% of the study group and the p-value means the ratio is 0.01 (significant). The femoral tunnel done via transportal method (n=29) has a high low ratio range of 19%-45% and mean of 32.9±6.3 and graft is anatomical in 72%. The femoral tunnel done via the retrograde method (n=31) has a deep shallow depth ratio range of 20%-38% with a mean of 33.9±4.1 and graft is anatomical in 94% of the study group with a p-value mean ratio being 0.51 (insignificant). Conclusion Watch out for the femoral tunnel placement in a deep shallow direction while going for standard transportal technique and high low direction while performing retrograde technique.
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Haroun HK, Abouelsoud MM, Allam MR, Abdelwahab MM. Transtibial versus independent femoral tunnel drilling techniques for anterior cruciate ligament reconstruction: evaluation of femoral aperture positioning. J Orthop Surg Res 2022; 17:166. [PMID: 35303903 PMCID: PMC8931956 DOI: 10.1186/s13018-022-03040-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Femoral tunnel can be drilled through tibial tunnel (TT), or independent of it (TI) by out-in (OI) technique or by anteromedial (AM) technique. No consensus has been reached on which technique achieves more proper femoral aperture position because there have been evolving concepts in the ideal place for femoral aperture placement. This meta-analysis was performed to analyze the current literature comparing femoral aperture placement by TI versus TT techniques in ACL reconstruction. Methods We performed a comprehensive systematic review and meta-analysis of English-language literature in PubMed, Cochrane, and Web of Science databases for articles comparing femoral aperture placement by TI versus TT techniques with aperture position assessed by direct measurement or by postoperative imaging, PXR and/or CT and/or MRI. Results We included 55 articles with study population of 2401 knees of whom 1252 underwent TI and 1149 underwent TT techniques. The relevant baseline characteristics, whenever compared, were comparable between both groups. There was nonsignificant difference between TI and TT techniques in the distance from aperture center to footprint center and both techniques were unable to accurately recreate the anatomic footprint position. TI technique significantly placed aperture at more posterior position than TT technique. TI technique significantly lowered position of placed aperture perpendicular to Blumensaat’s line (BL) than TT technique, and modifications to TT technique had significant effect on this intervention effect. Regarding sagittal plane aperture placement along both AP anatomical axis and BL, there was nonsignificant difference between both techniques. Conclusion Modifications to TT technique could overcome limitations in aperture placement perpendicular to BL. The more anterior placement of femoral aperture by TT technique might be considered, to some extent, a proper position according to recent concept of functional anatomical ACL reconstruction. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03040-5.
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Affiliation(s)
- Haitham K Haroun
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt.
| | - Maged M Abouelsoud
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt
| | | | - Mahmoud M Abdelwahab
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt
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Sivakumaran T, Jaffer R, Marwan Y, Hart A, Radu A, Burman M, Martineau PA, Powell T. Reliability of Anatomic Bony Landmark Localization of the ACL Femoral Footprint Using 3D MRI. Orthop J Sports Med 2021; 9:23259671211042603. [PMID: 34692880 PMCID: PMC8532227 DOI: 10.1177/23259671211042603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Nonanatomic placement of anterior cruciate ligament (ACL) grafts is a leading cause of ACL graft failure. Three-dimensional (3D) magnetic resonance imaging (MRI) femoral footprint localization could enhance planning for an ACL graft's position. Purpose: To determine the intra- and interobserver reliability of measurements of the ACL femoral footprint position and size obtained from 3D MRI scans. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 41 patients with complete ACL tears were recruited between November 2014 and May 2016. Preoperatively, a coronal-oblique proton-density fast spin echo 3D acquisition of the contralateral uninjured knee was obtained along the plane of the ACL using a 1.5T MRI scanner. ACL footprint parameters were obtained independently by 2 musculoskeletal radiologists (observers A and B). The distal and anterior positions of the center of the footprint were measured relative to the apex of the deep cartilage at the posteromedial aspect of the lateral femoral condyle, and the surface area of the ACL femoral footprint was approximated from multiplanar reformatted images. After 1 month, the measurements were repeated. Intraclass correlation coefficients (ICCs) were calculated to assess for intra- and interobserver reliability. Bland-Altman plots were produced to screen for potential systematic bias in measurement and to calculate limits of agreement. Results: The ICCs for intraobserver reliability of the ACL femoral distal and anterior footprint coordinates were 0.75 and 0.78, respectively, for observer A. For observer B, they were 0.75 and 0.74, respectively. The ICCs for interobserver reliability were 0.75 and 0.85 for the distal and anterior coordinates, respectively. Bland-Altman plots demonstrated no significant systematic bias. For surface area measurements, the intraobserver ICCs were 0.37 and 0.62 for observers A and B, respectively. The interobserver reliability was 0.60. Observer B consistently measured the footprints as slightly larger versus observer A (1.19 ± 0.27 vs 1 ± 0.22 cm2, respectively; P < .001). Conclusion: Locating the center of the anatomic footprint of the ACL with 3D MRI showed substantial intra- and interobserver agreement. Interobserver agreement for the femoral footprint surface area was fair to moderate.
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Affiliation(s)
- Thiru Sivakumaran
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rehana Jaffer
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Yousef Marwan
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Adam Hart
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Arnold Radu
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Mark Burman
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Paul A Martineau
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
| | - Tom Powell
- McGill University Health Sciences Centre, McGill University, Montreal, Quebec, Canada
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Takahashi T, Takeshita K. Remnant Tissue Preserved Transtibial Anterior Cruciate Ligament Reconstruction With Femoral Tunnel Created Behind the Resident's Ridge. Arthrosc Tech 2021; 10:e2501-e2506. [PMID: 34868854 PMCID: PMC8626692 DOI: 10.1016/j.eats.2021.07.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/18/2021] [Indexed: 02/03/2023] Open
Abstract
Although the transtibial (TT) technique for single-bundle (SB) arthroscopic anterior cruciate ligament (ACL) reconstruction has been widely used, surgeons often disadvantageously create the femoral bone tunnel at the arthroscopically noon position, which is alleged the "ACL isometric point," when the femoral bone tunnel could be created behind the resident's ridge with TT-SB ACL reconstruction by paying attention to the location of the tibial tunnel inlet and the angle of tibial tunnel. This alternative approach preserves ACL remnant tissue, which might contribute to better postoperative remodeling and regeneration of proprioceptive mechanoreceptors. This technique reduces surgical invasiveness and can enhance postoperative graft remodeling and proprioceptive recovery. To successfully use the devices required for this procedure, surgeons must understand the proper techniques. Hence, this technical note aims to demonstrate TT-SB ACL reconstruction with remnant tissue preservation.
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Affiliation(s)
- Tsuneari Takahashi
- Department of Orthopaedic Surgery, Ishibashi General Hospital, Shimotsuke, Japan
- Address correspondence to Tsuneari Takahashi, M.D., Ph.D., Department of Orthopaedic Surgery, Ishibashi General Hospital, Shimotsuke, 1-15-4 Shimokoyama, 329-0502, Japan.
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
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Loucas M, Loucas R, D'Ambrosi R, Hantes ME. Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211024591. [PMID: 34277881 PMCID: PMC8255613 DOI: 10.1177/23259671211024591] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/28/2021] [Indexed: 01/14/2023] Open
Abstract
Background: The drilling technique used to make a femoral tunnel is critically important for determining outcomes after anterior cruciate ligament (ACL) reconstruction. The 2 most common methods are the transtibial (TT) and anteromedial (AM) techniques. Purpose: To determine whether graft orientation and placement affect clinical outcomes by comparing clinical and radiological outcomes after single-bundle ACL reconstruction with the AM versus TT technique. Study Design: Systematic review; Level of evidence, 3. Methods: Articles in PubMed, EMBASE, the Cochrane Library, ISI Web of Science, Scopus, and MEDLINE were searched from inception until April 25, 2020, using the following Boolean operators: transtibial OR trans-tibial AND (anteromedial OR trans-portal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament. Results: Of 1270 studies retrieved, 39 studies involving 11,207 patients were included. Of these studies, 14 were clinical, 13 were radiological, and 12 were mixed. Results suggested that compared with the TT technique, the AM technique led to significantly improved anteroposterior and rotational knee stability, International Knee Documentation Committee (IKDC) scores, and recovery time from surgery. A higher proportion of negative Lachman (P = .0005) and pivot-shift test (P = .0001) results, lower KT-1000 arthrometer maximum manual displacement (P = .00001), higher Lysholm score (P = .001), a higher incidence of IKDC grade A/B (P = .05), and better visual analog scale score for satisfaction (P = .00001) were observed with the AM technique compared with the TT technique. The AM drilling technique demonstrated a significantly shorter tunnel length (P = .00001). Significant differences were seen between the femoral and tibial graft angles in both techniques. Low overall complication and revision rates were observed for ACL reconstruction with the AM drilling technique, similar to the TT drilling technique. Conclusion: In single-bundle ACL reconstruction, the AM drilling technique was superior to the TT drilling technique based on physical examination, scoring systems, and radiographic results. The AM portal technique provided a more reproducible anatomic graft placement compared with the TT technique.
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Affiliation(s)
- Marios Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Rafael Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Michael Elias Hantes
- Department of Orthopedic Surgery, Faculty of Medicine, University of Thessaly, Larissa, Greece
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Kim SH, Park YB, Kim DH, Pujol N, Lee HJ. Predictive factors for failure of anterior cruciate ligament reconstruction via the trans-tibial technique. Arch Orthop Trauma Surg 2020; 140:1445-1457. [PMID: 32529386 DOI: 10.1007/s00402-020-03483-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/14/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Factors for graft failure after trans-tibial (TT) ACL reconstruction, including anterolateral ligament (ALL) injury and degree of synovialization, remain unclear. This study is to evaluate the risk factors for graft failures after TT ACL reconstruction including ALL injury and synovialization. MATERIALS AND METHODS A total 391 patients who underwent primary TT ACL reconstruction were included. Failure was defined as greater than grade 2 laxity on the Lachman or pivot shift tests or 5 mm of anterior translation on stress radiograph. After applying inclusion/exclusion criteria, 31 patients with failure were categorized as group 1 and 89 patients without failure were categorized as group 2. Chi-square test and Cox proportional hazard analyses were performed. RESULTS Preoperatively, 64 patients had ALL injuries (53.3%), 58 had medial meniscal (MM) tears (48.3%), and 62 had lateral meniscal (LM) tears (51.6%). Ninety-three patients (77.5%) had acute injuries and 27 had chronic injuries as per 6-weeks duration. Significant risk factors for failure were LM tear (hazard ratio [HR], 4.018; 95% confidence interval [CI] 1.677-9.629; p = 0.002), chronicity (HR, 6.812; 95% CI 2.758-16.824; p = 0.000), presence of ALL injury (HR, 3.655; 95% CI 1.442-9.265; p = 0.006), and poor synovialization (HR, 3.134; 95% CI 1.298-7.566; p = 0.011) in Cox proportional hazard analysis. If combined MM and LM tears were found, an increased risk of failure was also identified (combined tears: HR, 3.951; 95% CI 1.754-8.901; p = 0.001/preoperative high-grade laxity: HR, 4.546; 95% CI 1.875-11.02; p = 0.001). CONCLUSION Chronic ACL injuries, meniscus tear, preoperative ALL injuries, preoperative high-grade laxity and poor synovialization are significant risk factors. Therefore, these factors should be carefully assessed and properly treated in TT ACL reconstruction. LEVEL OF EVIDENCE IV, retrospective cohort study.
