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Sugawara Y, Iwasaki K, Suzuki Y, Hishimura R, Matsubara S, Matsuoka M, Onodera T, Kondo E, Iwasaki N. Bone Density Distribution Pattern in the Lateral Wall of the Femoral Intercondylar Notch: Implications for the Direct Insertion of the Femoral ACL Attachment. Orthop J Sports Med 2024; 12:23259671241236807. [PMID: 38571484 PMCID: PMC10986171 DOI: 10.1177/23259671241236807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 04/05/2024] Open
Abstract
Background The ideal position of the femoral bone tunnel in the anterior cruciate ligament (ACL) is controversial. The functional importance of the ACL fiber varies depending on where it is attached to the femur. Functionally important fibers can cause high mechanical stress on the bone, and the Wolff law predicts that bone mineral density will increase at high mechanical stress sites. Purpose/Hypothesis The purpose of this study was to use computed tomography imaging to determine the distribution pattern of bone density in the lateral intercondylar wall. It was hypothesized that the high-density area (HDA) of the lateral intercondylar wall would reflect the functional insertion of the ACL as reported in previous anatomic studies. Study Design Descriptive epidemiology study. Methods Data from 39 knees without ACL injuries were retrospectively collected. The HDA of the lateral intercondylar wall was defined as the region containing the top 10% of the radiodensity values. The shape of the HDA was approximated as an ellipse, and the quadrant method was used to determine the center of the ellipse. The association between the ratio of the minor axis to the major axis of the ellipse and background characteristics was investigated. Results According to the quadrant method, the center of the HDA ellipse was 33.6% in the deep-shallow direction and 23.4% in the high-low direction. The center of the ellipse was comparable to the anatomic center of the ACL footprint, as previously reported. The ratio of the minor axis to the major axis of the ellipse was 0.58 (95% CI, 0.54-0.62). There was a significant negative correlation between the ratio of the minor axis to the major axis of the HDA ellipse and the posterior tibial slope (r = -0.38, P = .02). Conclusion The center of the HDA ellipse was found to be similar to the anatomic center of the ACL footprint. Considering the mechanical stress responses in bone, the HDA of the lateral intercondylar wall has the potential to represent the ACL insertion, especially functional insertion.
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Affiliation(s)
- Yutaro Sugawara
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuki Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryosuke Hishimura
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinji Matsubara
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masatake Matsuoka
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Dai Y, Gao WJ, Li WC, Xiang XX, Wang WM. Research progress on preparation of lateral femoral tunnel and graft fixation in anterior cruciate ligament reconstruction. World J Clin Cases 2023; 11:8247-8255. [PMID: 38130627 PMCID: PMC10731198 DOI: 10.12998/wjcc.v11.i35.8247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/01/2023] [Accepted: 12/01/2023] [Indexed: 12/14/2023] Open
Abstract
Anterior cruciate ligament (ACL) injury is one of the most common types of sports injuries. People's need to participate in sports and desire for a high quality of life promotes the continuous development of ACL reconstruction technology. Arthroscopic ACL reconstruction has been recognized as an effective method for the treatment of ACL injuries. This review analyses and summarizes the advantages and limitations of each surgical procedure for arthroscopic ACL reconstruction reported in the relevant literature so as to promote the future development of more relevant techniques.
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Affiliation(s)
- Yue Dai
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Wen-Jie Gao
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Wen-Chuan Li
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Xian-Xiang Xiang
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
| | - Wei-Ming Wang
- Department of Sports Medicine, Dalian University Affiliated Xinhua Hospital, Dalian 116021, Liaoning Province, China
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Xiao Y, Liang Z, Shen S, Liu F, Hu H, Chen B. Increased ACL direct insertion coverage provided more positive biomechanical effects on graft and bone tunnel during knee flexion: a simulation study. J Exp Orthop 2023; 10:108. [PMID: 37897510 PMCID: PMC10613193 DOI: 10.1186/s40634-023-00677-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023] Open
Abstract
PURPOSE Flattened femoral tunnels were recently applied in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Little is known about the biomechanical effect of such changes during knee flexion. The aim of the present simulation study was to assess the effect of altered ACL direct insertion coverage on the biomechanics of the graft and bone tunnel. METHODS Five finite element (FE) models, including a round femoral tunnel and four progressively flattened rounded rectangular femoral tunnels, were established to represent the ACL reconstructions. In vivo knee kinematics data obtained from the validated dual fluoroscopic imaging techniques controlled the FE models to simulate lunge motions. The maximal principal stress of the graft and the volume of equivalent strain within 1000-3000 microstrain (V1000-3000) of the cancellous bone were subsequently calculated at 0°, 30°, 60° and 90° of knee flexion. RESULTS A lower stress state on the graft and a more beneficial strain state on the cancellous bone were observed when the femoral tunnel better covered the ACL direct insertion. The average maximal principal stress of each model were 3.93 ± 0.60 MPa, 3.82 ± 0.54 MPa, 3.43 ± 0.44 MPa, 3.45 ± 0.44 MPa and 3.05 ± 0.43 MPa, respectively. The average V1000-3000 of the cancellous bone of each model were 179.06 ± 89.62 mm3, 221.40 ± 129.83 mm3, 247.57 ± 157.78 mm3, 282.74 ± 178.51 mm3 and 295.71 ± 162.59 mm3, respectively. Both the stress and strain values exhibited two peaks during the flexion simulation. The highest value occurred at 30° of flexion, and the second highest value occurred at 90° of flexion. CONCLUSIONS Increased ACL direct insertion coverage provided more positive biomechanical effects after anatomical single-bundle ACL reconstruction during knee flexion.
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Affiliation(s)
- Yang Xiao
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhaoxin Liang
- The First Clinical College of Southern Medical University, Guangzhou, China
| | - Shiwen Shen
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fei Liu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hai Hu
- Department of Orthopedic Surgery and Orthopedic Biomechanical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Bin Chen
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Mae T, Tsujii A, Sato S, Hirose T, Ishibashi Y, Suzuki T, Nakata K. Ultrasonic Technique for Femoral Tunnel Creation in Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2023; 12:e1271-e1280. [PMID: 37654883 PMCID: PMC10466142 DOI: 10.1016/j.eats.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/19/2023] [Indexed: 09/02/2023] Open
Abstract
Bone tunnel creation in the anatomical location is essential in anterior cruciate ligament (ACL) reconstruction with an autogenous graft and is commonly performed with a drill bit matched to graft diameter. Anatomic rectangular tunnel ACL reconstruction with a bone-patellar tendon-bone autograft has been developed to anatomically create bone tunnels inside the ACL footprints and has been reported to achieve excellent outcomes. To make the rectangular tunnel, the surgeon needs to dilate 2 adjacent bone tunnels after creation of 2 round tunnels with a drill bit, while the tunnel wall occasionally cracks during dilating. An ultrasonic (US) device was developed with improvement of output power and has been implemented with a rectangular shape blade in the field of arthroscopic surgery. This US device can provide a precise and effective bone cut compared to drills. We introduced this device to clinically create a rectangular tunnel during ACL reconstruction. The US device can be useful for rectangular femoral tunnel creation and can create a precise rectangular femoral tunnel in the ACL footprint.
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Affiliation(s)
- Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan, Osaka, Japan
| | - Akira Tsujii
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan, Osaka, Japan
| | - Seira Sato
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Japan, Osaka, Japan
| | - Takehito Hirose
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Japan, Osaka, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Tomoyuki Suzuki
- Department of Orthopaedic Surgery, Sapporo Maruyama Seikeigeka Hospital, Sapporo, Hokkaido, Japan
| | - Ken Nakata
- Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
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Zaffagnini S, Lucidi GA, Macchiarola L, Agostinone P, Neri MP, Marcacci M, Grassi A. The 25-year experience of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: the story so far. J Exp Orthop 2023; 10:36. [PMID: 37005946 PMCID: PMC10067780 DOI: 10.1186/s40634-023-00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023] Open
Abstract
This article presents with an evidence based approach, the kinematical rationale, biological evidence and the long term results of the "Over-The-Top" anterior cruciate ligament reconstruction with lateral plasty technique. This surgery was developed more than 25 years ago at the Rizzoli Institute by professor Marcacci and Zaffagnini and it is still widely performed in many orthopedic center worldwide.
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Affiliation(s)
- Stefano Zaffagnini
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Gian Andrea Lucidi
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Luca Macchiarola
- Ortopedia E Traumatologia, IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Piero Agostinone
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy.
| | - Maria Pia Neri
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Maurilio Marcacci
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Clinical and Research Center, Milan, Italy
| | - Alberto Grassi
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
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Cheng YH, Chiu CH, Chen ACY, Chan YS, Hsu KY. Outcomes of Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction According to GNRB Arthrometer Measurement. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020366. [PMID: 36837568 PMCID: PMC9966521 DOI: 10.3390/medicina59020366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/02/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023]
Abstract
Background and Objectives: To investigate the prognosis of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction, we used a GNRB (Genourob, Laval, France) arthrometer to measure surgical outcomes. Materials and Methods: This retrospective study reviewed patients who underwent combined ACL and ALL reconstruction and had a minimum follow-up of 2 years. Subjective outcomes, namely the International Knee Documentation Committee (IKDC) evaluation form scale scores and Lysholm scores, were evaluated preoperatively and postoperatively. We used a GNRB arthrometer to test the side-to-side laxity under pressures of 134 and 200 N, and we calculated the differential of the slope of the curves. We also recorded complications. Results: Our study examined 18 patients (mean age: 30.56 ± 8.9 years, range: 19-53) with a mean follow-up of 27.37 ± 3.4 months (range: 24-36). Both Lysholm and IKDC scores were significantly improved following the operation. The GNRB arthrometer measured mean anteroposterior laxity side-to-side as 0.76 ± 0.78 mm and 0.82 ± 0.8 mm under pressures of 134 and 200 N, respectively. The mean side-to-side differential slope under 200 N was 3.52 ± 2.17 μm/N. These values indicated that patients displayed no graft tear or low functional knee instability. All patients had a grade 3 pivot shift preoperatively; only two patients had a grade 1 pivot shift postoperatively, with the rest having a negative pivot shift. Conclusions: Our study revealed that combined ACL and ALL reconstruction has an excellent prognosis. GNRB measurement demonstrated excellent stability, and most patients had no residual pivot shift.
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Affiliation(s)
- You-Hung Cheng
- Department of Orthopedic Surgery, New Taipei Municipal Tu-Cheng Hospital, Chang Gung Memorial Hospital, New Taipei City 236, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chih-Hao Chiu
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Alvin Chao-Yu Chen
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Yi-Sheng Chan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Kuo-Yao Hsu
- Department of Orthopedic Surgery, New Taipei Municipal Tu-Cheng Hospital, Chang Gung Memorial Hospital, New Taipei City 236, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Correspondence: ; Tel.: +886-3-328-1200 (ext. 2163); Fax: +886-3-327-8113
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Borque KA, Laughlin MS, Pinheiro VH, Jones M, Williams A. Rebranding the 'anatomic' ACL reconstruction: Current concepts. J ISAKOS 2023; 8:23-28. [PMID: 36435433 DOI: 10.1016/j.jisako.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022]
Abstract
The anterior cruciate ligament (ACL) is a complex ribbon-like structure, which is approximately 3.5 times larger at the tibial and femoral insertions than at the midpoint. Accordingly, it is impossible to recreate with a single cylindrical graft. However, this has not stopped surgeons from using the term "anatomic" to describe multiple ACL reconstruction techniques inserting at a number of different locations within the original ACL footprint, causing confusion. The term "anatomic" should be discarded and replaced by an anatomic description of the tunnel placements on the tibia and femur. Current ACL reconstruction techniques cite anatomical studies that identified "direct and indirect fibres" of the ACL. The "direct fibres" bear 85-95% of the load and provide the main resistance to both anterior tibial translation and internal rotation/pivot shift. On the femur, these fibres insert in a line just posterior to the intercondylar ridge and comprise the portion of the ACL that surgeons should strive to restore. Placement of the graft just posterior to the intercondylar ridge creates a line of placement options from the anteromedial bundle to the "central" position and finally to the posterolateral bundle position. The authors prefer placing the femoral tunnel in the isometric anteromedial position and addressing a high-grade pivot shift at the IT-band with a lateral extra-articular tenodesis. As with the femoral tunnel, the native ACL footprint on the tibia is much larger than the ACL graft and thus can be placed in multiple "anatomic" locations. The authors prefer placement of the tibial tunnel in the anterior most position of the native footprint that does not cause impingement in the femoral notch. Additional research is needed to determine the ideal tunnel positions on the femur and tibia and validating the technique with patient outcomes. However, this cannot be accomplished without describing tunnel placement with specific anatomical locations so other surgeons can replicate the technique.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Hospital, Houston, TX, 77479, USA.