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Affiliation(s)
- Seong Hwan Kim
- Department of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang University, Namyangju-Si, Kyunggi-Do, South Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Dong-Hyun Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Nicolas Pujol
- Orthopedic Department, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea.
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Does Bone Plug and Graft Orientation (Inferior Versus Posterior) Alter Native Femoral Footprint Coverage in Bone Patellar Tendon Bone Anterior Cruciate Ligament Reconstruction? Arthroscopy 2020; 36:1875-1881. [PMID: 32061734 DOI: 10.1016/j.arthro.2020.01.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this study was to compare the percentage of native femoral anterior cruciate ligament (ACL) footprint covered by the 2 most clinically relevant bone plug/graft orientations used with interference screw fixation in ACL reconstruction. A secondary purpose was to assess whether a transtibial or tibia-independent drilling technique would affect this outcome. METHODS Five matched pairs of cadaver knees were used. Each matched pair had 1 knee assigned to a 10-mm femoral socket prepared via a transtibial (TT) drilling technique and the other via an anteromedial (AM) drilling technique. The bone plug of each graft was press-fitted into the femoral socket with the graft collagen in 2 distinct clinically relevant orientations (collagen inferior or posterior). The digitized graft collagen cross-sectional area (CSA) in each orientation was overlaid onto the native femoral ACL footprint CSA to generate a percentage of native ACL footprint covered by graft collagen. RESULTS The average native ACL femoral footprint CSA was 110.5 ± 9.1 mm2, with no difference between knees assigned to TT or AM drilling (112.6 ± 2.7 vs 108.4 ± 13.0 mm2, P = .49). The average femoral socket CSA was 95.4 ± 8.7 mm2, with no difference between TT and AM tunnels (95.5 ± 9.9 vs 95.3 ± 8.4 mm2, P = .96). There was no difference between the percentage of native footprint covered between TT and AM sockets (76.8% ± 7.8% vs 82.2% ± 13.7%, P = .47). Irrespective of drilling technique, there was significantly greater native ACL footprint covered by graft collagen when the bone plug was oriented with graft collagen inferior rather than posterior (75.6% ± 6.3% vs 65.4% ± 11.4%, P = .02). CONCLUSION Orienting the femoral bone plug such that the graft collagen is inferior rather than posterior significantly increases native ACL femoral footprint coverage in bone-patellar tendon-bone ACL reconstruction. This effect is consistent across AM and TT drilling techniques. CLINICAL RELEVANCE Surgeons attempting to restore an anatomic ACL footprint should consider bone plug-graft orientation when performing ACL reconstruction. STUDY DESIGN Controlled laboratory study.
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Lee SS, Seo IW, Cho MS, Shin YS. Comparison of femoral tunnel length and obliquity of anatomic versus nonanatomic anterior cruciate ligament reconstruction: A meta-analysis. PLoS One 2020; 15:e0230497. [PMID: 32203530 PMCID: PMC7089554 DOI: 10.1371/journal.pone.0230497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 03/03/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose Theoretical considerations suggest that femoral tunnel length might cause graft mismatch, and femoral tunnel obliquity could be related to the longevity of graft in anterior cruciate ligament (ACL) reconstruction. However, controversy still exists regarding these issues in the context of the comparison of anatomic and nonanatomic ACL reconstructions. The purpose of this meta-analysis was to compare the length and obliquity of the femoral tunnel created by drilling through either anatomic or nonanatomic ACL reconstructions. Materials and method In this meta-analysis, we reviewed studies that compared femoral tunnel length and femoral tunnel obliquity in the coronal plane with the use of anatomic or nonanatomic ACL reconstruction. The major databases were reviewed for appropriate studies from the earliest available date of indexing through December 31, 2018. No restrictions were placed on the language of publication. Results Twenty-seven studies met the criteria for inclusion in this meta-analysis. The femur tunnel length of anatomic ACL reconstruction was significantly shorter compared with that of nonanatomic ACL reconstruction by 8.66 mm (95% CI: 7.10–10.22 mm; P<0.001), while the femur tunnel obliquity in the coronal plane of anatomic ACL reconstruction was significantly more oblique versus that of nonanatomic ACL reconstruction by 15.29° (95% CI: 8.07°–22.52°; P<0.001). Similar results in terms of femoral tunnel length were found for the subgroup with cadaveric (7.15 mm; 95% CI: 2.69–11.61 mm; P = 0.002) and noncadaveric (8.96 mm; 95% CI: 7.24–10.69 mm; P<0.001) studies, whereas different results in terms of femoral tunnel obliquity were noted for the subgroup with cadaveric (10.62°; 95% CI: −6.12° to 27.37°; P = 0.21) and noncadaveric (15.86°; 95% CI: 8.11°–23.60°; P<0.001) studies. Conclusion Anatomic ACL reconstruction resulted in the femoral tunnel length and femoral tunnel obliquity in the coronal plane being shorter and more oblique, respectively, as compared with nonanatomic ACL reconstruction. Level of evidence Therapeutic study, Level III.
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Affiliation(s)
- Sang-Soo Lee
- Institute for Skeletal Aging & Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University School of Medicine, Chuncheon, Republic of Korea
| | - In-Wook Seo
- Department of Orthopedic Surgery, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Min-Soo Cho
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University School of Medicine, Chuncheon, Republic of Korea
| | - Young-Soo Shin
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University School of Medicine, Chuncheon, Republic of Korea
- * E-mail:
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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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Cone SG, Howe D, Fisher MB. Size and Shape of the Human Anterior Cruciate Ligament and the Impact of Sex and Skeletal Growth: A Systematic Review. JBJS Rev 2019; 7:e8. [PMID: 31246862 DOI: 10.2106/jbjs.rvw.18.00145] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND High rates of anterior cruciate ligament (ACL) injury and surgical reconstruction in both skeletally immature and mature populations have led to many studies investigating the size and shape of the healthy ligament. The purposes of the present study were to compile existing quantitative measurements of the geometry of the ACL, its bundles, and its insertion sites and to describe effects of common covariates such as sex and age. METHODS A search of the Web of Science was conducted for studies published from January 1, 1900, to April 11, 2018, describing length, cross-sectional area, volume, orientation, and insertion sites of the ACL. Two reviewers independently screened and reviewed the articles to collect quantitative data for each parameter. RESULTS Quantitative data were collected from 92 articles in this systematic review. In studies of adults, reports of average ACL length, cross-sectional area, and volume ranged from 26 to 38 mm, 30 to 53 mm, and 854 to 1,858 mm, respectively. Reported values were commonly found to vary according to sex and skeletal maturity as well as measurement technique. CONCLUSIONS Although the geometry of the ACL has been described widely in the literature, quantitative measurements can depend on sex, age, and measurement modality, contributing to variability between studies. As such, care must be taken to account for these factors. The present study condenses measurements describing the geometry of the ACL, its individual bundles, and its insertion sites, accounting for common covariates when possible, to provide a resource to the clinical and scientific communities. CLINICAL RELEVANCE Quantitative measures of ACL geometry are informative for developing clinical treatments such as ACL reconstruction. Age and sex can impact these parameters.
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Affiliation(s)
- Stephanie G Cone
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Danielle Howe
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina.,Department of Orthopaedics, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
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Seo SS, Kim CW, Lee CR, Kwon YU, Kim MW, Kim OG, Seo HW. Effect of Femoral Tunnel Position on Stability and Clinical Outcomes After Single-Bundle Anterior Cruciate Ligament Reconstruction Using the Outside-In Technique. Arthroscopy 2019; 35:1648-1655. [PMID: 30979621 DOI: 10.1016/j.arthro.2018.11.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 11/16/2018] [Accepted: 11/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effects of the femoral tunnel location in the femoral footprint of the anterior cruciate ligament (ACL) on postoperative knee stability and clinical outcomes after ACL reconstruction (ACLR) using the outside-in technique. METHODS From December 2012 to August 2014, ACLR was performed using the outside-in technique in 137 patients. Among these patients, those who had a follow-up period of over 2 years were retrospectively reviewed. A total of 102 patients met the inclusion criteria. The relative location of the femoral tunnel in the lateral condyle was evaluated as a percentage using the standardized grid system on a 3-dimensional computed tomography image. Each patient was then classified into the anterior group, center group (anteroposterior plane, 29.3% ± 3.5%), or posterior group depending on the location of the femoral tunnel. Knee laxity was evaluated using a GNRB knee arthrometer, stress radiography, and the pivot-shift test. From a clinical perspective, patient-reported outcomes (International Knee Documentation Committee subjective form and Lysholm knee score) were then evaluated. RESULTS Of 102 patients, 31 (30.4%) were assigned to the anterior group, 46 (45.1%) were assigned to the center group, and 25 (24.5%) were assigned to the posterior group. Postoperative side-to-side differences, which were measured using stress radiographs and the GNRB arthrometer, were significantly smaller in the posterior group (1.7 ± 0.6 mm and 1.5 ± 0.5 mm, respectively) than in the center group (2.3 ± 0.9 mm and 2.2 ± 2.8 mm, respectively) and anterior group (2.4 ± 0.7 mm and 2.4 ± 1.3 mm, respectively) (P = .002 for stress radiography and P = .002 for GNRB arthrometer). No significant between-group differences were observed in the pivot-shift test results and patient-reported outcomes among the 3 groups. CONCLUSIONS The location of the femoral tunnel in the anatomic ACL footprint did not affect postoperative stability and clinical outcomes in the case of ACLR using the outside-in technique. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Seung-Suk Seo
- Department of Orthopedic Surgery, Haeundae Bumin Hospital, Busan, Republic of Korea
| | - Chang-Wan Kim
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Chang-Rack Lee
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Busan, Republic of Korea.