| | | | | | - Mary Jones
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
| | - Andy Williams
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
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Kinoshita T, Hashimoto Y, Iida K, Nakamura H. ACL Graft Matching: Cadaveric Comparison of Microscopic Anatomy of Quadriceps and Patellar Tendon Grafts and the Femoral ACL Insertion Site. Am J Sports Med 2022; 50:2953-2960. [PMID: 35914183 DOI: 10.1177/03635465221110895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal graft choice between the bone-patellar tendon-bone (BPTB) and the quadriceps tendon remains controversial. Studies evaluating the microscopic anatomy of the quadriceps tendon-patellar bone (QTB) and BPTB grafts for anterior cruciate ligament (ACL) reconstruction are currently lacking. HYPOTHESIS The relationship between post-ACL reconstruction graft bending angle (GBA) and the angle corresponding to the GBA (cGBA) would indicate that the BPTB can bend more than the QTB at the femoral tunnel aperture. STUDY DESIGN Controlled laboratory study. METHODS Twenty paired human cadaveric knees fixed at <10° of knee joint flexion (mean age, 82.5 years) underwent histological sectioning and staining with Masson trichrome and toluidine blue. The femoral ACL insertion, QTB graft, and BPTB graft were microscopically analyzed. The width of the direct insertion, thickness of the uncalcified fibrocartilage and calcified fibrocartilage, ligament attachment angle, and cGBA for each group were measured. Eighteen patients who underwent ACL reconstruction with QTB or BPTB autograft were included for the evaluation of GBA using computed tomography images at 1 week postoperatively. RESULTS The mean insertion widths of the femoral ACL, QTB, and BPTB were 7.81, 9.07, and 6.54 mm, respectively. The QTB was 16% wider than the ACL, while the BPTB was 16% narrower than the ACL. The mean insertion thicknesses of the femoral ACL, QTB, and BPTB were 0.53, 0.94, and 0.38 mm, respectively. The QTB was 77% thicker than the ACL (P < .001), while the BPTB was 28% thinner than the ACL (P = .017). The mean ligament attachment angles of the femoral ACL, QTB, and BPTB were 20.3°, 30.2°, and 33.3°, respectively, and the QTB and the BPTB were 49% and 64% larger, respectively, than the ACL. The mean cGBAs of the femoral ACL, QTB, and BPTB were 33.9°, 35.1°, and 12.3°, respectively. The BPTB was 64% smaller than the ACL, while there was no significant difference between the QTB and the ACL. The mean GBA was 57.7°. CONCLUSION The insertion width and thickness were significantly greater and smaller in the QTB and BPTB grafts, respectively, than in the ACL. The relationship between GBA after ACL reconstruction and cGBA in knee extension indicates that at the femoral tunnel aperture, the BPTB can bend more than the QTB. CLINICAL RELEVANCE QTB graft may allow more anatomic ACL reconstruction to be performed.
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Affiliation(s)
- Takuya Kinoshita
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ken Iida
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Systematic Review of Cadaveric Studies on Anterior Cruciate Ligament Anatomy Focusing on the Mid-substance Insertion and Fan-like Extension Fibers. Indian J Orthop 2022; 56:1525-1532. [PMID: 36052387 PMCID: PMC9385902 DOI: 10.1007/s43465-022-00695-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/30/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this systematic review was to review the anatomical reports concerning the anterior cruciate ligament (ACL) focusing on the mid-substance insertion and fan-like extension fibers, or direct and indirect insertions. METHODS Following the PRISMA, data collection was performed. PubMed, Web of Science, and the Cochran library were searched with the terms "anterior cruciate ligament reconstruction", "anatomy", and "cadaver". Studies were included when anatomical dissection of the ACL with cadavers was performed. Biomechanical studies without a detailed description of the anatomical dissection, reviews, and studies not including pictures of the anatomical specimens were excluded from this study. In the full article review, documentation of the mid-substance insertion and fan-like extension fibers, or direct and indirect insertions in the ACL morphology was evaluated in detail. RESULTS Fifty-seven studies were included for detailed evaluation. In 2006, Mochizuki et al. reported a macroscopic differentiation between the mid-substance insertion and fan-like extension fibers in the ACL footprint. In 2010, Iwahashi et al. detected the existence of direct and indirect insertions within the femoral ACL footprint, microscopically. Following Mochizuki's report, anatomical evaluation of the mid-substance insertion and fan-like extension fibers, or direct and indirect insertions was reported in 16 of 51 ACL anatomical studies. In studies focusing on the morphology of the ACL, 16 of 28 studies addressed this subject. In these studies, the mid-substance insertion and fan-like extension fibers were differentiated macroscopically, and the direct and indirect insertions were differentiated microscopically within the ACL footprint. Fan-like extension fibers or indirect insertion was reported to surround the mid-substance insertion or direct insertion within the femoral ACL footprint. CONCLUSIONS The results of this systematic review showed that, the existence of the mid-substance insertion and fan-like extension fibers, or direct and indirect insertions in ACL morphology is being recognized more widely. These structures should be taken into consideration when surgeons perform ACL surgery. LEVEL OF EVIDENCE III. Systematic review of Level-III studies. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-022-00695-4.
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Sasaki E, Kimura Y, Sasaki S, Fujita Y, Yamamoto Y, Tsuda E, Ishibashi Y. Influence of hamstring tendon and bone-patellar tendon-bone autografts on worsened patient reported outcome measurements in revision anterior cruciate ligament reconstruction: Comparing outcomes between primary and revision reconstructions. Asia Pac J Sports Med Arthrosc Rehabil Technol 2022; 29:1-8. [PMID: 35662999 PMCID: PMC9120044 DOI: 10.1016/j.asmart.2022.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/07/2022] [Accepted: 04/26/2022] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to compare the clinical outcomes and patient reported outcome measurement scales (PROMs) between hamstring tendon (HT) or bone-patellar tendon-bone (BTB) grafts in each primary and revision anterior cruciate ligament (ACL) reconstruction. Additionally, the clinical outcomes and PROMs between primary and revision surgeries were compared. Methods A total of 150 patients (109 primary and 41 revision ACL reconstructions) were enrolled and followed up for an average of 3.9 years (2 years minimum). Knee injury and osteoarthritis outcome scores (KOOS) were examined as PROMs. Side-to-side differences of anterior knee laxity were assessed using KT-1000 and were recorded at the final follow-up. After categorizing patients into HT and BTB reconstruction groups, regression analysis was performed to determine the relationship between revision surgery and changes in KOOS. Results In patients who underwent primary surgery, there was no significant difference in side-to-side differences of anterior laxity and KOOS between HT and BTB grafts. In those who underwent revision surgery, BTB grafts had a higher KOOS for activities of daily living (ADL) than HT grafts (p = 0.032). Comparing primary and revision surgeries, postoperative side-to-side differences of anterior laxity in the revision group were significantly larger than those in the primary group (p = 0.001). The KOOS for sports after overall revision reconstruction was significantly lower than that after primary reconstruction (p = 0.026). Comparing the KOOS after dividing all patients into HT and BTB reconstruction groups, in the HT reconstruction group, postoperative KOOS results were not different in any subscale from BTB grafts. In contrast, the KOOS for sports (p = 0.008) and QOL (p = 0.039) were significantly lower in revision surgery than in primary surgery. Furthermore, regression analysis including multiple confounders in the HT reconstruction group showed revision surgery using HT graft was correlated with worsened KOOS for symptoms (p = 0.012) and sports (p = 0.010). Revision surgery using BTB graft was not correlated with decreased KOOS. Conclusions There were no differences between the clinical outcome and KOOS in primary and revision surgery, except for ADL scores following revision ACL reconstruction using BTB graft. Side-to-side difference of anterior laxity and KOOS for sports following revision ACL reconstruction were inferior to those following primary ACL reconstruction.Furthermore, revision ACL reconstruction using HT grafts were correlated with low scores in KOOS for symptoms and sports, while there was no difference of anterior laxity between BTB and HT grafts in revision surgery.
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Affiliation(s)
- Eiji Sasaki
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shizuka Sasaki
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Fujita
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Yamamoto
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Li Z, Zhang W, Ren S, Zhou R, Zhang X, You T, Bai L. Relationship Between Number of Lateral Intercondylar Ridges and Area of Denser Bone on the Lateral Intercondylar Wall. Orthop J Sports Med 2022; 10:23259671221091332. [PMID: 35571965 PMCID: PMC9096202 DOI: 10.1177/23259671221091332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background: A deeper understanding of the anatomy of the intercondylar notch of the femur may help reduce technical errors during anatomic anterior cruciate ligament (ACL) reconstruction. Purposes: To classify the number of ridges on the lateral intercondylar wall, identify factors influencing the number of ridges, and define the relationship between the area of denser bone on the lateral intercondylar wall and the lateral intercondylar ridge. Study Design: Descriptive laboratory study. Methods: Included were 89 patients with computed tomography (CT) images of the knee joint. On full lateral view of the lateral femoral condyle, the authors evaluated for the presence of a lateral intercondylar ridge. The height and area of the lateral intercondylar wall (notch height and lateral notch area) and the length of Blumensaat line were calculated. Notch outlet length, axial notch area, notch width index, and transepicondylar length were also calculated using 3-dimensional CT. Maximum intensity projection was used to identify the area of denser bone on the femoral lateral intercondylar wall, and the relationship between this area and the lateral intercondylar ridge was investigated. Results: The lateral intercondylar ridge exhibited 3 types of morphological variations. The invisible type (no ridge) was observed in 20 knees (22.5%); the ridge type (1 ridge), in 23 knees (25.8%); and the plateau type (2 ridges), in 46 knees (51.7%). There were significant differences in notch height, lateral notch area, Blumensaat line length, and denser bone area among the ridge types (P ≤ .031 for all). The locations of the anterior ridge of the plateau type and of all 23 ridges of the ridge type corresponded to the anterior margin line of the area of denser bone. Conclusion: Significant differences were seen in the 3 types of lateral intercondylar ridges. The anterior margin line of the denser bone area on the lateral intercondylar wall was found to correspond to the anterior border of the plateau type and the ridge type. Clinical Relevance: The variations in the lateral intercondylar ridge may affect measurement accuracy during evaluation of ACL tunnel position while using the ridge as a landmark. The plateau-type ridge and the area of denser bone on the lateral intercondylar wall may provide a new way for surgeons to determine the femoral tunnel.
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Affiliation(s)
- Zijian Li
- Department of Sports Medicine and Rehabilitation, Peking University Shenzhen Hospital, Shenzhen, China
| | - Wentao Zhang
- Department of Sports Medicine and Rehabilitation, Peking University Shenzhen Hospital, Shenzhen, China
| | - Shiyou Ren
- Department of Sports Medicine and Rehabilitation, Peking University Shenzhen Hospital, Shenzhen, China
| | - Ri Zhou
- Department of Sports Medicine and Rehabilitation, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xintao Zhang
- Department of Sports Medicine and Rehabilitation, Peking University Shenzhen Hospital, Shenzhen, China
| | - Tian You
- Department of Sports Medicine and Rehabilitation, Peking University Shenzhen Hospital, Shenzhen, China
| | - Lu Bai
- Department of Sports Medicine and Rehabilitation, Peking University Shenzhen Hospital, Shenzhen, China
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A Modified Anatomic Transtibial Double-Bundle Anterior Cruciate Ligament Reconstruction Provides Reliable Bone Tunnel Positioning. Arthrosc Sports Med Rehabil 2022; 4:e435-e445. [PMID: 35494299 PMCID: PMC9042757 DOI: 10.1016/j.asmr.2021.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate the femoral and tibial tunnel positions via a modified anatomic transtibial double-bundle anterior cruciate ligament (ACL) reconstruction. Methods Patients who underwent double-bundle ACL reconstruction using the transtibial tunnel creation technique were identified. Double-bundle ACL reconstruction was performed for 94 knees using the transtibial tunnel creation technique. Tunnel aperture configurations and center positions of the anteromedial (AM) and posterolateral (PL) tunnels via postoperative 3-dimensional computed tomography were evaluated. Results There were 94 knees included. Regarding the intra-articular tunnel aperture configurations, the AM and PL tunnels overlapped at the femoral and tibial aperture in 66.0% and 94.7% cases, respectively. The mean femoral bone tunnel center was located at 23.0 ± 3.9% in the posterior-to-anterior ratio and 28.7 ± 6.0% in the proximal-to-distal ratio for the AM tunnels and at 32.8 ± 4.7% and 51.2 ± 5.2% for the PL tunnels, respectively. In the tibial tunnels, the mean AM tunnel center was located at 31.4 ± 3.6% in the anterior-to-posterior ratio and 44.3 ± 1.8% in the medial-to-lateral ratio and at 47.5 ± 3.8% and 44.3 ± 1.9% in the PL tunnel center, respectively. The femoral tunnels of outliers, both those created in nonanatomic positions as well as the posterior wall blowouts, were revealed in 7.4% cases. The nonanatomical bone tunnel group had significant heavier weight patients, lower tibial posterior slope, and were anterior in the AM and PL tunnel position. Posterior wall blowouts were related to posterior and proximal PL bone tunnel positions. Conclusions Modified transtibial double-bundle ACL reconstruction is a reliable tunnel creation technique with anatomic placement in 92.6% of the cases. The modification required that partially superimposing configuration of the 2 tibial tunnel apertures. The nonanatomic tunnels were related to patients of heavier weight and lower tibial posterior sloped knees, whereas the posterior wall blowouts were related to the posterior and proximal PL bone tunnel positions. Level of Evidence Level IV, therapeutic case series.