| | - Yong-Uk Kwon
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Mu-Won Kim
- Department of Orthopedic Surgery, Bumin Hospital, Busan, Republic of Korea
| | - Ok-Gul Kim
- Department of Orthopedic Surgery, Bumin Hospital, Busan, Republic of Korea
| | - Hyeong-Won Seo
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Busan, Republic of Korea
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Parkar AP, Adriaensen MEAPM, Giil LM, Solheim E. Computed Tomography Assessment of Anatomic Graft Placement After ACL Reconstruction: A Comparative Study of Grid and Angle Measurements. Orthop J Sports Med 2019; 7:2325967119832594. [PMID: 30915380 PMCID: PMC6429657 DOI: 10.1177/2325967119832594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The anatomic placement of anterior cruciate ligament (ACL) grafts is often assessed with postoperative imaging. In clinical practice, graft angles are measured to indicate anatomic placement on magnetic resonance imaging, whereas grid measurements are performed on computed tomography (CT). Recently, a study indicated that graft angle measurements could also be assessed on CT. No consensus has yet been reached on which measurement method is best suited to assess anatomic graft placement. Purpose: To compare the ability of grid measurements and angle measurements to identify anatomic versus nonanatomic tunnel placement on CT performed in patients undergoing ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A total of 100 knees undergoing primary reconstruction with a hamstring graft (HAM group), 91 undergoing reconstruction with a bone–patellar tendon–bone graft (BPTB group), and 117 undergoing revision ACL reconstruction (REV group) were assessed with CT. Grid measurements of the femoral and tibial tunnels and angle measurements of grafts were performed. Graft placement, rated as anatomic or nonanatomic, was assessed with both methods. Pearson chi-square, analysis of variance, Kruskal-Wallis, and weighted kappa tests were performed as appropriate. Results: The grid assessment classified 10% of the HAM group, 4% of the BPTB group, and 17% of the REV group as nonanatomic (P < .001). The angle assessment classified 37% of the HAM group, 54% of the BPTB group, and 47% of the REV group as nonanatomic. The weighted kappa between angle measurements and grid measurements was low in all groups (HAM: 0.009; BPTB: 0.065; REV: 0.041). Conclusion: The agreement between grid measurements and angle measurements was very low. The angle measurements seemed to overestimate nonanatomic tunnel placement. Grid measurements were better in identifying malpositioned grafts.
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Affiliation(s)
- Anagha P Parkar
- Department of Radiology, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | | | - Lasse M Giil
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Eirik Solheim
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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16
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Comparison of three approaches for femoral tunnel during double-bundle anterior cruciate ligament reconstruction: A case controlled study. J Orthop Sci 2019; 24:147-152. [PMID: 30245095 DOI: 10.1016/j.jos.2018.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 06/12/2018] [Accepted: 08/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is still controversial whether which femoral tunnel creation technique is best during anterior cruciate ligament reconstruction (ACLR). We aimed to clarify the features of three different techniques based on the femoral tunnel position created with the same tunnel-creating concept and the measurement data. METHODS The femoral tunnel of double-bundle (DB) ACLR was created using the behind-remnant approach in a remnant preserved manner following the policy of our institute. The trans-tibial approach (TT) was applied for all primary ACL injured cases until December 2012. The trans-portal approach (TP) was applied from January to September 2013, and the outside-in approach (OI) was indicated from October 2013 to March 2014. We compared the femoral tunnel aperture positions with the postoperative three-dimensional computed tomography (3D-CT). Additionally, the femoral tunnel length and the septum distance of each anteromedial (AM) and posterolateral (PL) tunnel were analyzed. RESULTS The AM tunnel aperture position of TT was significantly higher and shallower than that of TP in knee flexion position. The femoral tunnel length of TP was significantly shorter than that of TT and OI. The septum between each tunnel of OI trended wider than that of TT and TP. CONCLUSIONS The AM tunnel aperture position of TT runs the risk of a high and shallow position. TP runs the risk of insufficiently short tunnel length. It is important to apply each method flexibly to each case because no single best approach was found.
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Take Y, Shino K, Mae T, Tachibana Y, Iuchi R, Nakagawa S, Nakata K. Early Structural Results After Anatomic Triple Bundle Anterior Cruciate Ligament Reconstruction Validated by Tunnel Location, Graft Orientation, and Static Anteroposterior Tibia-Femur Relationship. Arthroscopy 2018; 34:2656-2665. [PMID: 30078691 DOI: 10.1016/j.arthro.2018.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 04/06/2018] [Accepted: 04/13/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To elucidate how closely the structural characteristics of the anterior cruciate ligament (ACL) grafts after anatomic triple bundle (ATB) reconstruction resembled those of the normal ACL. METHODS From 2012 to 2016, patients who underwent primary ATB ACL reconstruction using hamstring tendon autografts and the same number of healthy control subjects were included. Using magnetic resonance imaging (MRI) taken at 6 months postoperatively, ACL graft orientation was evaluated by the angles against the tibial plateau measured in the sagittal and oblique coronal planes at the anteromedial and posterolateral portions (ACL-tibial plateau angle [ATA]). For factors affecting the graft orientation, the static tibiofemoral relationship was evaluated by anteroposterior tibial translocation (APTT) in the identical MRI using a previously established method, and tunnel locations were evaluated using the quadrant method. To test equivalence, the widely used two one-sided test procedure was performed, with the equivalence margins of 5° and 3 mm for ATA and APTT, respectively. RESULTS Thirty-five patients were enrolled for each group. ATAs were not significantly different, and the 95% confidence interval (CI) of these differences was within 5° (sagittal: P = .211 [95% CI, -2.9 to 0.6]; oblique coronal ATA for the anteromedial and posterolateral portions: P = .269 [95% CI, -1.9 to 0.5] and P = .456 [95% CI,-2.1 to 0.9], respectively). The difference in APTT was neither statistically nor clinically significant (P = .114; 95% CI, -2.0 to 0.2). CONCLUSIONS These data suggest that ACL grafts using the ATB technique achieved a graft orientation equivalent to that of the normal ACL, with an equivalent postoperative anteroposterior tibiofemoral relationship in the static MRI. Thus, the ATB ACL reconstruction technique with the presented tunnel locations produced grafts that were similar to the native ACL in orientation. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Yasuhiro Take
- Department of Health and Sport Sciences, Medicine for Sports and Performing Arts, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Konsei Shino
- Sport Orthopaedic Center, Yukioka Hospital, Osaka, Japan
| | - Tatsuo Mae
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuta Tachibana
- Sport Orthopaedic Center, Yukioka Hospital, Osaka, Japan
| | - Ryo Iuchi
- Sport Orthopaedic Center, Yukioka Hospital, Osaka, Japan
| | | | - Ken Nakata
- Department of Health and Sport Sciences, Medicine for Sports and Performing Arts, Osaka University Graduate School of Medicine, Osaka, Japan
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Deng XH, Lebaschi A, Camp CL, Carballo CB, Coleman NW, Zong J, Grawe BM, Rodeo SA. Expression of Signaling Molecules Involved in Embryonic Development of the Insertion Site Is Inadequate for Reformation of the Native Enthesis: Evaluation in a Novel Murine ACL Reconstruction Model. J Bone Joint Surg Am 2018; 100:e102. [PMID: 30063598 PMCID: PMC6661256 DOI: 10.2106/jbjs.16.01066] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Since healing of anterior cruciate ligament (ACL) grafts occurs by formation of a fibrovascular scar-tissue interface rather than by reformation of the native fibrocartilage transition zone, the purpose of our study was to examine expression of various signaling molecules and transcription factors that are known to be involved in embryologic insertion-site development following ACL reconstruction. We also aimed to characterize a murine model of ACL reconstruction to allow future study of the molecular mechanisms of healing. METHODS Seventy-nine mice underwent reconstruction of the ACL with autograft. Healing was assessed using histology in 12 mice and quantitative real-time polymerase chain reaction (qRT-PCR) gene-expression analysis in 3 mice at 1 week postoperatively (Group-1 mice) and by biomechanical analysis in 7, histological analysis in 7, immunohistochemical analysis in 5, microcomputed tomography analysis in 5, and qRT-PCR analyses in 8 at 2 weeks (Group-2 mice) and 4 weeks (Group-3 mice) postoperatively. Fifteen additional mice did not undergo surgery and were used for biomechanical (7 mice), qRT-PCR (3 mice), and immunohistochemical (5 mice) analyses to obtain baseline data for the native ACL. RESULTS Histological analysis demonstrated healing by formation of fibrovascular tissue at the tendon-bone interface. Immunohistochemical analysis showed a positive expression of proteins in the Indian hedgehog, Wnt, and parathyroid hormone-related protein (PTHrP) pathways. There was minimal Sox-9 expression. Gene-expression analysis showed an initial increase in markers of tissue repair and turnover, followed by a subsequent decline. Mean failure force and stiffness of the native ACL were 5.60 N and 3.44 N/mm, respectively. Mean failure force and stiffness were 1.29 N and 2.28 N/mm, respectively, in Group 2 and were 1.79 N and 2.59 N/mm, respectively, in Group 3, with 12 of 14 failures in these study groups occurring by tunnel pull-out. CONCLUSIONS The spatial and temporal pattern of expression of signaling molecules that direct embryologic insertion-site formation was not adequate to restore the structure and composition of the native insertion site. CLINICAL RELEVANCE Development of a murine model to study ACL reconstruction will allow the use of transgenic animals to investigate the cellular, molecular, and biomechanical aspects of tendon-to-bone healing following ACL reconstruction, ultimately suggesting methods to improve healing in patients.
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Affiliation(s)
- Xiang-Hua Deng
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Amir Lebaschi
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Christopher L. Camp
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY,Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Camila B. Carballo
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Nathan W. Coleman
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Jianchun Zong
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Brian M. Grawe
- Sports Medicine and Shoulder Reconstruction, Department of Orthopaedics, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Scott A. Rodeo
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY,E-mail address for S.A. Rodeo:
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Bombaci H, Aykanat F. Drilling through anteromedial portal with a femoral aiming device ensures a sufficient length and a proper graft position, and prevents posterior wall breakage during anterior cruciate ligament reconstruction. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1403-1409. [PMID: 29705911 DOI: 10.1007/s00590-018-2211-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/14/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the characteristics of the femoral tunnel (FT) which was drilled through the AM portal by using a femoral aimer device and AP stability of the knee. METHODS Thirty-eight patients, with the mean age 29.6 (range: 20-43) years, were evaluated after ACL reconstruction. The mean follow-up time was 31.9 (range: 16-57) months. The FT was drilled using a femoral aimer with different offset according to the graft size measured, through the AM portal. The semitendinous and gracilis tendon autograft was used for reconstruction. The angles of FT and the exit point on the lateral condyle were measured on AP views of the knee. AP stability of the knee was measured with the KT-2000. RESULTS The mean angle of FT was 46.5° (± 8.4°), on the AP view. The mean distance between the exit point of FT and the most distal end of the femoral condyles was 46.7 (± 4.9) mm. The mean FT length was 36.1 (± 3.1) mm. The mean difference of anterior translation compared to the intact knee was 1.9 (± 1.6) mm. Except the three patients, with "one positive" pivot shift test, in the remaining 35 knees stability was equal to the healthy knee. CONCLUSIONS Femoral drilling by using a femoral aimer device through AM portal provided long enough FT for safe graft fixation and appropriate coronal plan obliquity. The exit point was far proximal from the insertion site of the popliteus tendon and lateral collateral ligament. Furthermore, the AM portal technique significantly improved AP stability of the knee.
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Affiliation(s)
- Hasan Bombaci
- Orthopaedics and Traumatology Department, Haydarpasa Numune Education and Research Hospital, Tibbiye Cad., 34671, Üsküdar, Istanbul, Turkey.
| | - Faruk Aykanat
- Sani Konukoglu Hospital, Sanko University, Gaziantep, Turkey
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Kim JG, Kang SH, Kim JH, Lim CO, Wang JH. Comparison of Clinical Results, Second-Look Arthroscopic Findings, and MRI Findings Between the Transportal and Outside-In Techniques for Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Trial With a Minimum 2-Year Follow-up. Am J Sports Med 2018; 46:544-556. [PMID: 29293362 DOI: 10.1177/0363546517744535] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques. PURPOSE To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups. RESULTS No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05). CONCLUSION With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.
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Affiliation(s)
- Jae Gyoon Kim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Seung Hoon Kang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Chae Ouk Lim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
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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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Chen H, Tie K, Qi Y, Li B, Chen B, Chen L. Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials. J Orthop Surg Res 2017; 12:167. [PMID: 29115973 PMCID: PMC5678560 DOI: 10.1186/s13018-017-0671-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 10/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study was to compare the clinical outcome and postoperative complication between single-bundle anterior cruciate ligament (ACL) reconstruction with an anteromedial (AM) technique and a transtibial (TT) technique. Methods The study includes clinical randomized controlled trials comparing the clinical outcomes of ACL reconstruction using the autologous hamstring tendon with an AM method and a TT method published up to September 2017 were retrieved from PubMed, Cochrane Library, and Embase databases. Relevant data were extracted and the Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality. Stata/SE 12.0 was used to perform a meta-analysis of the clinical outcome. Results Five RCTs were included, with a total of 479 patients: 239 patients and 240 patients in the AM group and the TT group, respectively. Assessing postoperative stability, better results were found in the AM group for the negative rate of the Lachman test (P < 0.05), the negative rate of the pivot-shift test (P < 0.05) and the side-to-side difference (P < 0.05). Assessing postoperative functional outcome, the AM group yielded superior results in proportion with International Knee Documentation Committee (IKDC) grade A (P < 0.05) and the Lysholm scores (P < 0.05) but had a comparable IKDC score (P > 0.05). In terms of postoperative complication, no significant difference was found between the AM group and the TT group (P > 0.05). Conclusions The outcome of single-bundle ACL reconstruction with the AM technique is better than that with the TT technique in terms of postoperative stability and functional recovery of the knee.
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Affiliation(s)
- Haitao Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Kai Tie
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yongjian Qi
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Bin Li
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Biao Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Liaobin Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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High non-anatomic tunnel position rates in ACL reconstruction failure using both transtibial and anteromedial tunnel drilling techniques. Arch Orthop Trauma Surg 2017; 137:1293-1299. [PMID: 28721590 DOI: 10.1007/s00402-017-2738-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Although it is well known from cadaveric and biomechanical studies that transtibial femoral tunnel (TT) positioning techniques are associated with non-anatomic tunnel positions, controversial data exist as so far no clinical differences could have been found, comparing transtibial with anteromedial techniques (AM). The purpose of the study was to analyze if graft failure following TT ACL reconstruction was more commonly associated with non-anatomic tunnel position in comparison with the AM technique. We hypothesized that, compared to AM techniques, non-anatomic tunnel positions correlate with TT tunnel positioning techniques. MATERIALS AND METHODS A total of 147 cases of ACL revision surgery were analyzed retrospectively. Primary ACL reconstructions were analyzed regarding the femoral tunnel drilling technique. Femoral and tibial tunnel positions were determined on CT scans using validated radiographic measurement methods. Correlation analysis was performed to determine differences between TT and AM techniques. RESULTS A total of 101 cases were included, of whom 64 (63.4%) underwent the TT technique and 37 (36.6%) the AM technique for primary ACL reconstruction. Non-anatomic femoral tunnel positions were found in 77.2% and non-anatomical tibial tunnel positions in 40.1%. No correlations were found comparing tunnel positions in TT and AM techniques, revealing non-anatomic femoral tunnel positions in 79.7 and 73% and non-anatomic tibial tunnel positions in 43.7 and 35.1%, respectively (p > 0.05). CONCLUSIONS Considerable rates of non-anatomic femoral and tibial tunnel positions were found in ACL revisions with both transtibial and anteromedial femoral drilling techniques. Despite the potential of placing tunnels more anatomically using an additional AM portal, this technique does not ensure anatomic tunnel positioning. Consequently, the data highlight the importance of anatomic tunnel positioning in primary ACL reconstruction, regardless of the applied drilling technique.
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Camp CL, Lebaschi A, Cong GT, Album Z, Carballo C, Deng XH, Rodeo SA. Timing of Postoperative Mechanical Loading Affects Healing Following Anterior Cruciate Ligament Reconstruction: Analysis in a Murine Model. J Bone Joint Surg Am 2017; 99:1382-1391. [PMID: 28816898 DOI: 10.2106/jbjs.17.00133] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Following anterior cruciate ligament (ACL) reconstruction, the mechanical loading of the tissues has a significant impact on tendon-to-bone healing. The purpose of this study was to determine the effect of the timing of the initiation of mechanical loading on healing of a tendon graft in a bone tunnel. METHODS ACL reconstruction using a flexor tendon autograft was performed in 56 mice randomized to 4 groups with differing times to initiation of postoperative mechanical loading: (1) immediate, (2) 5 days, (3) 10 days, or (4) 21 days following surgery. An external fixator was placed across the knee at the time of surgery and removed when mechanical loading was scheduled to commence. Following removal of the external fixator, animals were permitted free, unrestricted cage activity. All mice were killed on postoperative day 28, and tendon-to-bone healing was assessed by biomechanical testing, microcomputed tomography (micro-CT), and histological analysis. RESULTS The mean failure force (and standard deviation) of the reconstructed ACL at the time of sacrifice was highest for Group 2 (3.29 ± 0.68 N) compared with Groups 1, 3, and 4 (p = 0.008). Micro-CT bone volume fraction was greatest for Group 2 in the femoral tunnel (p = 0.001), tibial tunnel (p = 0.063), and both bones (p < 0.001). Similarly, histological analysis demonstrated a narrower scar tissue interface and increased direct contact at the tendon-bone interface (p = 0.012) for Group 2. CONCLUSIONS Following ACL reconstruction, a defined period of immobilization without weight-bearing appears to improve biomechanical strength of the healing tendon-bone interface, while prolonged periods without mechanical load and motion decrease the ultimate load to failure in this murine model. CLINICAL RELEVANCE The ideal period of restricted weight-bearing and motion following ACL reconstruction remains undefined. In a murine model, improved healing was noted for animals immobilized for a brief period of 5 days. This work may serve as an initial step in determining the ideal time period in a clinical population.
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Affiliation(s)
- Christopher L Camp
- 1Mayo Clinic, Rochester, Minnesota 2Tissue Engineering, Regeneration, and Repair Program, Hospital for Special Surgery, New York, NY
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Tanksley JA, Werner BC, Conte EJ, Lustenberger DP, Burrus MT, Brockmeier SF, Gwathmey FW, Miller MD. ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels? Orthop J Sports Med 2017; 5:2325967117704152. [PMID: 28567428 PMCID: PMC5439652 DOI: 10.1177/2325967117704152] [Citation(s) in RCA: 7] [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] [Indexed: 11/17/2022] Open
Abstract
Background: Anatomic femoral tunnel placement for single-bundle anterior cruciate ligament (ACL) reconstruction is now well accepted. The ideal location for the tibial tunnel has not been studied extensively, although some biomechanical and clinical studies suggest that placement of the tibial tunnel in the anterior part of the ACL tibial attachment site may be desirable. However, the concern for intercondylar roof impingement has tempered enthusiasm for anterior tibial tunnel placement. Purpose: To compare the potential for intercondylar roof impingement of ACL grafts with anteriorly positioned tibial tunnels after either transtibial (TT) or independent femoral (IF) tunnel drilling. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaver knees were randomized to either a TT or IF drilling technique. Tibial guide pins were drilled in the anterior third of the native ACL tibial attachment site after debridement. All efforts were made to drill the femoral tunnel anatomically in the center of the attachment site, and the surrogate ACL graft was visualized using 3-dimensional computed tomography. Reformatting was used to evaluate for roof impingement. Tunnel dimensions, knee flexion angles, and intra-articular sagittal graft angles were also measured. The Impingement Review Index (IRI) was used to evaluate for graft impingement. Results: Two grafts (2/6, 33.3%) in the TT group impinged upon the intercondylar roof and demonstrated angular deformity (IRI type 1). No grafts in the IF group impinged, although 2 of 6 (66.7%) IF grafts touched the roof without deformation (IRI type 2). The presence or absence of impingement was not statistically significant. The mean sagittal tibial tunnel guide pin position prior to drilling was 27.6% of the sagittal diameter of the tibia (range, 22%-33.9%). However, computed tomography performed postdrilling detected substantial posterior enlargement in 2 TT specimens. A significant difference in the sagittal graft angle was noted between the 2 groups. TT grafts were more vertical, leading to angular convergence with the roof, whereas IF grafts were more horizontal and universally diverged from the roof. Conclusion: The IF technique had no specimens with roof impingement despite an anterior tibial tunnel position, likely due to a more horizontal graft trajectory and anatomic placement of the ACL femoral tunnel. Roof impingement remains a concern after TT ACL reconstruction in the setting of anterior tibial tunnel placement, although statistical significance was not found. Future clinical studies are planned to develop better recommendations for ACL tibial tunnel placement. Clinical Relevance: Graft impingement due to excessively anterior tibial tunnel placement using a TT drilling technique has been previously demonstrated; however, this may not be a concern when using an IF tunnel drilling technique. There may also be biomechanical advantages to a more anterior tibial tunnel in IF tunnel ACL reconstruction.