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Morales-Avalos R, Perelli S, Vilchez-Cavazos F, Castillo-Escobedo T, Peña-Martínez VM, Elizondo-Omaña R, Guzmán-López S, Padilla-Medina JR, Monllau JC. The morphology of the femoral footprint of the anterior cruciate ligament changes with aging from a large semicircular shape to a small flat ribbon-like shape. Knee Surg Sports Traumatol Arthrosc 2022; 30:3402-3413. [PMID: 35318508 PMCID: PMC9464138 DOI: 10.1007/s00167-022-06935-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 03/04/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Compare the differences in the morphology of the ACL femoral footprint between the cadavers of the young and elderly in consideration of the degenerative physiological process that occurs with aging. METHODS The femoral footprint of the ACL was dissected in 81 knees of known gender and age (45 male/36 female). They were divided into four groups by age and gender, establishing 50 years as the cut-off point to divide patients by age. Three observers analyzed the femoral footprint dissections, and the shapes were described and classified. The area and morphometric characteristics of the femoral insertion of the ACL were determined and these were compared between genders and age groups. RESULTS The femoral footprint of the ACL from the cadavers of males younger than 50 years of age presented a semicircular morphology in 90% of the cases. In males aged more than 50 years, a ribbon-like morphology was found in 96% of the cases. In women less than 50 years old, the semicircular morphology was observed in 93.7% of the cases. In women aged over 50 years old, the ribbon-like morphology was found in 95% of the cases. A significant difference was observed between the prevalence rates of the morphologies, area size and measurements of the younger and older groups (p < 0.001 for both genders). CONCLUSIONS The femoral insertion of the ACL presents variations in its morphology, area and morphometric characteristics over time. It goes from a large semicircular shape that almost contacts the posterior articular cartilage to a smaller, flattened ribbon-like shape that moves away from the edge of the articular cartilage. It is bounded anteriorly by the lateral intercondylar ridge. These findings should be considered to avoid employing reconstruction techniques in which femoral tunnels with oval or rectangular shapes are used in patients under 50 years of age because they do not correspond to the morphology of the femoral insertion of the ACL in this age group.
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Affiliation(s)
- Rodolfo Morales-Avalos
- Knee and Arthroscopy Unit (ICATKNEE-EQUILAE), Department of Orthopedic Surgery, Institut Catalá de Traumatologia i Medicina de l'Esport (I.C.A.T.M.E.), Hospital Universitari Dexeus, Universitat Autonoma de Barcelona (U.A.B.), Barcelona, Catalunya, Spain. .,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain. .,Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autonoma de Nuevo León (U.A.N.L), Monterrey, Nuevo León, México.
| | - Simone Perelli
- Knee and Arthroscopy Unit (ICATKNEE-EQUILAE), Department of Orthopedic Surgery, Institut Catalá de Traumatologia i Medicina de l’Esport (I.C.A.T.M.E.), Hospital Universitari Dexeus, Universitat Autonoma de Barcelona (U.A.B.), Barcelona, Catalunya Spain ,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Félix Vilchez-Cavazos
- Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine and University Hospital “Dr. José Eleuterio González”, Universidad Autonoma de Nuevo León (U.A.N.L), Monterrey, Nuevo León México
| | - Tadeo Castillo-Escobedo
- Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine and University Hospital “Dr. José Eleuterio González”, Universidad Autonoma de Nuevo León (U.A.N.L), Monterrey, Nuevo León México
| | - Víctor M. Peña-Martínez
- Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine and University Hospital “Dr. José Eleuterio González”, Universidad Autonoma de Nuevo León (U.A.N.L), Monterrey, Nuevo León México
| | - Rodrigo Elizondo-Omaña
- Department of Human Anatomy, School of Medicine , Universidad Autonoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León México
| | - Santos Guzmán-López
- Department of Human Anatomy, School of Medicine , Universidad Autonoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León México
| | - José Ramón Padilla-Medina
- Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine and University Hospital “Dr. José Eleuterio González”, Universidad Autonoma de Nuevo León (U.A.N.L), Monterrey, Nuevo León México
| | - Juan Carlos Monllau
- Knee and Arthroscopy Unit (ICATKNEE-EQUILAE), Department of Orthopedic Surgery, Institut Catalá de Traumatologia i Medicina de l’Esport (I.C.A.T.M.E.), Hospital Universitari Dexeus, Universitat Autonoma de Barcelona (U.A.B.), Barcelona, Catalunya Spain ,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
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Liew MY, Mortimer JW, Paxton JZ, Tham S, Rust PA. Histomorphology of the Subregions of the Scapholunate Interosseous Ligament and Its Enthesis. J Wrist Surg 2021; 10:467-475. [PMID: 34881102 PMCID: PMC8635837 DOI: 10.1055/s-0041-1723792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Background The scapholunate interosseous ligament (SLIL) has three subregions: dorsal, proximal, and volar. The SLIL enthesis has not previously been studied despite its important mechanical function in wrist joint biomechanics. Questions/Purposes This study aims to compare the histomorphological differences between the SLIL subregions, including at their entheses. Three questions are explored: Do the gross dimensions differ between SLIL subregions? Does the enthesis qualitatively, and its calcified fibrocartilage (CF) quantitatively, differ between (a) SLIL subregions and (b) scaphoid and lunate attachments? Methods Twelve fresh-frozen human cadaveric wrists were dissected and the gross dimensions of the SLIL subregions measured. Subregions were histologically processed for morphological and compositional analyses, including quantification of enthesis CF area. Results The dorsal subregion was the thickest. The dorsal and volar subregions had fibrocartilaginous entheses, while the proximal subregion was attached to articular cartilage. The dorsal subregion had significantly more CF than the volar subregion. There was no significant difference in the enthesis CF between scaphoid and lunate attachments in the three subregions. Conclusions There are significant morphological differences between the SLIL subregions. The dorsal subregion has the largest amount of CF, which is consistent with the greater biomechanical force subjected to this subregion. The similar histomorphology of the ligament at the scaphoid and lunate entheses suggests that similar biomechanical forces are applied to both attachments. Clinical Relevance The histomorphological results confirm that the dorsal subregion is the strongest of the three subregions. The results from the entheseal region may have important implications in the study of graft incorporation during SLIL reconstruction.
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Affiliation(s)
- Mei Yen Liew
- Department Plastic Surgery, Hooper Hand Unit, St John's Hospital, Livingston, United Kingdom
- Department of Anatomy, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Scotland, United Kingdom
| | - Jeremy W. Mortimer
- Department of Anatomy, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Scotland, United Kingdom
| | - Jennifer Z. Paxton
- Department of Anatomy, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Scotland, United Kingdom
| | - Stephen Tham
- Department of Plastic and Hand Surgery, St Vincent's Hospital, Hand and Wrist Biomechanics Laboratory/O'Brien Institute, Melbourne, Australia
| | - Philippa A. Rust
- Department Plastic Surgery, Hooper Hand Unit, St John's Hospital, Livingston, United Kingdom
- Department of Anatomy, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Scotland, United Kingdom
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Sasaki S, Sasaki E, Kimura Y, Yamamoto Y, Tsuda E, Ishibashi Y. Clinical Outcomes and Postoperative Complications After All-Epiphyseal Double-Bundle ACL Reconstruction for Skeletally Immature Patients. Orthop J Sports Med 2021; 9:23259671211051308. [PMID: 34778480 PMCID: PMC8586179 DOI: 10.1177/23259671211051308] [Citation(s) in RCA: 6] [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: 07/04/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
Background The treatment strategy for pediatric anterior cruciate ligament (ACL) tears, especially in patients with open physes, remains controversial. Purpose To assess clinical outcomes and postoperative complications after all-epiphyseal double-bundle ACL (DB-ACL) reconstruction for patients with open physes. Study Design Cohort study; Level of evidence, 3. Methods Included were 102 patients aged ≤15 years who underwent ACL reconstruction at a single institution and had a minimum of 2 years of follow-up. Of these patients, 18 had undergone all-epiphyseal DB-ACL reconstruction (mean age, 12.4 ± 1.2 year) and 84 had undergone conventional DB-ACL reconstruction (mean age, 14.1 ± 0.9 year). The outcomes of the all-epiphyseal group were compared with those of the conventional group. Objective clinical outcomes included KT-1000 arthrometer measurements of side-to-side difference in anterior tibial translation, Lachman test grade, and pivot-shift test grade. Radiographic angular deformity (defined as >3° of the side-to-side difference in femorotibial angle) and incidence of second ACL injury were also compared. Results The postoperative side-to-side difference in laxity significantly improved from 6.1 ± 2.4 to 0.6 ± 0.9 mm in the all-epiphyseal group (P = .001), and postoperative laxity was similar to that of the conventional group (0.4 ± 0.8 mm; P = .518). A Lachman grade 1 positive result was observed in 20% of the all-epiphyseal group and 3% of the conventional group (P = .042), and a pivot-shift grade 1 positive result was observed in 22% of the all-epiphyseal group and 4% of the conventional group (P = .074). A total of 4 patients (26.7%) in the all-epiphyseal group and 4 (6.1%) in the conventional group demonstrated angular deformity (P = .035). The incidence of postoperative ipsilateral ACL tear was 16.7% in the all-epiphyseal group and 23.8% in the conventional group (P = .757). The incidence of contralateral ACL tear was 11.1% in the all-epiphyseal group and 14.3% in the conventional group (P ≥ .999). Conclusion All-epiphyseal DB-ACL reconstruction for skeletally immature patients achieved satisfactory clinical outcomes compared with conventional DB-ACL reconstruction. The incidence of ipsilateral graft rupture was relatively high in both groups. The all-epiphyseal group had a significantly higher incidence of angular deformity.
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Affiliation(s)
- Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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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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Anterior cruciate ligament reconstruction with femoral direct fiber insertion: a novel arthroscopic surgical procedure for treatment of anterior cruciate ligament injury. Chin Med J (Engl) 2021; 135:231-233. [PMID: 34670245 PMCID: PMC8769122 DOI: 10.1097/cm9.0000000000001771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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18
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Wen Z, Zhang H, Yan W, Mohamed SI, Zhao P, Huang X, Xu Z, Zhang J, Zhou A. Anatomical Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autografts: A Comparative Study of Three Different Techniques. J Knee Surg 2021; 34:1243-1252. [PMID: 32369840 DOI: 10.1055/s-0040-1702164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The ideal procedure for anterior cruciate ligament (ACL) reconstruction is one that can achieve anatomical restoration for a better ACL function. This retrospective comparative study was conducted to evaluate the objective and subjective clinical results of the conventional single-bundle femoral round (SBR) tunnel technique, the single-bundle femoral oval (SBO) tunnel technique, and the double-bundle (DB) surgical technique for anatomical ACL reconstruction with hamstring tendon autografts. Patients who underwent the SBO, SBR, and DB ACL reconstructions from January 2016 to August 2017 were included in this study. A total of 163 patients underwent different surgical techniques; 41 patients underwent the SBO procedure, 78 patients received SBR, and the remaining 44 patients underwent the DB procedure. The Lachman's test, pivot-shift test, Lysholm's score, International Knee Documentation Committee (IKDC) score, and Tegner's score were compared among groups postoperatively. KT-1000 was used to measure the anterior laxity of the knee. Magnetic resonance imaging was used to compare the ACL graft maturity. Second-look arthroscopy was conducted to compare the graft status and synovial coverage. Significant differences among groups were found with respect to the Lysholm's score, Tegner's score, and IKDC score. Patients in the SBO and DB groups acquired higher functional scores than the SBR group. More patients with positive pivot-shift test were observed in the SBR group than other groups at 12- and 24-month postoperative follow-ups. The postoperative KT-1000 was better in the SBO and DB groups than in the SBR group. The mean signal/noise quotient (SNQ) of the SBO group was 2.70 ± 0.92, significantly lower than 3.58 ± 1.21 of the SBR group. Despite a higher proportion of patients with grade B or C synovial coverage and partial graft injury found in the SBR group, there were no significant differences among the groups. The SBO and DB technique achieved better clinical results than the SBR technique. The SBO technique was indeed an ideal surgical procedure for ACL reconstruction provided that the shortcoming of DB technique must be taken into account. This is a Level III, retrospective comparative study.