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Affiliation(s)
- John A Tanksley
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Evan J Conte
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - David P Lustenberger
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - M Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Reid JC, Yonke B, Tompkins M. The angle of inclination of the native ACL in the coronal and sagittal planes. Knee Surg Sports Traumatol Arthrosc 2017; 25:1101-1105. [PMID: 28246878 DOI: 10.1007/s00167-017-4419-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 01/02/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE The purpose of this cross-sectional study was to evaluate the angle of inclination of the native anterior cruciate ligament (ACL) in both the sagittal and coronal planes and to evaluate these findings based on sex, height, BMI, and skeletal maturity. METHODS Inclusion criteria for the study included patients undergoing routine magnetic resonance imaging (MRI) of the knee at a single outpatient orthopedic center who had an intact ACL on MRI. Measurements of the angle of inclination were made on MRIs in both the sagittal and coronal planes. Patients were compared based on sex, height, BMI, and skeletal maturity. RESULTS One-hundred and eighty-eight patients were included (36 skeletally immature/152 skeletally mature; 98 male/90 female). The overall angle of inclination was 74.3° ± 4.8° in the coronal plane and 46.9° ± 4.9° in the sagittal plane. Skeletally immature patients (coronal: 71.8° ± 6.1°; sagittal: 44.7° ± 5.5°) were significantly different in both coronal and sagittal planes (P = 0.04 and 0.01, respectively) from skeletally mature patients (coronal: 75.3° ± 4.7°; sagittal: 47.4° ± 4.7°). There were no differences based on sex, height, or BMI. CONCLUSIONS There are differences between the angle of inclination findings in this study and other studies, which could be due to MRI and measurement techniques. Clinically, skeletal maturity may be important to account for when using the ACL angle of inclination to evaluate anatomic ACL reconstruction. LEVEL OF EVIDENCE Prognostic retrospective study, Level of evidence III.
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Affiliation(s)
- Jonathan C Reid
- University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Bret Yonke
- TRIA Orthopaedic Center, 8100 Northland Drive, Bloomington, MN, 55431, USA
| | - Marc Tompkins
- University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
- TRIA Orthopaedic Center, 8100 Northland Drive, Bloomington, MN, 55431, USA
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Ahn JH, Lee YS, Jeong HJ, Park JH, Cho Y, Kim KJ, Ko TS. Comparison of transtibial and retrograde outside-in techniques of anterior cruciate ligament reconstruction in terms of graft nature and clinical outcomes: a case control study using 3T MRI. Arch Orthop Trauma Surg 2017; 137:357-365. [PMID: 28132087 DOI: 10.1007/s00402-016-2606-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Indexed: 01/12/2023]
Abstract
INTRODUCTION This study was performed to compare ACL graft maturation and morphologies using MRI between trans-tibial (TT) and retrograde outside-in (OI) techniques, and to compare clinical outcomes between the two groups. MATERIALS AND METHODS Patients underwent single-tunnel ACL reconstruction using quadrupled hamstring autografts, with the TT technique used on 42 patients (TT group) and the retrograde OI technique used on 39 patients (OI group). All patients were examined with 3 T MRI at 6 months (between 5 and 7 months) after surgery. The signal intensity of the reconstructed graft was analyzed and compared between the two groups, using the signal/noise quotient (SNQ), the orientation of the ACL graft and the tibial tunnel location of the graft. The SNQ value is indicative of graft maturation, and the orientation of the graft and the tibial tunnel location of the graft represent graft morphology. Clinical evaluation was performed before the surgery and 2 years or more after the surgery. RESULTS The mean SNQ value of the TT group was significantly (P = 0.030) lower than that of the OI group. The mean sagittal ACL angle (P < 0.001) and the mean coronal ACL angle (P < 0.001) were more vertical in the TT group. The tibial tunnel aperture was located at a significantly (P < 0.001) more posterior position in the TT group. There was no statistically significant difference in the clinical results between the two groups. CONCLUSIONS The OI technique showed a more anteriorly positioned tibial tunnel and a more oblique graft orientation in both sagittal and coronal planes. However, in comparison with the TT group, a significantly higher SNQ value was noticed in the follow-up MRI of the OI group at 6 months, although clinical results of the two groups were not significantly different during at least the 2-year follow-up.
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Affiliation(s)
- Jin Hwan Ahn
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, South Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Hwa Jae Jeong
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, South Korea
| | - Jai Hyung Park
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, South Korea
| | - Yohan Cho
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, South Korea
| | - Kwang-Jeong Kim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, South Korea
| | - Taeg Su Ko
- Department of Orthopaedic Surgery, Barunbone Hospital, 261 Neungdong-ro, Gwangjin-gu, Seoul, 04998, South Korea.
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Venosa M, Delcogliano M, Padua R, Alviti F, Delcogliano A. Femoral Tunnel Positioning in Anterior Cruciate Ligament Reconstruction: Anteromedial Portal versus Transtibial Technique-A Randomized Clinical Trial. JOINTS 2017; 5:34-38. [PMID: 29114628 PMCID: PMC5672862 DOI: 10.1055/s-0037-1601413] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose The purpose of this study was to investigate, through three-dimensional computed tomography (3D-CT), the accuracy of femoral tunnel positioning in patients undergoing anterior cruciate ligament (ACL) reconstruction, comparing transtibial (TT) and anteromedial (AM) techniques. Methods We evaluated postoperative 3D-CT scans of 26 patients treated with ACL reconstruction with hamstrings autograft using a low accessory AM portal technique and 26 treated with the TT technique. The position of the femoral tunnel center was measured with the quadrant method. Results Using quadrant method on CT scans, femoral tunnels were measured at a mean of 32.2 and 28.1% from the proximal condylar surface (parallel to Blumensaat line) and at a mean of 31.2 and 15.1% from the notch roof (perpendicular to Blumensaat line) for the AM and TT techniques, respectively. Conclusion The AM portal technique provides more anatomical graft placement than TT techniques. Level of Evidence Level I, randomized clinical study.
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Affiliation(s)
- Michele Venosa
- Department of Orthopaedic Surgery, San Carlo di Nancy Hospital - GVM, Rome, Italy
| | - Marco Delcogliano
- Department of Orthopaedic Surgery, EOC - Ente Ospedaliero Cantonale - Lugano, Switzerland
| | - Roberto Padua
- GLOBE, Evidence-based Orthopaedics Working Group of the Italian Society of Orthopaedics and Traumatology; Nicola's Foundation, Arezzo, Italy
| | - Federica Alviti
- Department of Physical Medicine and Rehabilitation, “La Sapienza” University, Rome, Italy
| | - Antonio Delcogliano
- Department of Orthopaedic Surgery, San Carlo di Nancy Hospital - GVM, Rome, Italy
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Snoj Ž, Zupanc O, Stražar K, Salapura V. A descriptive study of potential effect of anterior tibial translation, femoral tunnel and anterior cruciate ligament graft inclination on clinical outcome and degenerative changes. INTERNATIONAL ORTHOPAEDICS 2017; 41:789-796. [PMID: 28064350 DOI: 10.1007/s00264-016-3386-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/20/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is no evidence that anatomically correct anterior cruciate ligament reconstruction (ACLR) offers lower rate of degenerative changes development or that it would lead to a better outcome. The significance and understanding of the abnormal anterior tibial translation (ATT) in ACLR patients is yet to be established. METHODS Sixty subjects (40 patients at 5.9 years after ACLR, 20 healthy controls) underwent 3 T MRI. Quantitative cartilage T2 mapping and morphological whole organ magnetic resonance imaging score (WORMS) evaluation was performed. Self-reported questionnaires were used for subjective clinical evaluation. Correlations were calculated with the following MRI measurements; femoral tunnel inclination, ACL graft inclination, lateral and medial compartment ATT. RESULTS In the ACLR group positive correlation was found between the patellar cartilage T2 values and sagittal ACL graft inclination. In the ACLR group lateral compartment ATT showed negative correlation with ACL graft inclination and subjective clinical evaluation, and positive correlation with morphological degenerative changes. Femoral tunnel showed positive correlation with ACL graft inclination in the same plane. CONCLUSIONS Increased ATT offers worse clinical outcome and increased rate of degenerative changes. Furthermore, ATT is affected by the ACL inclination. Inclination of the drilling tunnel affects ACL graft inclination; thereby independent drilling techniques provide superior results of anatomical ACL graft positioning.
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Affiliation(s)
- Žiga Snoj
- Institute of Radiology, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia.
| | - Oskar Zupanc
- Department of Orthopaedic Surgery of the Ljubljana University Medical Centre, Zaloška 9, 1000, Ljubljana, Slovenia
| | - Klemen Stražar
- Department of Orthopaedic Surgery of the Ljubljana University Medical Centre, Zaloška 9, 1000, Ljubljana, Slovenia
| | - Vladka Salapura
- Institute of Radiology, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
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Guler O, Mahırogulları M, Mutlu S, Cercı MH, Seker A, Cakmak S. Graft position in arthroscopic anterior cruciate ligament reconstruction: anteromedial versus transtibial technique. Arch Orthop Trauma Surg 2016; 136:1571-1580. [PMID: 27484876 DOI: 10.1007/s00402-016-2532-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Indexed: 01/15/2023]
Abstract
INTRODUCTION When treating anterior cruciate ligament (ACL) injuries, the position of the ACL graft plays a key role in regaining postoperative knee function and physiologic kinematics. In this study, we aimed to compare graft angle, graft position in tibial tunnel, and tibial and femoral tunnel positions in patients operated with anteromedial (AM) and transtibial (TT) methods to those of contralateral healthy knees. MATERIALS AND METHODS Forty-eight patients who underwent arthroscopic ACL reconstruction with ipsilateral hamstring tendon autograft were included. Of these, 23 and 25 were treated by AM and TT techniques, respectively. MRI was performed at 18.4 and 19.7 months postoperatively in AM and TT groups. Graft angles, graft positions in the tibial tunnel and alignment of tibial and femoral tunnels were noted and compared in these two groups. The sagittal graft insertion tibia midpoint distance (SGON) has been used for evaluation of graft position in tunnel. RESULTS Sagittal ACL graft angles in operated and healthy knees of AM patients were 57.78° and 46.80° (p < 0.01). With respect to TT patients, ACL graft angle was 58.87° and 70.04° on sagittal and frontal planes in operated knees versus 47.38° and 61.82° in healthy knees (p < 0.001). ACL graft angle was significantly different between the groups on both sagittal and frontal planes (p < 0.001). Sagittal graft insertion tibia midpoint distance ratio was 0.51 and 0.48 % in the operated and healthy knees of AM group (p < 0.001) and 0.51 and 0.48 % in TT group (p < 0.001). Sagittal tibial tunnel midpoint distance ratio did not differ from sagittal graft insertion tibia midpoint distance of healthy knees in either group. Femoral tunnel clock position was better in AM [right knee 10:19 o'clock-face position (310° ± 4°); left knee 1:40 (50° ± 3°)] compared with TT group [right knee 10:48 (324° ± 5°); left knee 1:04 (32° ± 4°)]. With respect to the sagittal plane, the anterior-posterior position of femoral tunnel was better in AM patients. Lysholm scores and range of motion of operated knees in the AM and TT groups showed no significant difference (p > 0.05). CONCLUSIONS Precise reconstruction on sagittal plane cannot be obtained with either AM or TT technique. However, AM technique is superior to TT technique in terms of anatomical graft positioning. Posterior-placed grafts in tibial tunnel prevent ACL reconstruction, although tibial tunnel is drilled on sagittal plane.