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Affiliation(s)
- Zhenxing Wen
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,The College of Clinical Medicine, Chongqing Medical University, Chongqing, People's Republic of China
| | - Hua Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Wenlong Yan
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Sheikh Ibrahimrashid Mohamed
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,The College of Clinical Medicine, Chongqing Medical University, Chongqing, People's Republic of China.,Department of Orthopaedics, Webuye County Hospital, Webuye, Kenya
| | - Pei Zhao
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiao Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zijie Xu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,The College of Clinical Medicine, Chongqing Medical University, Chongqing, People's Republic of China
| | - Jian Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Aiguo Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Uchida R, Shino K, Iuchi R, Tachibana Y, Yokoi H, Nakagawa S, Mae T. Anatomical Triple Bundle Anterior Cruciate Ligament Reconstructions With Hamstring Tendon Autografts: Tunnel Locations and 2-Year Clinical Outcomes. Arthroscopy 2021; 37:2891-2900. [PMID: 33887415 DOI: 10.1016/j.arthro.2021.03.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To anatomically clarify the location of the tunnel apertures created using the bony landmark strategy and to elucidate clinical outcomes after anatomic triple-bundle (ATB) anterior cruciate ligament (ACL) reconstruction. METHODS Thirty-two patients with unilateral ACL injury who had consented to undergo computed tomography (CT) at 3 weeks, as well as 2-year follow-up evaluation, were enrolled. At the time of surgery, remnant tissues were thoroughly cleared to create 2 femoral and 3 tibial tunnels inside the ACL attachment areas bordered by the bony landmarks. Two double-looped semitendinosus tendon autografts were prepared and fixed on the femur with two EndoButton-CLs and secured to the tibia with pullout sutures and plates with 10-20N of tension. The location of the tunnel aperture areas was assessed using 3-dimensional CT images, and 2-year postoperative clinical outcomes were evaluated. RESULTS The CT evaluation showed 100% of the femoral tunnel aperture area and at least 79% of the tibial tunnel aperture area were located inside the anatomic attachment areas. Thirty patients were available for clinical evaluation. The International Knee Documentation Committee subjective assessment showed all of the patients were classified as "normal" or "nearly normal." Lachman and pivot-shift tests were negative in 100% and 93%, respectively. The mean side-to-side difference of anterior laxity at the maximum manual force with a KT-1000 Knee Arthrometer was 0.7 ± 0.7 mm, ranging from 0 to 2 mm. CONCLUSION In ATB ACL reconstructions with hamstring tendon grafts, the tunnels can be created in proper locations using the arthroscopically-identifiable bony landmarks. Moreover, ATB ACL reconstruction with hamstring tendon grafts via the proper tunnels result in consistently satisfactory clinical outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ryohei Uchida
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka; Department of Orthopaedic Sports Medicine, Kansai Rosai Hospital, Hyogo.
| | - Konsei Shino
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Ryo Iuchi
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Yuta Tachibana
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Hiroyuki Yokoi
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Shigeto Nakagawa
- Department of Sports Orthopaedic Center, Yukioka Hospital, Osaka
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Yamauchi S, Ishibashi K, Sasaki E, Sasaki S, Kimura Y, Ishibashi Y. Failure load of the femoral insertion site of the anterior cruciate ligament in a porcine model: comparison of different portions and knee flexion angles. J Orthop Surg Res 2021; 16:526. [PMID: 34429129 PMCID: PMC8383361 DOI: 10.1186/s13018-021-02676-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study compared the failure load of the femoral insertion site of the anterior cruciate ligament between different portions and knee flexion angles. METHODS In total, 87 fresh-frozen, porcine knees were used in this study. Three knees were used for histological evaluation; the remaining 84 knees were randomly divided into 4 groups: anterior anteromedial bundle, posterior anteromedial bundle, anterior posterolateral bundle, and posterior posterolateral bundle groups (n=21 per group). The anterior cruciate ligament femoral insertion site was divided into these four areas and excised, leaving a 3-mm square attachment in the center of each bundle. Tibia-anterior cruciate ligament-femur complexes were placed in a material testing machine at 30°, 120°, and 150° of knee flexion (n=7), and the failure load for each portion was measured under anterior tibial loading (0.33 mm/s). RESULTS Histological study showed that the anterior cruciate ligament femoral insertion site consisted of direct and indirect insertions. Comparison of the failure load between the knee flexion angles revealed that all the failure loads decreased with knee flexion; significant decreases were observed in the failure load between 30 and 150° knee flexion in the posterior anteromedial bundle and posterior posterolateral bundle groups. Comparison of the failure load according to different portions revealed a significant difference between the anteromedial and posterolateral bundle groups at 150° of knee flexion, but no significant difference among the groups at 30° of flexion. CONCLUSIONS Although the failure load of the posterior portion decreased significantly in the knee flexion position, it (mainly consisting of indirect insertion) plays a significant role against anterior tibial load in the knee extension position; this appears to be related to the characteristics of the insertion site. Reflecting the complex structure and function of the ACL, this study showed that the failure load of the femoral insertion site varies with differences in positions and knee flexion angles.
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Affiliation(s)
- Shohei Yamauchi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | | | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
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Hirtler L, Kainberger F, Röhrich S. The intercondylar fossa-A narrative review. Clin Anat 2021; 35:2-14. [PMID: 34374453 PMCID: PMC9291140 DOI: 10.1002/ca.23773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/22/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022]
Abstract
The intercondylar fossa (“intercondylar notch,” IN) is a groove at the distal end of the femur, housing important stabilizing structures: cruciate ligaments and meniscofemoral ligaments. As the risk for injury to these structures correlates with changes to the IN, exact knowledge of its morphology, possible physiological and pathological changes and different approaches for evaluating it are important. The divergent ways of assessing the IN and the corresponding measurement methods have led to various descriptions of its possible shapes. Ridges at the medial and lateral wall are considered clinically important because they can help with orientation during arthroscopy, whereas ridges at the osteochondral border could affect the risk of ligament injury. Changes related to aging and sex differences have been documented, further emphasizing the importance of individual assessment of the knee joint. Overall, it is of the utmost importance to remember the interactions between the osseous housing and the structures within.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Franz Kainberger
- Department of Radiology and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sebastian Röhrich
- Department of Radiology and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
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Taketomi S. Editorial Commentary: Tunnel Widening After Anterior Cruciate Ligament Reconstruction May Increase Laxity and Complicate Revision. Arthroscopy 2021; 37:2564-2566. [PMID: 34353560 DOI: 10.1016/j.arthro.2021.04.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 02/02/2023]
Abstract
Tunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction has been a research area of interest in ACL reconstruction. It has been demonstrated that femoral tunnels enlarge anteriorly and distally (ie, the direction where the mechanical traction force of the graft works) rather than concentrically after anatomic double-bundle ACL reconstruction using hamstring autografts. This finding suggests that the wall supporting the graft moves closer to the direction of the pull, leading to increased laxity of the knee joint due to TW. The causes of TW are presumed to be multifactorial, with both biological and mechanical features. Biological factors include osteolytic cytokines that enter the space between the graft and the bone through the synovial fluid. Mechanical factors include longitudinal graft motion by extracortical femoral fixation (known as the bungee effect), transverse graft motion (also called the windshield-wiper effect), improper graft placement, higher initial graft tension, accelerated rehabilitation, and so on. Although TW does not seem to affect short-term clinical outcomes from studies published to date, it is plausible to speculate that the expansion of the bone tunnel (ie, the edge where the graft tendon is fixed) would theoretically increase joint laxity to some extent, and it would be premature to conclude that TW has no effect on clinical outcomes relative to graft-tunnel micromotion. In addition, there is a general consensus that the presence of expanded tunnels often severely complicates revision ACL reconstruction. In ACL reconstruction using the hamstring tendon, it is necessary to take into account the possibility of a shift in the tunnel position when determining the location of the femoral tunnel.
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Sasaki Y, Fujii M, Araki D, Marshall BD, Linde MA, Smolinski P, Fu FH. Effect of Percentage of Femoral Anterior Cruciate Ligament Insertion Site Reconstructed With Hamstring Tendon on Knee Kinematics and Graft Force. Am J Sports Med 2021; 49:1279-1285. [PMID: 33656943 DOI: 10.1177/0363546521995199] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have stated that closely matching the size of the anterior cruciate ligament (ACL) insertion site footprint is important for biomechanical function and clinical stability after ACL reconstruction. However, the ACL varies widely regarding the area of femoral insertion, tibial insertion, and midsubstance of ACL, and reconstructing the insertion site area with a uniform diameter graft can result in a cross-sectional area that is greater than that of the midsubstance of the native ACL. Therefore, understanding the effect of relative graft size in ACL reconstruction on knee biomechanics is important for surgical planning. PURPOSE To assess how the percentage of femoral insertion site affects knee biomechanics in single- and double-bundle ACL reconstruction. STUDY DESIGN Controlled laboratory study. METHODS A total of 14 human cadaveric knees were scanned with magnetic resonance imaging and tested using a robotic system under an anterior tibial load and a combined rotational load. In total, 7 knee states were evaluated: intact ACL; deficient ACL; single-bundle ACL reconstruction with approximate graft sizes 25% (small), 50% (medium), and 75% (large) of the femoral insertion site; and double-bundle reconstruction of approximately 50% (medium) and 75% (large) of the femoral insertion site, based on the ratio of the cross-sectional area of the graft to the area of the femoral ACL insertion site determined by magnetic resonance imaging. RESULTS Anterior tibial translation was not significantly larger than the intact state in single-bundle and double-bundle medium graft reconstructions (P > .05) and was significantly greater in the single-bundle small graft reconstruction (P < .05). Anterior knee translation in single-bundle medium graft and large graft reconstructions was not statistically different (P > .05). In contrast, the anterior tibial translation for double-bundle large graft reconstruction was significantly smaller than for double-bundle medium graft reconstruction at low flexion angles (P < .05). The single-bundle small graft force was significantly different from the intact ACL in situ force (P < .05). The graft force with double-bundle large reconstruction was significantly greater than that with the double-bundle medium reconstruction (P < .05) but was not significantly different from that of the intact ACL (P > .05). CONCLUSION Knee biomechanics with a single-bundle small graft tended to be significantly different from those of the intact knee. In the kinematic and kinetic data for the single- and double-bundle medium graft reconstruction, only the anterior translation at full extension for the single-bundle reconstruction was significantly different (lower) from that of intact knee. This was a time zero study. CLINICAL RELEVANCE This study can provide surgeons with guidance in selecting the graft size for ACL reconstruction.
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Affiliation(s)
- Yusuke Sasaki
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Masataka Fujii
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daisuke Araki
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brandon D Marshall
- Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Monica A Linde
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Mao Z, Fan B, Wang X, Huang X, Guan J, Sun Z, Xu B, Yang M, Chen Z, Jiang D, Yu J. A Systematic Review of Tissue Engineering Scaffold in Tendon Bone Healing in vivo. Front Bioeng Biotechnol 2021; 9:621483. [PMID: 33791283 PMCID: PMC8005599 DOI: 10.3389/fbioe.2021.621483] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Tendon-bone healing is an important factor in determining the success of ligament reconstruction. With the development of biomaterials science, the tissue engineering scaffold plays an extremely important role in tendon-bone healing and bone tissue engineering. Materials and Methods: Electronic databases (PubMed, Embase, and the Web of Science) were systematically searched for relevant and qualitative studies published from 1 January 1990 to 31 December 2019. Only original articles that met eligibility criteria and evaluated the use of issue engineering scaffold especially biomaterials in tendon bone healing in vivo were selected for analysis. Results: The search strategy identified 506 articles, and 27 studies were included for full review including two human trials and 25 animal studies. Fifteen studies only used biomaterials like PLGA, collage, PCL, PLA, and PET as scaffolds to repair the tendon-bone defect, on this basis, the rest of the 11 studies using biological interventions like cells or cell factors to enhance the healing. The adverse events hardly ever occurred, and the tendon bone healing with tissue engineering scaffold was effective and superior, which could be enhanced by biological interventions. Conclusion: Although a number of tissue engineering scaffolds have been developed and applied in tendon bone healing, the researches are mainly focused on animal models which are with limitations in clinical application. Since the efficacy and safety of tissue engineering scaffold has been proved, and can be enhanced by biological interventions, substantial clinical trials remain to be done, continued progress in overcoming current tissue engineering challenges should allow for successful clinical practice.