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Affiliation(s)
- Olcay Guler
- Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey.
| | - Mahir Mahırogulları
- Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey
| | - Serhat Mutlu
- Orthopedics and Traumatology Department, Kanuni Sultan Suleyman Training Hospital, Istanbul, Turkey
| | - Mehmet H Cercı
- Orthopedics and Traumatology Department, Nisa Hospital, Istanbul, Turkey
| | - Ali Seker
- Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey
| | - Selami Cakmak
- Orthopedics and Traumatology Department, Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey
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Nawabi DH, Tucker S, Schafer KA, Zuiderbaan HA, Nguyen JT, Wickiewicz TL, Imhauser CW, Pearle AD. ACL Fibers Near the Lateral Intercondylar Ridge Are the Most Load Bearing During Stability Examinations and Isometric Through Passive Flexion. Am J Sports Med 2016; 44:2563-2571. [PMID: 27440804 DOI: 10.1177/0363546516652876] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The femoral insertion of the anterior cruciate ligament (ACL) has direct and indirect fiber types located within the respective high (anterior) and low (posterior) regions of the femoral footprint. HYPOTHESIS The fibers in the high region of the ACL footprint carry more force and are more isometric than the fibers in the low region of the ACL footprint. STUDY DESIGN Controlled laboratory study. METHODS Ten fresh-frozen cadaveric knees were mounted to a robotic manipulator. A 134-N anterior force at 30° and 90° of flexion and combined valgus (8 N·m) and internal (4 N·m) rotation torques at 15° of flexion were applied simulating tests of anterior and rotatory stability. The ACL was sectioned at the femoral footprint by detaching either the higher band of fibers neighboring the lateral intercondylar ridge in the region of the direct insertion or the posterior, crescent-shaped fibers in the region of the indirect insertion, followed by the remainder of the ACL. The kinematics of the ACL-intact knee was replayed, and the reduction in force due to each sectioned portion of insertion fibers was measured. Isometry was assessed at anteromedial, center, and posterolateral locations within the high and low regions of the femoral footprint. RESULTS With an anterior tibial force at 30° of flexion, the high fibers carried 83.9% of the total anterior ACL load compared with 16.1% in the low fibers (P < .001). The high fibers also carried more anterior force than the low fibers at 90° of flexion (95.2% vs 4.8%; P < .001). Under combined torques at 15° of flexion, the high fibers carried 84.2% of the anterior ACL force compared with 15.8% in the low fibers (P < .001). Virtual ACL fibers placed at the anteromedial portion of the high region of the femoral footprint were the most isometric, with a maximum length change of 3.9 ± 1.5 mm. CONCLUSION ACL fibers located high within the femoral footprint bear more force during stability testing and are more isometric during flexion than low fibers. CLINICAL RELEVANCE It may be advantageous to create a "higher" femoral tunnel during ACL reconstruction at the lateral intercondylar ridge.
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Affiliation(s)
- Danyal H Nawabi
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York, USA
| | - Scott Tucker
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Kevin A Schafer
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Hendrik Aernout Zuiderbaan
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York, USA
| | | | - Thomas L Wickiewicz
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York, USA
| | - Carl W Imhauser
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Andrew D Pearle
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York, USA
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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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Thein R, Spitzer E, Doyle J, Khamaisy S, Nawabi DH, Chawla H, Lipman JD, Pearle AD. The ACL Graft Has Different Cross-sectional Dimensions Compared With the Native ACL: Implications for Graft Impingement. Am J Sports Med 2016; 44:2097-105. [PMID: 27179055 DOI: 10.1177/0363546516645531] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Impingement of anterior cruciate ligament (ACL) grafts against the femoral notch and the posterior cruciate ligament (PCL) is thought to be influenced primarily by tunnel position and graft orientation. Recent data have implied that the native ACL is ribbon-shaped. PURPOSE To evaluate the 3-dimensional shape and cross-sectional area of the native ACL versus the ACL graft and to compare the degree of impingement against the femoral notch and PCL. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Bilateral knee magnetic resonance images were analyzed for 27 patients with unilateral bone-patellar tendon-bone (BPTB) ACL reconstruction performed via transtibial or anteromedial portal femoral tunneling techniques. Three-dimensional models of the ACL, PCL, femur, and tibia were digitally rendered. The cross-sectional area and dimensions of the native ACL and the reconstructed graft were determined at 3 equally spaced locations and compared via Wilcoxon-Mann-Whitney and Kruskal-Wallis tests. In addition, impingement of the ACL on the PCL and femoral notch was graded in 3 groups. Chi-square or Fisher exact tests were used to compare the proportional differences of impingement of the native and reconstructed ACL on the PCL and femoral notch, respectively. All analyses were performed using 2-sided hypothesis testing, with statistical significance at P < .05. RESULTS Cross-sectional areas at all 3 points on the ACL graft were significantly greater than those of the native ACL (P < .001). The long- to short-axis ratio for the native ACL was significantly greater at each location compared with the corresponding locations along the ACL graft (P < .001), implying that the native ACL is "flatter" than is an ACL graft. There were 19 operated knees (70%) with contact or impingement between the ACL graft and the femoral notch compared with zero knees with a native ACL (P < .001). In addition, 22 operated knees (81%) showed contact or impingement between the ACL graft and the PCL, compared with 7 knees (26%) with a native ACL (P < .001). No significant differences in impingement frequency were noted between the transtibial and anteromedial tunneling techniques for ACL graft specimens (P > .05). CONCLUSION Native ACLs have a smaller cross-sectional area, are "flatter," and experience less incidence of impingement compared with anatomically placed BPTB ACL grafts.
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Affiliation(s)
- Ran Thein
- Department of Orthopedic Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Elad Spitzer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - John Doyle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Saker Khamaisy
- Department of Orthopedic Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Danyal H Nawabi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Harshvardhan Chawla
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Joseph D Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Andrew D Pearle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Abstract
The anatomic anterior cruciate ligament (ACL) reconstruction concept has developed in part from renewed interest in the insertional anatomy of the ACL, using surgical techniques that can reproduce this anatomy reliably and accurately during surgical reconstruction. Several technical tools are available to help identify and place the tibial and femoral grafts anatomically, including arthroscopic anatomic landmarks, a malleable ruler device, and intraoperative fluoroscopy. The changes in technique for anatomic tunnel placement in ACL reconstruction follow recent biomechanical and kinematic data that demonstrate improved time zero characteristics. A better re-creation of native ACL kinematics and biomechanics is achieved with independent femoral drilling techniques that re-create a central footprint single-bundle ACL reconstruction or double-bundle reconstruction. However, to date, limited short-term and long-term clinical outcome data have been reported that support using either of these techniques rather than a transtibial drilling technique. This lack of clear clinical advantage for femoral independent and/or double-bundle techniques may arise because of the potentially offsetting biologic incorporation challenges of these grafts when placed using these techniques or could result from modifications made in traditional endoscopic transtibial techniques that allow improved femoral and tibial footprint restoration.
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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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Alazzawi S, Sukeik M, Ibrahim M, Haddad FS. Surgical treatment of anterior cruciate ligament injury in adults. Br J Hosp Med (Lond) 2016; 77:227-31. [DOI: 10.12968/hmed.2016.77.4.227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sulaiman Alazzawi
- Specialty Registrar in the Trauma and Orthopaedic Department, Royal London Hospital, London E1 1BB
| | - Mohamed Sukeik
- Specialty Registrar in the Trauma and Orthopaedic Department, Princess Alexandra Hospital, Harlow, Essex
| | - Mazin Ibrahim
- Specialty Registrar in the Trauma and Orthopaedic Department, University College Hospital, London
| | - Fares S Haddad
- Consultant Orthopaedic Surgeon, Divisional Clinical Director of Surgical Specialties and Director of the Institute of Sport, Exercise & Health, University College Hospital, London
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Kilinc BE, Kara A, Oc Y, Celik H, Camur S, Bilgin E, Erten YT, Sahinkaya T, Eren OT. Transtibial vs anatomical single bundle technique for anterior cruciate ligament reconstruction: A Retrospective Cohort Study. Int J Surg 2016; 29:62-9. [PMID: 26987514 DOI: 10.1016/j.ijsu.2016.03.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Most of the ACL reconstruction is done with isometric single-bundle technique. Traditionally, surgeons were trained to use the transtibial technique (TT) for drilling the femoral tunnel. Our study compared the early postoperative period functional and clinical outcomes of patients who had ACL reconstruction with TT and patients who had ACL reconstruction with anatomical single-bundle technique (AT). MATERIAL METHOD Fifty-five patients who had ACL reconstruction and adequate follow-up between January 2010-December 2013 were included the study. Patients were grouped by their surgery technique. 28 patients included into anatomical single-bundle ACL reconstruction surgery group (group 1) and 27 patients were included into transtibial AC reconstruction group (group 2). Average age of patients in group 1 and group 2 was 28.3 ± 6, and 27.9 ± 6.4, respectively. Lachman and Pivot-shift tests were performed to patients. Laxity was measured by KT-1000 arthrometer test with 15, 20 and 30 pound power. All patients' muscle strength between both extremities were evaluated with Cybex II (Humac) at 60°/sec, 240°/sec frequencies with flexion and extension peak torque. The maximum force values of non-operated knee and the operated knee were compared to each other. Groups were evaluated by using International Knee Documentation Committee (IKDC) knee ligament healing Standard form, IKDC activity scale, modified Lysholm and Cincinnati evaluation forms. Return to work and exercise time of patients were compared. Functional and clinical outcomes of two groups were compared. NCSS 2007 and PASS 2008 Statistical Software programs were used for statistical analysis. RESULT There was no statistically significant difference between Lachman and Pivot-shift results (p > 0.01). Positive value of Pivot-shift test and incidence of anterior translation in Lachman test were higher in the patients who had TT. Lysholm activity level of patients who had TT, 33.3% (n = 9) were excellent, 51.9% (n = 14) were good and 14.8% (n = 4) were moderate; patients who had AT, 57.1% (n = 16) were excellent, 39.3% (n = 11) were good and 3.6% (n = 1) was good level. There was no statistically significant difference between Lysholm Activity level of the patients (p < 0.01). Lysholm Activity level of patients who had AT significantly higher than TT. There was no statistically significant difference between Modified Cincinnati activity level of the patients (p < 0.05). Modified Cincinnati activity level of patients who had AT were significantly higher than those had TT. There was no statistically significant difference between two groups with post treatment IKDC activity level (p < 0.01). Intense activity after treatment rate of patient who had AT was significantly higher than those had TT. There was statistically significant difference between Cybex extension-flexion 60 measurement and extension 240 measurement of the patients (p < 0.01). KT-1000 arthrometer test results with AT was better than the TT in antero-posterior translation of the knee kinematics at 20 and 30 pound of forces. Return to exercise time of patients who had TT was significantly higher than those had AT (p < 0.01). There was no statistically significant difference between return to work time of patients (p > 0.05). CONCLUSION Single-bundle anatomic ACL reconstruction was better than the TT in term of clinical, functional, and laboratory results. We believe that AT ACL reconstruction will increase in use and traditional method which is TT ACL reconstruction surgery will decrease in the long term. Theoretically, anatomic relocation of the ACL can provide better knee kinematics.