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Affiliation(s)
- Zimu Mao
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
| | - Baoshi Fan
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Xinjie Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
| | - Ximeng Huang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
| | - Jian Guan
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
| | - Zewen Sun
- Qingdao University, Qingdao, China
- Department of Sports Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bingbing Xu
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
| | - Meng Yang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Zeyi Chen
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
| | - Dong Jiang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
| | - Jiakuo Yu
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
- Institute of Sports Medicine of Peking University, Beijing, China
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Combination of anterior tibial and femoral tunnels makes the signal intensity of antero-medial graft higher in double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:783-792. [PMID: 32350577 DOI: 10.1007/s00167-020-06014-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 04/17/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE To elucidate whether sagittal graft tunnel affects the signal intensity in anatomical ACL reconstruction (ACLR) and to clarify the prevalence of intercondylar roof impingement. It was hypothesized that if the tunnel apertures are located within the anatomical footprint of ACL, tunnel position would not affect the signal intensity. METHODS A total of 132 patients who underwent anatomical double-bundle ACLR (DB-ACLR) using hamstring autograft were recruited. Tunnel position was determined by the quadrant method on three-dimensional computed tomography; the femoral tunnel position was defined as "high and low" or "deep and shallow", while that of the tibial side was defined as "anterior and posterior" or "medial and lateral". Subjects were divided into three groups according to the tertile of % deep-shallow. The signal intensity was evaluated by the region of interest value of the antero-medial bundle (AMB) and postero-lateral bundle on magnetic resonance imaging at 12 months after reconstruction. Linear regression analysis was conducted to elucidate the relationship between the percentage position of each tunnel and the graft signal intensity. RESULTS In the shallow tertile group, AMB signal intensity increased in the anterior position of the tibial tunnel (β = - 0.34; P = 0.025). In the intermediate and deep tertile groups, the tunnel position did not correlate with the signal intensity. CONCLUSIONS A more anterior tibial tunnel position increases AMB signal intensity in shallower femoral tunnel. Conversely, this correlation is attenuated for deeper femoral tunnels. Surgeons should pay attention to sagittal femoral tunnel position to create a more anterior tibial tunnel position. LEVEL OF EVIDENCE Level III.
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Goto K, Hara M, Yamazaki Y, Urata T, Shimizu Y, Shimizu N. Smaller cross-sectional areas of the hamstring tendon measured from preoperative ultrasonography are likely to need additional gracilis harvesting for double-bundle anterior cruciate ligament reconstructions. Knee Surg Relat Res 2020; 32:34. [PMID: 32660588 PMCID: PMC7341671 DOI: 10.1186/s43019-020-00052-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Hamstring tendon autografts are commonly used for double-bundle anterior cruciate ligament reconstruction (DB-ACLR). If the volume of the semitendinosus (ST) tendon is insufficient, the gracilis (G) tendon is also harvested. Additional harvesting of the G autograft can affect patients' short-term postoperative outcome, such as muscle recovery; thus, preoperative information about whether an additional G autograft is needed would be useful. The purpose of this study was to investigate whether preoperative measurement of the ST tendon using ultrasonography could inform the intraoperative decision to harvest the G tendon. METHODS We enrolled 20 patients (13 men and seven women) who underwent DB-ACLR between October 2017 and March 2019. The mean patient age was 28.5 years. The ipsilateral ST tendon was measured using ultrasonography before surgery. Measurements included the diameter and breadth of the short-axis image. The cross-sectional area (CSA) was calculated from these measurements. During surgery, when two grafts with diameters of ≥ 5.0 mm could not be made, the G tendon was also harvested. Patients were categorized into two groups: the ST group where only the ST tendon was harvested, and the semitendinosus gracilis tendon (STG) group where the ST and G tendons were both harvested. The CSA value was compared between the two groups, and the cutoff value was calculated. RESULTS In the ST group (n = 8), the mean diameter and breadth of the semitendinosus tendon were 4.21 and 2.34 mm, respectively. In the STG group (n = 12), the mean diameter and breadth of the ST tendon were 3.39 and 1.78 mm, respectively. The CSAs calculated for the ST group and the STG group were 7.74 mm2 and 4.79 mm2, respectively. A cutoff value of 7.0 mm2 was found to correspond to a specificity and sensitivity to harvest the G tendon of 87.5% and 75.0%, respectively. CONCLUSIONS The preoperative CSA of the ST tendon determined using ultrasonography can, therefore, be informative for deciding whether to harvest the G tendon for DB-ACLR. The results of this study provide valuable information for graft selection in anterior cruciate ligament reconstruction. LEVEL OF EVIDENCE IV (Retrospective case series design).
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Affiliation(s)
- Kazumi Goto
- Department of Orthopaedic Surgery, Toshiba Rinkan Hospital, Toshiba Rinkan Hospital, 7-9-1, Kamitsuruma, Minami-ku, Sagamihara-Shi, Kanagawa, 252-0385, Japan.
| | - Masahiko Hara
- Japan Society of Clinical Research, Chuoh-ku, Tokyo, Japan
| | - Yoshiyuki Yamazaki
- Department of Orthopaedic Surgery, Toshiba Rinkan Hospital, Toshiba Rinkan Hospital, 7-9-1, Kamitsuruma, Minami-ku, Sagamihara-Shi, Kanagawa, 252-0385, Japan
| | - Taihei Urata
- Department of Orthopaedic Surgery, Toshiba Rinkan Hospital, Toshiba Rinkan Hospital, 7-9-1, Kamitsuruma, Minami-ku, Sagamihara-Shi, Kanagawa, 252-0385, Japan
| | - Yuki Shimizu
- Department of Orthopaedic Surgery, Toshiba Rinkan Hospital, Toshiba Rinkan Hospital, 7-9-1, Kamitsuruma, Minami-ku, Sagamihara-Shi, Kanagawa, 252-0385, Japan
| | - Naofumi Shimizu
- Department of Orthopaedic Surgery, Toshiba Rinkan Hospital, Toshiba Rinkan Hospital, 7-9-1, Kamitsuruma, Minami-ku, Sagamihara-Shi, Kanagawa, 252-0385, Japan
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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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Oval femoral tunnel technique is superior to the conventional round femoral tunnel technique using the hamstring tendon in anatomical anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:2245-2254. [PMID: 31776627 DOI: 10.1007/s00167-019-05809-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE This study was conducted to compare the efficacy between the oval femoral tunnel technique and the conventional round femoral tunnel technique in ACL reconstruction using an autologous hamstring tendon on the basis of the postoperative clinical outcomes and ACL graft tendon maturity. The hypothesis was that ACL reconstruction performed using the oval femoral tunnel technique was better than that performed using the round femoral tunnel technique in clinical functions and graft maturity. METHODS One hundred and eight patients who underwent anatomical single-bundle ACL reconstruction were included in this study and the follow-up period was at least 2 years. Thirty-nine patients admitted between February and August in 2016 were included in the oval femoral tunnel group and 69 patients admitted between September 2016 and March 2017 were included in the round femoral tunnel group. The Lachman test result, pivot-shift test result, Lysholm score, IKDC score, and VAS score were used for the clinical evaluation. An objective assessment of anteroposterior stability was performed using a KT1000 arthrometer. Postoperative MRI was conducted to compare the ACL graft maturity differences between the oval femoral tunnel group and round femoral tunnel group, where the signal/noise quotient (SNQ) was calculated. In addition, second-look arthroscopy was conducted to compare the graft status and synovial coverage at 24 months postoperatively. RESULTS All the patients presented with significant improvement in all clinical scores from the preoperative period to the 24-month follow-up. During the postoperative follow-up period, no statistically significant differences were found between the two groups in terms of the VAS score, knee ROM, Lachman test results, and graft status determined in the second-look arthroscopic evaluation. The Lysholm score was 97.1 ± 3.9 and 94.8 ± 5.6 in the oval femoral tunnel group and round femoral tunnel group, respectively, at the 24-month follow-up (p = 0.031). The IKDC subjective score was 92.0 ± 2.6 and 89.0 ± 3.6 in the oval femoral tunnel group and round femoral tunnel group, respectively, at the end of the follow-up period (p < 0.001). Significantly more patients with 1-degree positive pivot-shift test results were observed in the round femoral tunnel group (10/65) than in the oval femoral tunnel group (1/37) at the end of the follow-up period (p = 0.048). The mean SNQ of the oval femoral tunnel group was 2.7 ± 0.9, which was significantly lower than that of the round femoral tunnel group (3.6 ± 1.1) at the 24-month postoperative follow-up (p < 0.001). CONCLUSIONS Based on the clinical evaluations, MRI findings and second-look arthroscopy results of the two groups, the oval femoral tunnel technique yielded significantly better knee function and knee laxity restoration and more mature ACL grafts than the round femoral tunnel technique, whereas no significant differences were found at the second-look arthroscopy. LEVEL OF EVIDENCE III.
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Robinson J, Inderhaug E, Harlem T, Spalding T, Brown CH. Anterior Cruciate Ligament Femoral Tunnel Placement: An Analysis of the Intended Versus Achieved Position for 221 International High-Volume ACL Surgeons. Am J Sports Med 2020; 48:1088-1099. [PMID: 32182091 DOI: 10.1177/0363546520906158] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoral tunnels that are not anatomically placed within the native anterior cruciate ligament (ACL) footprint during ACL reconstruction are associated with residual instability, graft rupture, and poor clinical outcomes. Although surgeons may intend to place their femoral tunnels within the native ACL attachment, this is not always achieved. This study assesses the variation between intended and achieved femoral tunnel positions in a large cohort of experienced ACL surgeons. HYPOTHESIS The accuracy with which experienced ACL surgeons achieve their intended femoral tunnel position is dependent on viewing portal, localization strategy, and drilling technique. STUDY DESIGN Controlled laboratory study. METHODS A total of 221 surgeons indicated their intended femoral tunnel location on a true lateral radiograph of a cadaveric knee specimen and a scaled photograph. Each surgeon then arthroscopically demonstrated the femoral tunnel on the specimen. The position was captured using fluoroscopy. The Euclidean distance (the straight-line distance between 2 points) between the intended and achieved tunnel positions, referenced to a grid applied to the lateral femoral condyle, was compared. Data were analyzed according to surgeons' viewing portal (anteromedial [AM] or anterolateral [AL]), tunnel localization strategy (offset aimer, estimation from landmarks, ACL ruler, or C-arm fluoroscopy), and stated drilling technique (transtibial, AM portal, or outside-in). RESULTS Surgeons who viewed the lateral intercondylar notch wall through the AM portal were closer (mean distance, 9.5) to their intended position than those who viewed through the AL portal (mean distance, 15.1; P < .0001). By localization strategy, the mean distance between achieved and intended tunnel positions was greater for surgeons who used an offset aimer (14.5) and estimated the femoral tunnel position (12.9) than for those using a malleable ACL ruler (8.1; P < .0001) and fluoroscopy (4.3; P < .0001). Surgeons' preferred drilling technique (AM portal, transtibial, or outside-in) had no effect on distance between intended and achieved positions. However, the mean achieved position was higher in the intercondylar notch for those using transtibial drilling (P < .042). CONCLUSION Surgeons using the AM portal to view the femoral attachment site were closer to their intended tunnel position than those who viewed it with the arthroscope in the AL portal. Surgeons who used fluoroscopy to localize femoral tunnel position were the closest to their intended position. Those who used estimation or an offset aimer had the farthest distance between achieved and intended tunnel positions. CLINICAL RELEVANCE Although accurate tunnel placement can be achieved using any method, given the disparity between intended and achieved tunnel positions, it may be advisable, even for high-volume surgeons, to verify the placement of their tunnels using either fluoroscopy or a malleable ACL ruler to ensure that they achieve their intended position. Fluoroscopy may be particularly useful for cases where the native femoral stump is no longer visible and for revisions. Viewing through the AM portal is recommended to aid accuracy of tunnel placement.
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Affiliation(s)
| | - Eivind Inderhaug
- Haraldsplass Deaconess Hospital, Bergen, Norway.,University of Bergen, Norway
| | | | - Tim Spalding
- University Hospitals Coventry & Warwickshire, Coventry, UK
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Sabzevari S, Shaikh H, Marshall B, Zhu J, Linde MA, Smolinski P, Fu FH. The femoral posterior fan-like extension of the ACL insertion increases the failure load. Knee Surg Sports Traumatol Arthrosc 2020; 28:1113-1118. [PMID: 31642946 DOI: 10.1007/s00167-019-05753-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/07/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE To examine the role of the posterior fan-like extension of the ACL's femoral footprint on the ACL failure load. METHODS Sixteen (n = 16) fresh frozen, mature porcine knees were used in this study and randomized into two groups (n = 8): intact femoral ACL insertion (ACL intact group) and cut posterior fan-like extension of the ACL (ACL cut group). In the ACL cut group, flexing the knees to 90°, created a folded border between the posterior fan-like extension and the midsubstance insertion of the femoral ACL footprint and the posterior fan-like extension was dissected and both areas were measured. Specimens were placed in a testing machine at 30° of flexion and subjected to anterior tibial loading (60 mm/min) until ACL failure. RESULTS The intact ACL group had a femoral insertion area of 182.1 ± 17.1 mm2. In the ACL cut group, the midsubstance insertion area was 113.3 ± 16.6 mm2, and the cut posterior fan-like extension portion area was 67.1 ± 8.3 mm2. The failure load of the ACL intact group was 3599 ± 457 N and was significantly higher (p < 0.001) than the failure load of the ACL cut group 392 ± 83 N. CONCLUSION Transection of the posterior fan-like extension of the ACL femoral footprint has a significant effect on the failure load of the ligament during anterior loading at full extension. Regarding clinical relevance, this study suggests the importance of the posterior fan-like extension of the ACL footprint which potentially may be retained with remnant preservation during ACL reconstruction. Femoral insertion remnant preservation may allow incorporation of the fan-like structure into the graft increasing graft strength.