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Affiliation(s)
- Bekir Eray Kilinc
- Igdir State Hospital Orthopaedics and Traumatology Department, Turkey.
| | - Adnan Kara
- Istanbul Medipol University Orthopaedics and Traumatology Department, Turkey
| | - Yunus Oc
- Sisli Etfal Training and Research Hospital Orthopaedics and Traumatology Department, Turkey
| | - Haluk Celik
- Zonguldak State Hospital Orthopaedics and Traumatology Department, Turkey
| | - Savas Camur
- Catalca State Hospital Orthopaedics and Traumatology Department, Turkey
| | - Emre Bilgin
- İzmir Tepecik Training and Research Hospital, Orthopaedics and Traumatology Department, Turkey
| | | | | | - Osman Tugrul Eren
- Sisli Etfal Training and Research Hospital Orthopaedics and Traumatology Department, Turkey
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Lee DH, Kim HJ, Ahn HS, Bin SI. Comparison of Femoral Tunnel Length and Obliquity Between Transtibial, Anteromedial Portal, and Outside-In Surgical Techniques in Single-Bundle Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Arthroscopy 2016; 32:142-50. [PMID: 26422705 DOI: 10.1016/j.arthro.2015.07.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 06/27/2015] [Accepted: 07/27/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE It is unclear whether femoral tunnel length and obliquity differ after transtibial and independent femoral drilling techniques of anterior cruciate ligament (ACL) reconstruction. This meta-analysis therefore compared femoral tunnel length and obliquity in patients who underwent ACL reconstruction by the transtibial, anteromedial (AM) portal, and outside-in (OI) techniques. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, all studies comparing femoral tunnel length and obliquity with various measurement tools-from direct measurement to imaging methods such as plain radiography, computed tomography, or magnetic resonance imaging-in patients who underwent reconstruction by the transtibial or independent femoral drilling (AM portal or OI) techniques were included. RESULTS Fourteen studies were included in the meta-analysis. The femoral tunnel length was 7.8 to 11.0 mm longer (P < .05) and coronal obliquity was 7.5° to 29.1° more vertical (P < .05) with the transtibial technique than with the AM portal or OI technique. Femoral tunnel and graft obliquity in the sagittal plane, however, did not differ significantly (P > .05). CONCLUSIONS ACL reconstruction using the AM portal and OI femoral drilling techniques resulted in a shorter length and greater coronal obliquity of the femoral tunnel than did the transtibial technique. However, these 3 femoral drilling techniques resulted in similar obliquities of the femoral tunnel and graft in the sagittal plane. LEVEL OF EVIDENCE Level III, meta-analysis.
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Affiliation(s)
- Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyeong-Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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Parkar AP, Adriaensen MEAPM, Fischer-Bredenbeck C, Inderhaug E, Strand T, Assmus J, Solheim E. Measurements of tunnel placements after anterior cruciate ligament reconstruction--A comparison between CT, radiographs and MRI. Knee 2015; 22:574-9. [PMID: 26169660 DOI: 10.1016/j.knee.2015.06.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/28/2015] [Accepted: 06/22/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND A non-anatomic placement of the femoral and tibial tunnels may affect outcome in anterior cruciate ligament (ACL) reconstructions. Tunnel placements are validated with varying imaging modalities. We compared measurements of tunnel placements between radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in a clinical setting, assessed the reliability and aimed to decide on a possible "gold standard". METHODS All patients who had undergone at least two of three modalities, radiographs, MRI and CT, after ACL reconstruction between January 2011 and June 2013 were included. Two radiologists measured tunnel placements according to a standardized protocol. Interobserver agreement was assessed with intraclass correlation coefficients (ICC), the intermodality differences with Bland-Atman plots. Radiation data for CT studies were collected. RESULTS Forty-six CTs, 45 radiographs and 30 MRIs were reviewed. Femoral inter-observer agreement for radiographs was ICC=0.64, for CT ICC=0.86 and for MRI ICC = 0.75. Tibial inter-observer agreement for radiographs was ICC=0.92, for CT-mip ICC=0.91, for CT and MRI ICC = 0.87. No intermodality differences between the femoral measurements were observed. In the tibia, there were differences between radiographs and CT (-3.9%), radiographs-MRI (-3.6%), CT-CT mip (3.2%) and CTmip-MRI (-3.1%). The effective radiation doses varied between 0.025 and 0.045 mSv, mean and median was 0.033 mSv. CONCLUSION There were differences in the tibial measurements between summation and single slice images. Only 3D-CT depicted the femoral tunnel in both directions. CT was consistently reliable in both femoral and tibial measurements. Effective radiation dose from CT was lower than previously reported. CT can safely be used in routine clinical practice to evaluate tunnel placements after ACL reconstruction.
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Affiliation(s)
- Anagha P Parkar
- Radiology Department, Haraldsplass Deaconess Hospital, Postboks 6165 Posterminalen, 5892 Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Postboks 7804, 5021 Bergen, Norway.
| | | | | | - Eivind Inderhaug
- Surgical Department, Haraldsplass Deaconess Hospital, Postboks 6165 Posterminalen, 5892 Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Postboks 7804, 5021 Bergen, Norway.
| | - Torbjørn Strand
- Surgical Department, Haraldsplass Deaconess Hospital, Postboks 6165 Posterminalen, 5892 Bergen, Norway.
| | - Jörg Assmus
- Centre for Clinical Research, Haukeland University Hospital, 5021 Bergen, Norway.
| | - Eirik Solheim
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Postboks 7804, 5021 Bergen, Norway.
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Short-Term Study of the Outcome of a New Instrument for All-Inside Double-Bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy 2015; 31:1893-902. [PMID: 25980402 DOI: 10.1016/j.arthro.2015.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 03/01/2015] [Accepted: 03/18/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the short-term clinical results and location of the bone tunnel with a new surgical procedure for all-inside double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS The double-bundle ACL reconstruction procedure was performed in 24 patients (13 male and 11 female patients) with a mean age of 31.0 years. Anterior and posterior tibial translation using an arthrometer (KT-1000; MEDmetric, San Diego, CA) and the Lysholm score were measured before surgery and at a mean of 24.8 months (range, 13 to 45 months) postoperatively. Computed tomography scans were taken to evaluate the bone tunnel positions using 3-dimensional images with the quadrant method for the femoral tunnel and Stäubli's technique for the tibial tunnel. RESULTS Three-dimensional computed tomography scans showed that the anteromedial and posterolateral tunnels were placed in anatomically appropriate positions. Arthrometric measurements showed that the mean side-to-side differences were 5.3 mm (SD, 1.6 mm) preoperatively and 0.05 mm (SD, 0.7 mm) at a mean of 24.8 months postoperatively, indicating a remarkable improvement (P < .00001). The mean Lysholm score was 56.3 points (SD, 14.8 points) preoperatively and 95.5 points (SD, 3.8 points) at final follow-up and was significantly improved after the operation (P < .00001). CONCLUSIONS The all-inside double-bundle ACL reconstruction technique used in this study resulted in the creation of tunnels in an anatomically appropriate position. Short-term clinical follow-up showed improvement in patient-reported outcomes and knee stability. This technique may provide an alternative option for all-inside ACL reconstruction. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Andrei BI, Niculescu M, Popescu G. Position of anterior cruciate ligament after single-bundle arthroscopic reconstruction. INTERNATIONAL ORTHOPAEDICS 2015; 40:393-7. [PMID: 26330084 DOI: 10.1007/s00264-015-2964-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 08/04/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The goal of this study was to assess the position of the reconstructed anterior cruciate ligament (ACL) in arthroscopic single-bundle ligamentoplasties through an anteromedial portal technique based on a clinical case series of 74 patients followed prospectively. METHODS This cohort study involved 100 patients who underwent arthroscopic ACL reconstruction between January 2012 and January 2014. Patients who underwent isolated ACL reconstruction were selected from 194 cases with associated lesions. Graft placement at the femoral side was within the femoral footprint of ACL. All patients received computed tomography scans and magnetic resonance imaging of both knees to compare ACL graft position to tht of the native ACL in the unaffected knee and to show whether drilling the femoral tunnel through the anteromedial portal closely approximates the native ACL alignment. RESULTS Seventy-four patients were available for follow-up. Mean value for the sagittal angle was 52.6° ± 2.9° for the graft-Blumensaat angle was 4.73° ± 0.75°., closely matching measurements in the contralateral normal knee. CONCLUSION Using the anteromedial portal for single-bundle arthroscopic ACL reconstruction enables graft positioning within the normal footprint and as close as possible to anatomic ACL orientation.
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Affiliation(s)
- Bogdan Ioan Andrei
- Orthopaedics and Traumatology, Clinical Emergency Hospital, Bucharest, Romania
| | - Marius Niculescu
- Titu Maiorescu University, Faculty of Medicine, Colentina Clinical Hospital, Bucharest, Romania.
| | - Gheorghe Popescu
- Orthopaedics and Traumatology, Clinical Emergency Hospital, Bucharest, Romania
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Outcome of Single-Bundle Hamstring Anterior Cruciate Ligament Reconstruction Using the Anteromedial Versus the Transtibial Technique: A Systematic Review and Meta-analysis. Arthroscopy 2015; 31:1784-94. [PMID: 26354196 DOI: 10.1016/j.arthro.2015.06.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 05/25/2015] [Accepted: 06/04/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the clinical outcomes of single-bundle hamstring anterior cruciate ligament (ACL) reconstruction between the anteromedial (AM) and transtibial (TT) techniques. METHODS We performed a comprehensive systematic review and meta-analysis of the English-language literature in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases for articles that compared clinical outcomes of AM versus TT ACL reconstruction. The outcome measures analyzed included postoperative Lachman test, pivot-shift test, International Knee Documentation Committee (IKDC), and Lysholm scores. RESULTS We included 10 articles from an initial 308 abstracts for the systematic review and included 6 studies for the meta-analysis. The study population consisted of a total of 733 patients, of whom 366 (49.9%) underwent the AM technique and 367 (50.1%) underwent the TT technique for ACL reconstruction. For postoperative knee stability, the AM technique yielded superior results in terms of the proportion of negative Lachman test results (n = 243; odds ratio [OR], 2.98 [95% confidence interval (CI), 1.29 to 6.88]) and proportion of negative pivot-shift test results (n = 238; OR, 3.67 [95% CI, 1.80 to 7.52]). For postoperative functional status, the AM technique yielded superior results in terms of objective IKDC grading (proportion with IKDC grade A) (n = 269; OR, 2.19 [95% CI, 1.23 to 3.88]) but had comparable Lysholm scores (n = 478; mean difference, 1.43 [95% CI, 0.01 to 2.84]). CONCLUSIONS Single-bundle hamstring ACL reconstruction using the AM technique showed superior surgeon-recorded stability according to the IKDC knee score, Lachman test, and pivot-shift test. However, there was no difference in patient-reported functional outcome (Lysholm score). LEVEL OF EVIDENCE Level III, systematic review and meta-analysis of Level I, II, and III studies.