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Affiliation(s)
- Soheil Sabzevari
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA.,Department of Orthopaedic Surgery, Razavi Hospital, Imam Reza International University, Meshhad, Iran
| | - Humza Shaikh
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Brandon Marshall
- Deptartment of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Junjun Zhu
- Deptartment of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Monica A Linde
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA.,Deptartment of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA. .,Deptartment of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA.
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温 振, 张 华, 闫 文, 赵 沛, 黄 潇, 许 梓, 张 健, 周 爱. [Comparison of femoral oval tunnel technique and round tunnel technique in single-bundle anterior cruciate ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:323-329. [PMID: 32174077 PMCID: PMC8171655 DOI: 10.7507/1002-1892.201908030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/16/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of femoral oval tunnel technique versus round tunnel technique in single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS Between March 2016 and February 2018, 125 patients who underwent anatomical single-bundle ACL reconstruction with hamstring tendon and met the inclusive criteria were included in the retrospective study. Of the included patients, 43 patients underwent ACL reconstruction using oval tunnel technique (group A) and 82 patients with round tunnel technique (group B). There was no significant difference between the two groups in terms of age, gender, body mass index, the interval between injury and operation, the injured side, the cause of injury, and preoperative Lysholm score, International Knee Documentation Committee (IKDC) score, Tegner score, and the outcome of KT-1000 measurement ( P>0.05). At 3, 6, 12, and 24 months after operation, the knee function scores (Lysholm score, IKDC score, Tegner score) were recorded; and KT-1000 was used to evaluate the knee stability. The position and shape of the tunnels were evaluated by the three-dimensional CT (3D-CT) at 1 day after operation; and MRI was performed at 6, 12, and 24 months to calculate the signal/noise quotient (SNQ) of ACL grafts. Secondary arthroscopy was conducted to estimate the graft status, synovial coverage, and tension. RESULTS All patients were followed up 12-26 months (mean, 23 months). Two patients in group A and 5 patients in group B presented with redness and swelling of the surgical site, 1 patient in group B sustained a tibial tunnel fracture, and 1 patient in group A had postoperative stiffness. The Lysholm score, IKDC score, and Tegner score were significantly higher in group A than in group B at the different time points ( P<0.05) except for the Tegner score at 3 months. The outcomes of KT-1000 measurement were significantly lower in group A than in group B ( P<0.05). The entrances of the femoral tunnel and tibial tunnel in both groups were within the ACL anatomical footprint confirmed by 3D-CT. No re-rupture of ACL occurred confirmed by the MRI. There was no significant difference in SNQs of the middle and distal grafts between the two groups at 6 months ( P>0.05), whereas the SNQ of the proximal grafts in group A was significantly lower than that in group B ( P<0.05). The SNQs of the proximal, middle, and distal grafts in group A were significantly lower than those in group B at 12 and 24 months after operation ( P<0.05). Twenty-one patients in group A and 38 patients in group B underwent secondary arthroscopy and the results showed no significant difference in graft status, synovial coverage, and tension between the two groups ( P>0.05). CONCLUSION The effectiveness and graft maturity of the femoral oval tunnel technique were superior to the round tunnel technique. The single-bundle ACL reconstruction with femoral oval tunnel technique can obtain a better knee function.
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Affiliation(s)
- 振兴 温
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
- 重庆医科大学(重庆 400016)Chongqing Medical University, Chongqing, 400016, P.R.China
| | - 华 张
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - 文龙 闫
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - 沛 赵
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - 潇 黄
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - 梓杰 许
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
- 重庆医科大学(重庆 400016)Chongqing Medical University, Chongqing, 400016, P.R.China
| | - 健 张
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - 爱国 周
- 重庆医科大学附属第一医院骨科(重庆 400016)Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
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de Paula Leite Cury R, Simabukuro AM, de Marques Oliveira V, Escudeiro D, Jorge PB, Severino FR, Guglielmetti LGB. Anteromedial positioning of the femoral tunnel in anterior cruciate ligament reconstruction is the best option to avoid revision: a single surgeon registry. J Exp Orthop 2020; 7:11. [PMID: 32146549 PMCID: PMC7060973 DOI: 10.1186/s40634-020-00225-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 02/20/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The aim of the study is to compare the risk of revision of single-bundle hamstring anterior cruciate ligament (ACL) reconstruction between the anteromedial, transtibial and outside-in techniques. METHODS This cohort study was based on data from a single surgeon's registry. Patients who underwent primary single-bundle ACL reconstruction with hamstring tendon using the anteromedial portal, transtibial and outside-in technique, operated between 1 November 2003 to 31 December 2016, were eligible for inclusion. A minimum follow-up of 2 years was used, and the end-point of the study was revision surgery. RESULTS The total number of registered surgeries identified was 665; 109 were excluded, and 556 was the final sample. The overall revision rate was 8.7%. The transtibial technique presented 14/154 [9.9%] of revisions, the transportal 11/96 [11.4%] and the outside-in 22/306 [7.2%]. Separating the outside-in group into central outside-in and anteromedial (AM) outside-in, 18/219 [8.2%] was found for the central outside-in and 4/87 [4.5%] for the AM outside-in technique. Statistical evaluation of the first comparison (transtibial vs. transportal vs. outside-in) obtained p = (n.s.) The second comparison (transtibial vs. central transportal vs. central outside-in vs. AM outside-in, p = (n.s). Placement was also evaluated: high anteromedial placement (transtibial) vs. central (transportal and central outside-in technique) vs. AM placement (AM outside-in). The high AM placement presented 14/154 [9.9%] of revision, the central placement 29/315 [9.2%] and the AM placement 4/87 [4.5%], p = (n.s.) The AM placement was also compared with the other placements (high and central AM), p = (n.s.) CONCLUSION: Based on the registry of a single surgeon during 14 years of ACL reconstruction, the placement of the femoral tunnel in the high anteromedial region was associated with a rupture rate of 9.9%, central placement with 9.2% and anteromedial placement with 4.5%.
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Affiliation(s)
- Ricardo de Paula Leite Cury
- Orthopedics and Traumatology Department, Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 61 - Vila Buarque, São Paulo, 01221-020, Brazil
| | - Artur Mistieri Simabukuro
- Orthopedics and Traumatology Department, Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 61 - Vila Buarque, São Paulo, 01221-020, Brazil
| | - Victor de Marques Oliveira
- Orthopedics and Traumatology Department, Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 61 - Vila Buarque, São Paulo, 01221-020, Brazil
| | - Diego Escudeiro
- Orthopedics and Traumatology Department, Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 61 - Vila Buarque, São Paulo, 01221-020, Brazil.
| | - Pedro Baches Jorge
- Orthopedics and Traumatology Department, Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 61 - Vila Buarque, São Paulo, 01221-020, Brazil
| | - Fabrício Roberto Severino
- Orthopedics and Traumatology Department, Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 61 - Vila Buarque, São Paulo, 01221-020, Brazil
| | - Luiz Gabriel Betoni Guglielmetti
- Orthopedics and Traumatology Department, Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 61 - Vila Buarque, São Paulo, 01221-020, Brazil
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Tachibana Y, Shino K, Mae T, Iuchi R, Take Y, Nakagawa S. Anatomical rectangular tunnels identified with the arthroscopic landmarks result in excellent outcomes in ACL reconstruction with a BTB graft. Knee Surg Sports Traumatol Arthrosc 2019; 27:2680-2690. [PMID: 30460396 DOI: 10.1007/s00167-018-5300-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 11/13/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE To elucidate tunnel locations and clinical outcomes after anatomic rectangular tunnel (ART) anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) graft. METHODS Sixty-one patients with a primary unilateral ACL injury were included. Tunnels were created inside the ACL attachment areas after carefully removing the ACL remnant and clearly identifying the bony landmarks. Using 3-dimensional computed tomography (3-D CT) images, the proportion of the tunnel apertures to the anatomical attachment areas was evaluated at 3 weeks. The clinical outcomes were evaluated at 2 years postoperatively. RESULTS Geographically, the 3-D CT evaluation showed the entire femoral tunnel aperture; at least 75% of the entire tibial tunnel aperture area was consistently located inside the anatomical attachment areas surrounded by the bony landmarks. In the International Knee Documentation Committee (IKDC) subjective assessment, all patients were classified as 'normal' or 'nearly normal'. The Lachman test and pivot-shift test were negative in 98.4% and 95.1% of patients, respectively. The mean side-to-side difference of the anterior laxity at the maximum manual force with a KT- 1000 Knee Arthrometer was 0.2 ± 0.9 mm, with 95.1% of patients ranging from - 1 to + 2 mm. CONCLUSION By identifying arthroscopic landmarks, the entire femoral tunnel aperture and at least 75% of the entire tibial tunnel aperture area were consistently located inside the anatomical attachment areas. With properly created tunnels inside the anatomical attachment areas, the ART ACLR using a BTB graft could provide satisfactory outcomes both subjectively and objectively in more than 95% of patients. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Yuta Tachibana
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan.
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ryo Iuchi
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Yasuhiro Take
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Shigeto Nakagawa
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
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The Role of Fibers Within the Tibial Attachment of the Anterior Cruciate Ligament in Restraining Tibial Displacement. Arthroscopy 2019; 35:2101-2111. [PMID: 31272629 DOI: 10.1016/j.arthro.2019.01.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the load-bearing functions of the fibers of the anterior cruciate ligament (ACL) tibial attachment in restraining tibial anterior translation, internal rotation, and combined anterior and internal rotation laxities in a simulated pivot-shift test. METHODS Twelve knees were tested using a robot. Laxities tested were: anterior tibial translation (ATT), internal rotation (IR), and coupled translations and rotations during a simulated pivot-shift. The kinematics of the intact knee was replayed after sequentially transecting 9 segments of the ACL attachment and fibers entering the lateral gutter, measuring their contributions to restraining laxity. The center of effort (COE) of the ACL force transmitted to the tibia was calculated. A blinded anatomic analysis identified the densest fiber area in the attachment of the ACL and thus its centroid (center of area). This centroid was compared with the biomechanical COE. RESULTS The anteromedial tibial fibers were the primary restraint of ATT (84% across 0° to 90° flexion) and IR (61%) during isolated and coupled displacements, except for the pivot-shift and ATT in extension. The lateral gutter resisted 28% of IR at 90° flexion. The anteromedial fibers showed significantly greater restraint of simulated pivot-shift rotations than the central and posterior fibers (P < .05). No significant differences (all <2 mm) were found between the anatomic centroid of the C-shaped attachment and the COE under most loadings. CONCLUSIONS The peripheral anteromedial fibers were the most important area of the ACL tibial attachment in the restraint of tibial anterior translation and internal rotation during isolated and coupled displacements. These mechanical results matched the C-shaped anteromedial attachment of the dense collagen fibers of the ACL. CLINICAL RELEVANCE The most important fibers in restraining tibial displacements attach to the C-shaped anteromedial area of the native ACL tibial attachment. This finding provides an objective rationale for ACL graft position to enable it to reproduce the physiological path of load transmission for tibial restraint.
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Zhang JH, Ren S, Shao JY, Niu XY, Hu XQ, Ao YF. [Anatomical and finite element analysis of anterior cruciate ligament reconstruction within biomechanical insertion]. JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:586-590. [PMID: 31209435 DOI: 10.19723/j.issn.1671-167x.2019.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To provide new concepts of anterior cruciate ligament (ACL) reconstruction by anatomical gross observation of ACL tibial insertion and finite element analysis of distribution of ACL mechanical insertion. METHODS In the anatomical study, ten fresh adult cadaveric knees were dissected, including 6 males and 4 females, all knees were generally observed through standard medial parapatellar approaches, paying attention to the close anatomical relationship of tibial insertion and anterior horn of lateral meniscus, and ACL was exposed and gradually removed from the inside. The shape of tibial insertion of ACL was observed and recorded, and anterior-posterior diameters and left-right diameters of tibial insertion were measured with vernier caliper. For the study of finite element analysis, three-dimensional thin-layer magnetic resonance imaging of normal knee joint was used to establish knee joint model. Three-dimensional reconstruction software MIMICS and finite element analysis software ANSYS were used to establish knee joint model, subsequently, clinical physical examination Lachman test and pivot-shift test were simulated to observe the force distribution of ACL tibial insertion and femoral insertion. RESULTS The ACL tibial mechanical insertion was rather flat and long similar as an arc shape without a clear separation between anterior medial bundle (AMB) and posterolateral bundle (PLB) in gross observation. The dense fibers lies belonged to the medial intercondylar ridge and ended up anterior with the osseous landmark of anterior ridge. Its average anterior-posterior diameter was (13.8±2.0) mm, the average left-right diameter of midsubstance was (5.3±0.6) mm, and the average left-right diameter of anterior margin was (11.5±1.2) mm. The finite element analysis showed that distribution on the femoral side was oval shape mainly below the residents' ridge, while the tibial side was rather flat mainly along the medial intercondylar ridge, which was consistent with the anatomical observation. The biomechanical characteristics of ACL attachments were verified theoretically. CONCLUSION Anatomical study and finite element analysis have confirmed the flat arc shape of ACL tibial insertion. The ideal reconstruction technique of ACL should be based on its biomechanical insertion. Based on anatomical study and biomechanical analysis, we have proposed the idea of ACL biomechanical insertion reconstruction (BIR) and established a surgical model with oval femoral tunnel and rounded-rectangle tibial tunnel.
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Affiliation(s)
- J H Zhang
- Institute of Sports Medicine, Peking University Third Hospital; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - S Ren
- Institute of Sports Medicine, Peking University Third Hospital; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - J Y Shao
- Institute of Sports Medicine, Peking University Third Hospital; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - X Y Niu
- Institute of Sports Medicine, Peking University Third Hospital; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - X Q Hu
- Institute of Sports Medicine, Peking University Third Hospital; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - Y F Ao
- Institute of Sports Medicine, Peking University Third Hospital; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
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Oishi K, Sasaki E, Naraoka T, Kimura Y, Tsuda E, Shimoda H, Ishibashi Y. Anatomical relationship between insertion sites, tunnel placement, and lateral meniscus anterior horn injury during single and double bundle anterior cruciate ligament reconstructions: A comparative macroscopic and histopathological evaluation in cadavers. J Orthop Sci 2019; 24:494-500. [PMID: 30446333 DOI: 10.1016/j.jos.2018.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 10/09/2018] [Accepted: 10/22/2018] [Indexed: 02/09/2023]
Abstract
PURPOSE The influence of tunnel extension outside the anatomical anterior cruciate ligament (ACL) insertion in single-bundle (SB) or double-bundle (DB) ACL reconstruction is unclear. This study aimed to investigate the anatomical relationship between ACL insertion and tunnel extension in SB and DB ACL reconstruction, and the impact of tibial tunnel extension to the insertion of anterior horn of lateral meniscus in terms of injury. METHODS Forty-six paired cadaver knees (mean age, 82.7 ± 10.7 years) were used. Right and left knees were used for SB (10 mm) and DB tunnel reaming (6 mm for the anteromedial and posterolateral bundles). Tibial and femoral tunnels were created to aim at the center of the ACL insertion by arthroscopic visualization. The relationship between tunnel extension and ACL insertion was evaluated macroscopically, and there ratio in two groups were compared by chi-square test. Further, the relative risk for meniscus injury based on tunnel placement was estimated. Coronal section of tibia and parallel section to Blumensaat line in femur were prepared to evaluate the relationship among tunnel position, ACL insertion, and anterior horn of the meniscus histologically. RESULTS Tibial tunnel extension out of the ACL insertion was observed macroscopically in 9 (39.1%) knees of the SB group, and 3 (13.0%) of the DB group (p = 0.045). In femoral tunnels, extension out of the ACL insertion was seen in 8 (34.8%) knees of the SB group and 1 (4.3%) of the DB group (p = 0.011). Partial injuries of the lateral meniscus anterior horn (LMAH) were observed in 5 (21.7%) knees of the SB group and 1 (4.3%) knee of the DB group (p = 0.091). The relative risk for LMAH injury was calculated as 5.0 (odds ratio, 6.1). Microscopically, SB tunnels appeared to expand out of ACL insertion, both in the femur and tibia. CONCLUSIONS The incidence of tunnel extension out of the ACL insertion in femur and tibia were higher with SB than with DB reconstruction. Furthermore, injury rate of the LMAH in the DB group was lower.
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Affiliation(s)
- Kazuki Oishi
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Sasaki
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Takuya Naraoka
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hiroshi Shimoda
- Department of Anatomical Science, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Tanaka K, Kanazawa T, Gotoh M, Tanesue R, Nakamura H, Ohzono H, Okawa T, Shiba N. Effects of Estrogen-Deficient State on Rotator Cuff Healing. Am J Sports Med 2019; 47:389-397. [PMID: 30625277 DOI: 10.1177/0363546518815869] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff retears after surgical repair are a concern, despite advances in operative techniques, but few studies have investigated the effects of the estrogen-deficient state on tendon-to-bone healing at the repair site. PURPOSE We evaluated the effect of the estrogen-deficient state on tendon-to-bone healing after rotator cuff repair in an ovariectomized rat model. STUDY DESIGN Controlled laboratory study. METHODS Female Sprague Dawley rats underwent detachment and immediate repair of the supraspinatus tendon. Surgery was performed in 24 rats at 4.5 weeks of age 17 weeks after ovariectomy (OVX group) and in 24 age-matched control rats without ovariectomy (control group). Animals were sacrificed at 2, 4, 8, and 12 weeks after surgery for biomechanical and histological evaluations of reattachment. Bone mineral density (BMD) at the insertion site and cancellous bone in the humeral head was assessed by micro-computed tomography. RESULTS BMD was significantly lower both at the insertion site and in cancellous area in the OVX group than in the control group at weeks 2 to 12. Ultimate load to failure, ultimate stress, linear stiffness, and the Young modulus were significantly lower in the OVX group than in the control group at 2 and 4 weeks, but the difference was no longer significant at 8 and 12 weeks. At 2 and 4 weeks, relatively immature granulation tissue was observed in the OVX group compared with the control group. At 8 and 12 weeks after surgery, there were differences in the tendon-bone interface in the 2 groups: Direct insertion with well-established chondroid tissue was seen in the control group, and indirect insertion without chondroid tissue was seen in the OVX group. Consistently, the amount of chondroid tissue was greater and collagen organization was better in the control group than in the OVX group. Cells expressing cathepsin K were significantly more numerous both at the insertion site and in cancellous bone in the OVX group than in the control group. CONCLUSION The estrogen-deficient state by ovariectomy, compared with control rats, led to decreased biomechanical properties and poor development of chondroid tissue that influenced the repair of the tendon insertion after surgery. CLINICAL RELEVANCE Agents that modulate bone metabolism might improve tendon-to-bone healing in patients with an estrogen-deficient state, such as postmenopausal women who undergo rotator cuff surgery.
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Affiliation(s)
- Koji Tanaka
- Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Tomonoshin Kanazawa
- Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Masafumi Gotoh
- Department of Orthopaedic Surgery, Kurume University Medical Center, Kurume, Japan
| | - Ryo Tanesue
- Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Hidehiro Nakamura
- Department of Orthopaedic Surgery, Kurume University Medical Center, Kurume, Japan
| | - Hiroki Ohzono
- Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Takahiro Okawa
- Department of Orthopaedic Surgery, Kurume University Medical Center, Kurume, Japan
| | - Naoto Shiba
- Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume, Japan
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Tomihara T, Hashimoto Y, Taniuchi M, Takigami J, Takahashi S, Nishida Y, Shimada N. Shallow knee flexion angle during femoral tunnel creation using modified transtibial technique can reduce femoral graft bending angle in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:618-625. [PMID: 30302534 DOI: 10.1007/s00167-018-5191-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/01/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose of this study was to compare femoral graft bending angle between patients with femoral tunnel reamed at less than 80° of knee flexion and those with 80° and above in anatomical anterior cruciate ligament (ACL) reconstruction using modified transtibial technique. METHODS Forty-eight patients who underwent ACL reconstruction using bone-patellar-tendon-bone autograft in modified transtibial technique and CT scan at 1 week postoperatively were included in this study. A femoral guidewire insertion into aimed femoral position at the medial wall of the femoral lateral condyle was started at about 75° of knee flexion. When the tip of the guidewire was blown out into femoral posterior wall, the guidewire was inserted again after increasing knee flexion angle. Distance from femoral tunnel exit on the femoral lateral cortex-femoral posterior cortex (Distance-E) was measured on postoperative lateral radiograph. Femoral and tibial tunnel position was measured on 3-D CT images. In addition, femoral graft bending angle was measured on reconstructed 2-D CT images. Patients were divided into two groups depending on whether femoral tunnel was created at less than 80° of knee flexion (group A) or 80° or more (group B). RESULTS There were 32 patients in group A and 16 patients in group B, respectively. Average knee flexion angle was 77.2° [standard deviation (SD) 1.6] in group A and 83.6° (SD 2.4) in group B, respectively (p < 0.05). Average Distance-E was 5.1 mm (SD 2.6) in group A and 6.6 mm (SD 3.8) in group B, respectively. There was no significant difference in the femoral and tibial tunnel position between group A and B. Femoral graft bending angle was significantly smaller in group A [average angle: 50.9° (SD 6.6)] than in group B [average angle: 55.0° (SD 6.6)] (p < 0.05). CONCLUSIONS Anatomical femoral tunnel was able to be created at less than 80° of knee flexion in two-thirds of patients. Shallower flexion angle (less than 80°) provided gentler femoral graft bending angle compared to 80° or more of knee flexion. Therefore, femoral tunnel creation in modified transtibial technique should be started at between 75° and 80° of knee flexion to reduce femoral graft bending angle. Shallow knee flexion angle during femoral tunnel creation using modified transtibial technique can reduce femoral graft bending angle and may lead to better clinical outcomes in ACL reconstruction. LEVELS OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Tomohiro Tomihara
- Department of Orthopaedic Surgery, Shimada Hospital, 100-1 Kashiyama, Habikino, 583-0875, Japan.
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masatoshi Taniuchi
- Department of Orthopaedic Surgery, Shimada Hospital, 100-1 Kashiyama, Habikino, 583-0875, Japan
| | - Junsei Takigami
- Department of Orthopaedic Surgery, Shimada Hospital, 100-1 Kashiyama, Habikino, 583-0875, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yohei Nishida
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Nagakazu Shimada
- Department of Orthopaedic Surgery, Shimada Hospital, 100-1 Kashiyama, Habikino, 583-0875, Japan
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Iwama G, Iriuchishima T, Horaguchi T, Aizawa S. Measurement of the Whole and Midsubstance Femoral Insertion of the Anterior Cruciate Ligament: The Comparison with the Elliptically Calculated Femoral Anterior Cruciate Ligament Footprint Area. Indian J Orthop 2019; 53:727-731. [PMID: 31673173 PMCID: PMC6804389 DOI: 10.4103/ortho.ijortho_434_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to measure the detailed morphology of the femoral anterior cruciate ligament (ACL) footprint. The correlation and the comparison between the measured area and the area which mathematically calculated as elliptical were also evaluated. MATERIALS AND METHODS Thirty nine nonpaired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. The ACL was carefully dissected, and the periphery of the ACL insertion site was outlined on both the whole footprint and the midsubstance insertion. Lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area, length, and width of the femoral ACL footprint were measured with Image J software (National Institution of Health). Using the length and width of the femoral ACL footprint, the elliptical area was calculated as 0.25 π (length × width). Statistical analysis was performed to reveal the correlation and the comparison of the measured and elliptically calculated area. RESULTS The sizes of the whole and midsubstance femoral ACL footprints were 127.6 ± 41.7 mm2 and 61 ± 20.2 mm2, respectively. The sizes of the elliptically calculated whole and midsubstance femoral ACL footprints were 113.9 ± 4.5 mm2 and 58.4 ± 3 mm2, respectively. Significant difference was observed between the measured and the elliptically calculated area. In the midsubstance insertion, significant correlation was observed between the measured and the elliptically calculated area (Pearson's correlation coefficient = 0.603, P = 0.001). However, no correlation was observed in the whole ACL insertion area. CONCLUSION The morphology of the femoral ACL insertion resembles an elliptical shape. However, due to the wide variation in morphology, the femoral ACL insertion cannot be considered mathematically elliptical.
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Affiliation(s)
- Genki Iwama
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Takanori Iriuchishima
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan,Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Minakami, Japan
| | - Takashi Horaguchi
- Department of Orthopedic Surgery, Nihon University Hospital, Tokyo, Japan,Address for correspondence: Dr. Takanori Iriuchishima, Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Minakami, Japan. E-mail:
| | - Shin Aizawa
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
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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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Jorge PB, Escudeiro D, Severino NR, Santili C, de Paula Leite Cury R, Junior AD, Guglielmetti LGB. Positioning of the femoral tunnel in anterior cruciate ligament reconstruction: functional anatomical reconstruction. BMJ Open Sport Exerc Med 2018; 4:e000420. [PMID: 30305927 PMCID: PMC6173259 DOI: 10.1136/bmjsem-2018-000420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 01/14/2023] Open
Abstract
The aim of this study was to review and update the literature in regard to the anatomy of the femoral origin of the ACL, the concept of the double band and its respective mechanical functions, and the concept of direct and indirect fibres in the ACL insertion. These topics will be used to help determine which might be the best place to position the femoral tunnel and how this should be achieved, based on the idea of functional positioning, that is, where the most important ACL fibres in terms of knee stability are positioned. Low positioning of the femoral tunnel, reproducing more of the posterolateral band, and positioning the tunnel away from the lateral intercondylar ridge, that is, in the indirect fibres, would theoretically rebuild a ligament that is less effective in relation to knee stability. The techniques described to determine the femoral tunnel's centre point all involve some degree of subjectivity; the point is defined manually and depends on the surgeon's expertise. The centre of the ACL insertion in the femur should be used as a parameter. Once the centre of the ligament in its footprint is marked, the centre of the tunnel must be defined, drawing the marking toward the intercondylar ridge and anteromedial band. This will allow the femoral tunnel to occupy the region containing the most important original ACL fibres in terms of this ligament's function.