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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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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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Clinical and three-dimensional computed tomographic comparison between ACL transportal versus ACL transtibial single-bundle reconstructions with hamstrings. Knee 2014; 21:1203-9. [PMID: 25257780 DOI: 10.1016/j.knee.2014.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/17/2014] [Accepted: 05/14/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction using a single-bundle transtibial technique can achieve good or excellent results in more than 90% of patients, but anatomical and biomechanical studies have questioned its ability to restore knee function. The purpose of this study was to evaluate clinical and tomographic results (patient satisfaction, knee function, and tunnel location) of patients who underwent transportal or transtibial single-bundle ACL reconstruction. METHODS Seventy-one patients with ACL tears were included. Forty-one patients were treated by the single-bundle transportal technique and 30 patients were treated by the single-bundle transtibial technique. Clinical and tomographic data were analyzed in both groups. RESULTS After a minimum of 2-year period, the transportal group showed more patients with normal clinical tests than the transtibial group (Lachman [p=0.037], pivot shift [0.00], anterior drawer [0.002]; and arthrometer [0.002] tests). Regarding CT evaluation, transportal and transtibial groups obtained the following femoral central tunnel location (mean [SD]), as percentage: 30 (6.5) and 4.2 (6.4) in high-low axis; and 30.9 (5.9) and 33.2 (4.6) in the deep-shallow axis. Values in the tibial side were, respectively: 38 (6.5) and 46.0 (6.8) in the anterior-posterior axis; and 47.2 (2.5) and 46.9 (2.1) in the medial-lateral axis. CONCLUSION CT findings showed that the transportal single-bundle technique positions the ACL tunnel closer to the native ACL footprint in both femur and tibia compared with the transtibial single-bundle technique. Moreover, mild asymptomatic instability and extension deficit were observed more often in the transtibial group.
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Moon DK, Yoon CH, Park JS, Kang BJ, Cho SH, Jo HS, Hwang SC. Effect of anteromedial portal entrance drilling angle during anterior cruciate ligament reconstruction: a three-dimensional computer simulation. Yonsei Med J 2014; 55:1584-91. [PMID: 25323895 PMCID: PMC4205698 DOI: 10.3349/ymj.2014.55.6.1584] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE The object of this study was to evaluate entrance angle effects on femoral tunnel length and cartilage damage during anteromedial portal drilling using three-dimensional computer simulation. MATERIALS AND METHODS Data was obtained from an anatomic study performed using 16 cadaveric knees. The anterior cruciate ligament femoral insertion was dissected and the knees were scanned by computer tomography. Tunnels with different of three-dimensional entrance angles were identified using a computer simulation. The effects of different entrance angles on the femoral tunnel length and medial femoral cartilage damage were evaluated. Specifically, tunnel length and distance from the medial femoral condyle to a virtual cylinder of the femoral tunnel were measured. RESULTS In tunnels drilled at a coronal angle of 45°, an axial angle of 45°, and a sagittal angle of 45°, the mean femoral tunnel length was 39.5±3.7 mm and the distance between the virtual cylinder of the femoral tunnel and the medial femoral condyle was 9.4±2.6 mm. The tunnel length at a coronal angle of 30°, an axial angle of 60°, and a sagittal angle of 45°, was 34.0±2.9 mm and the distance between the virtual cylinder of the tunnel and the medial femoral condyle was 0.7±1.3 mm, which was significantly shorter than the standard angle (p<0.001). CONCLUSION Extremely low and high entrance angles in both of axial plane and coronal plane produced inappropriate tunnel angles, lengths and higher incidence of cartilage damage. We recommend that angles in proximity to standard angles be chosen during femoral tunnel drilling through the anteromedial portal.
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Affiliation(s)
- Dong Kyu Moon
- Department of Orthopaedic Surgery, Military Hospital, Hongcheon, Korea
| | - Chul Ho Yoon
- Department of Rehabilitation Medicine and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin Seung Park
- Department of Orthopaedic Surgery and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, Korea
| | - Bun Jung Kang
- Department of Orthopaedic Surgery and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, Korea
| | - Seong Hee Cho
- Department of Orthopaedic Surgery and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, Korea
| | - Ho Seung Jo
- Department of Orthopaedic Surgery and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, Korea
| | - Sun Chul Hwang
- Department of Orthopaedic Surgery and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, Korea.
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Li H, Chen S, Tao H, Li H, Chen S. Correlation Analysis of Potential Factors Influencing Graft Maturity After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2014; 2:2325967114553552. [PMID: 26535275 PMCID: PMC4555546 DOI: 10.1177/2325967114553552] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Postoperatively, signal changes of the reconstructed anterior cruciate ligament (ACL) graft on magnetic resonance imaging (MRI) images commonly occurs, which may be a cause for concern. The signal intensity changes are usually expressed by signal/noise quotient (SNQ) value, representing graft maturity. To date, little is known about the factors influencing the SNQ value of the reconstructed ACL graft. Purpose: To evaluate ACL graft SNQ value and associated factors after ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Male patients who underwent ACL reconstruction using autograft or allograft tendon from September 2004 to September 2011 were randomly invited to take part in this investigation, including functional scores, physical examination, and MRI scan. The femoral side graft was fixed with Endobutton CL or Rigidfix pins, and the tibial side graft was fixed with a bio-intrafix. SNQ values of each graft were measured on MRI to represent graft maturity. Sagittal ACL angle, ACL–Blumensaat line angle, and medial and lateral posterior tibial slope (PTS) were measured using MRI 3-dimensional dual-echo steady-state images. Potential risk factors, including age, body mass index, postoperative time, Tegner activity scale (TAS), sagittal ACL angle, ACL–Blumensaat line angle, medial PTS, lateral PTS, and primary graft diameter, were tested for their association with the graft SNQ value by multivariate stepwise regression analysis. Results: A total of 104 male subjects (mean follow-up, 30.7 months) were examined, including 62 allograft and 42 autograft reconstructions. There was a significant association between graft SNQ and postoperative time (r = −0.431, P < .001), TAS (r = 0.295, P = .002), and ACL–Blumensaat line angle (r = −0.304, P = .002). Univariate regression analysis showed that TAS (β = 6.15, P < .001) positively correlated, postoperative time (β = −0.26, P < .001) negatively correlated, and ACL–Blumensaat line angle (β = −0.40, P = .038) negatively correlated with graft SNQ. Multivariate stepwise regression analysis showed that TAS, postoperative time, ACL–Blumensaat line angle, and age were significant independent factors associated with graft SNQ. Conclusion: The graft SNQ value had a significant positive correlation with physical activity level and a significant negative correlation with postoperative time in this study. Males with a shorter postoperative time and a higher physical activity level had higher graft signal intensity postoperatively.
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Affiliation(s)
- Hong Li
- Department of Sports Medicine, Huashan Hospital, Shanghai, People's Republic of China
| | - Shuang Chen
- Department of Radiology, Huashan Hospital, Shanghai, People's Republic of China
| | - Hongyue Tao
- Department of Radiology, Huashan Hospital, Shanghai, People's Republic of China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Shanghai, People's Republic of China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, Shanghai, People's Republic of China
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Wang H, Fleischli JE, Hutchinson ID, Zheng NN. Knee moment and shear force are correlated with femoral tunnel orientation after single-bundle anterior cruciate ligament reconstruction. Am J Sports Med 2014; 42:2377-85. [PMID: 25062662 DOI: 10.1177/0363546514541232] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Increasing evidence has shown that anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) better restores normal knee kinematics and functionality than nonanatomic ACLR. Whether anatomic reconstruction results in better knee kinetics during daily activities has not been fully investigated. PURPOSE To assess the relationship between femoral tunnel angle and kinetic parameters of the knee joint during walking after single-bundle ACLR and to compare the radiographic and kinetic results of patients who underwent anatomic ACLR with those of patients who underwent nonanatomic ACLR. STUDY DESIGN Controlled laboratory study. METHODS Twenty-one patients who underwent unilateral ACLR were recruited, and 20 healthy subjects from a previous study were used as a control group. All surgical procedures were performed by a single surgeon, 11 using the transtibial (TT) technique and 10 using the anteromedial portal (AMP) technique. Femoral tunnel orientation was measured from posterior-to-anterior radiographs. Dynamic knee joint moments and shear forces during gait were evaluated using 3-dimensional motion analysis and inverse dynamics. Relationships between femoral tunnel angles and kinetic results were evaluated via linear regression. Results were compared between 2 ACLR groups and controls using 1-way analysis of variance. RESULTS Femoral tunnel angle had significant correlations with peak external knee flexion moment and posterior shear force during early stance. The TT group had a significantly smaller (more vertical) mean femoral tunnel angle (19.4° ± 4.1°) than the AMP group (36.4° ± 5.8°). Significant reductions were found in the normalized peak external knee flexion moment (TT, 0.15 ± 0.12 Nm/kg·m; AMP, 0.25 ± 0.12 Nm/kg·m; control, 0.25 ± 0.16 Nm/kg·m) (P = .032) and posterior shear force (TT, 0.64 ± 0.55 N/kg; AMP, 1.10 ± 0.58 N/kg; control, 1.35 ± 0.55 N/kg) (P = .024) in the TT group compared with controls, but not in the AMP group. Moreover, a significantly greater medial shear force was found in the TT group during the late stance phase (TT, 1.08 ± 0.32 N/kg; AMP, 0.89 ± 0.26 N/kg; control, 0.83 ± 0.22 N/kg) (P = .038). A greater peak external knee adduction moment was found in both ACL groups during the early stance phase (TT, 0.25 ± 0.07 Nm/kg·m; AMP, 0.25 ± 0.07 Nm/kg·m; control, 0.19 ± 0.05 Nm/kg·m) (P < .01). CONCLUSION Knee joint kinetic changes are seen within months (~10 months) after ACLR. This study revealed significant relationships between femoral tunnel orientation and postoperative knee joint flexion moment and posterior shear force during walking. The AMP technique provides better restoration of these knee kinetic parameters compared with the TT technique at this postoperative time point. CLINICAL RELEVANCE The femoral tunnel angle measured from plain radiographs can be used as an important metric of postoperative knee joint kinetics. This information provides a better understanding of the knee joint's biomechanical environment after ACLR using commonly used single-bundle techniques.
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Affiliation(s)
- Hongsheng Wang
- Department of Mechanical Engineering and Engineering Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - James E Fleischli
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA
| | - Ian D Hutchinson
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Naiquan Nigel Zheng
- Department of Mechanical Engineering and Engineering Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA Center for Biomedical Engineering and Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
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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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