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Affiliation(s)
- Pedro Baches Jorge
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Diego Escudeiro
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Nilson Roberto Severino
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Cláudio Santili
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | | | - Aires Duarte Junior
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
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Takata Y, Nakase J, Oshima T, Shimozaki K, Asai K, Tsuchiya H. No difference in the graft shift between a round and a rounded rectangular femoral tunnel for anterior cruciate ligament reconstruction: an experimental study. Arch Orthop Trauma Surg 2018; 138:1249-1255. [PMID: 29770879 DOI: 10.1007/s00402-018-2958-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We developed a novel technique of creating a rounded rectangular femoral bone tunnel for anatomical, single-bundle, autologous hamstring tendon anterior cruciate ligament (ACL) reconstruction. Although this tunnel has many advantages, its non-circular shape has raised concerns regarding excessive graft shift within the bone tunnel. This study aimed to compare the graft shift between round and rounded rectangular tunnels using a graft diameter tester for simulating the femoral bone tunnel. MATERIALS AND METHODS Seven semitendinosus tendon grafts harvested from fresh-frozen cadavers were prepared by removing all excess soft tissue. The two ends of a double-fold hamstring tendon were sutured using a baseball stitch and then looped over a TightRope (Arthrex Co., Ltd., Naples, Florida, USA) to make a fourfold graft. The diameter of the graft was standardized to 8 mm using a round graft diameter tester. A round and an original rounded rectangular graft diameter tester were used for simulating the respective femoral bone tunnels. The graft was inserted into the tunnel, with the TightRope positioned on the outside of the tunnel. The distal end of the graft was tensioned to 40 N at an angle of 75° to reproduce the most severe graft bending angle. Digital photographs of the tunnel aperture taken at each simulated tunnel and the range of graft shift in the simulated tunnel were analyzed by ImageJ software. Statistical analyses were performed using the Tukey test. P < 0.05 was considered to be significant. RESULTS There were no significant differences between the round and the rounded rectangular tunnel groups (P > 0.05) in terms of graft shift, gap area, and graft shift ratio. CONCLUSION In a simulated ACL reconstruction, there is no difference in the graft shift between a round and a rounded rectangular bone tunnel.
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Affiliation(s)
- Yasushi Takata
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Takeshi Oshima
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kengo Shimozaki
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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Naraoka T, Kimura Y, Tsuda E, Yamamoto Y, Ishibashi Y. Does Remnant Preservation Influence Tibial Tunnel Enlargement or Graft-to-Bone Integration After Double-Bundle Anterior Cruciate Ligament Reconstruction Using Hamstring Autografts and Suspensory Fixation? A Computed Tomography and Magnetic Resonance Imaging Evaluation. Orthop J Sports Med 2018; 6:2325967118790238. [PMID: 30182026 PMCID: PMC6111403 DOI: 10.1177/2325967118790238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Remnant-preserving anterior cruciate ligament (ACL) reconstruction was
introduced to improve clinical outcomes and biological healing. However, the
influences of remnant preservation on tibial tunnel position and enlargement
are still uncertain. Purpose: To evaluate whether remnant-preserving ACL reconstruction influences tibial
tunnel position or enlargement and to examine the relationship between
tunnel enlargement and graft-to-bone integration in the tibial tunnel. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 91 knees with double-bundle ACL reconstructions were enrolled in
this study. ACL reconstruction was performed without a remnant (<25% of
the intra-articular portion of the graft) in 44 knees (nonremnant [NR]
group) and with remnant preservation in the remaining 47 knees
(remnant-preserving [RP] group). Tibial tunnel position and enlargement were
assessed using computed tomography (CT). Comparisons between groups were
performed. Furthermore, graft-to-bone integration in the tibial tunnel was
evaluated using magnetic resonance imaging, and the relationship between
tunnel enlargement and graft-to-bone integration at 1 year after ACL
reconstruction was assessed. Results: A total of 48 knees (25 in NR group, 23 in RP group) were included; 19 and 24
knees in the NR and RP groups were excluded, respectively, because of graft
reruptures and a lack of CT scans. There were no significant between-group
differences in tibial tunnel position (P > .05). The
degree of posterolateral tunnel enlargement in the axial plane was
significantly higher in the RP group than that in the NR group
(P = .007) 1 year after ACL reconstruction. The degree
of anteromedial tunnel enlargement on axial CT was significantly smaller in
knees with graft-to-bone integration than in those without integration
(P = .002) 1 year after ACL reconstruction. Conclusion: ACL reconstruction with remnant preservation did not influence tibial tunnel
position and did not decrease the degree or incidence of tibial tunnel
enlargement. At 1 year postoperatively, tunnel enlargement did not affect
graft-to-bone integration in the posterolateral tunnel, but graft-to-bone
integration was delayed in the anteromedial tunnel.
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Affiliation(s)
- Takuya Naraoka
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Quiles C, Constantino JA, Gañán Y, Macías D, Quiles M. Stereophotogrammetric surface anatomy of the anterior cruciate ligament's tibial footprint: Precise osseous structure and distances to arthroscopically-relevant landmarks. Knee 2018; 25:531-544. [PMID: 29705076 DOI: 10.1016/j.knee.2018.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/16/2018] [Accepted: 03/27/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND While femoral tunnel malposition is widely recognized as the main technical error of failed anterior cruciate ligament (ACL) surgery, tibial tunnel malposition is likely underrecognized and underappreciated. PURPOSE To describe more precisely the qualitative and quantitative anatomy of the ACL's tibial attachment in vitro using widely available technology for stereophotogrammetric surface reconstruction, and to test its applicability in vivo. METHODS Stereophotogrammetric surface reconstruction was obtained from fourteen proximal tibias of cadaver donors. Measurements of areas and distances from the center of the ACL footprint and the footprint of the obtained bundles to selected arthroscopically-relevant anatomic landmarks were carried out using a three-dimensional design software program, and means and 95% confidence intervals were calculated for these measurements. Reference landmarks were tested in three-dimensional models obtained with arthroscopic videos. MAIN FINDINGS The osseous footprint of the ACL was described in detail, including its precise elevated limits, size, and shape, with its elevation pattern described as a quarter-turn-staircase-like ridge. Its internal indentations were related to inter-spaces identified as bundle divisions. Distances from the footprint center to arthroscopically relevant landmarks were obtained and compared to its internal structure, yielding a useful X-like landmark pointing to the most accurate placeholder for the ACL footprint's "anatomic" center. Certain structures and reference landmarks described were readily recognized in three-dimensional models from arthroscopic videos. CONCLUSIONS Stereophotogrammetric surface reconstruction is an accessible technique for the investigation of anatomic structures in vitro, offering a detailed three-dimensional depiction of the ACL's osseous footprint.
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Affiliation(s)
- Carlos Quiles
- Department of Orthopaedic Surgery and Traumatology, University Hospital Infanta Cristina, Badajoz 06080, Spain.
| | - Juan A Constantino
- Department of Orthopaedic Surgery and Traumatology, University Hospital Infanta Cristina, Badajoz 06080, Spain; Department of Medico-Surgical Therapy, University of Extremadura, Badajoz 06080, Spain.
| | - Yolanda Gañán
- Department of Anatomy, Cell Biology, and Zoology, University of Extremadura, Badajoz 06080, Spain.
| | - Domingo Macías
- Department of Anatomy, Cell Biology, and Zoology, University of Extremadura, Badajoz 06080, Spain.
| | - Manuel Quiles
- Department of Orthopaedic Surgery and Traumatology, University Hospital Infanta Cristina, Badajoz 06080, Spain; Department of Medico-Surgical Therapy, University of Extremadura, Badajoz 06080, Spain.
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Gali JC, Camargo DB, Oliveira FAMD, Pereira RHN, Silva PACD. Anatomia descritiva da inserção femoral do ligamento cruzado anterior. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Costa LAV, Mestriner MB, Amaral TAD, Barbosa BDS, Kaleka CC, Cury RDPL. Estudo histológico da inserção femoral do ligamento cruzado posterior. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Gali JC, Camargo DB, Oliveira FAMD, Pereira RHN, Silva PACD. Descriptive anatomy of the anterior cruciate ligament femoral insertion. Rev Bras Ortop 2018; 53:421-426. [PMID: 30027073 PMCID: PMC6051963 DOI: 10.1016/j.rboe.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/02/2017] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the morphology of the anterior cruciate ligament (ACL) femoral insertion in order to describe its anatomical features and insertion site location, with the aim of verifying if the ACL femoral insertion has individual characteristics and to provide information for appropriate femoral tunnel placement on anatomic ACL reconstruction. Methods Sixteen knees obtained from amputations were studied. The ACL femoral bundles and insertion shape were observed macroscopically, and the ligaments insertion length and thickness were measured with a digital caliper. The distances between the limits of the ligament to the articular cartilage, and the measurement of the area of insertion were checked using ImageJ software. Results The ACL femoral insertion site was eccentric, closer to the deep condyle cartilage. In ten knees (62.5%), the ACL femoral insertion was oval; the mean length of the insertion was 16.4 mm, varying from 11.3 to 19.3 mm, the mean thickness varied from 7.85 to 11.23 mm, and the mean area of the insertion was 99.7 mm2, varying from 80.9 a 117.2 mm2. The mean distances between the limits of the ligament to the superficial, deep, and inferior articular cartilage were 9.77 ± 1.21, 2.60 ± 1.20, and 1.86 ± 1.15 mm, respectively. Conclusion There was a 30% to 40% difference between the minimum and maximum results of measurements of ACL femoral insertion length, thickness, and area demonstrating an important individual variation. The insertion site was eccentric, closer to the deep cartilage of the lateral femoral condyle.
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Affiliation(s)
- Julio Cesar Gali
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Danilo Bordini Camargo
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Felipe Azevedo Mendes de Oliveira
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Rafael Henrique Naves Pereira
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Phelipe Augusto Cintra da Silva
- Departamento de Ortopedia, Faculdade de Ciências Médicas e da Saúde de Sorocaba, Pontifícia Universidade Católica de São Paulo (PUC-SP), Sorocaba, SP, Brazil
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Costa LAV, Mestriner MB, Amaral TAD, Barbosa BDS, Kaleka CC, Cury RDPL. Histological study of the posterior cruciate ligament femoral insertion. Rev Bras Ortop 2018; 53:415-420. [PMID: 30027072 PMCID: PMC6052190 DOI: 10.1016/j.rboe.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 03/06/2017] [Indexed: 11/16/2022] Open
Abstract
Objectives To describe the microscopic anatomy of the posterior cruciate ligament femoral insertion in order to identify and establish differences between the direct and indirect insertions of this ligament. Methods Ten cadaveric knees were used for this study. The posterior cruciate ligament femoral insertion was observed microscopically. Hematoxylin and eosin staining was performed to observe the morphology of the posterior cruciate ligament insertion. Alcian blue staining was performed to determine the location of the cartilage matrix and better assist in the observation and differentiation between direct and indirect insertions. Results The direct insertion was observed to be a more complex structure than the indirect insertion because it showed four different histological layers (ligament, uncalcified fibrocartilage, calcified fibrocartilage, and bone). Chondrocytes were observed in the uncalcified and calcified fibrocartilage layers. It was observed that the indirect insertion was composed of two layers in which the ligament was anchored directly to the bone by collagen fibers. Indirect insertion was located in the marginal region of the posterior cruciate ligament between the direct insertion and the anterior articular cartilage. Conclusion Through histological analysis, it was demonstrated that the indirect insertion was adjacent to the anterior articular cartilage and presents a histological pattern where the collagen fibers insert directly into the bone (two-layer insertion). The direct insertion is posterior to the indirect insertion and has four histologically distinct layers.
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Affiliation(s)
- Lauro Augusto Veloso Costa
- Departamento de Ortopedia e Traumatologia, Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas, São Paulo, SP, Brazil
| | - Marcos Barbieri Mestriner
- Departamento de Ortopedia e Traumatologia, Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas, São Paulo, SP, Brazil
| | - Thiago Alvim do Amaral
- Departamento de Ortopedia e Traumatologia, Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas, São Paulo, SP, Brazil
| | - Bárbara Dos Santos Barbosa
- Departamento de Anatomia Patológica, Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas, São Paulo, SP, Brazil
| | - Camila Cohen Kaleka
- Departamento de Ortopedia e Traumatologia, Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas, São Paulo, SP, Brazil
| | - Ricardo de Paula Leite Cury
- Departamento de Ortopedia e Traumatologia, Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas, São Paulo, SP, Brazil
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Mediolateral Differences of Proteoglycans Distribution at the ACL Tibial Footprint: Experimental Study of 16 Cadaveric Knees. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3762580. [PMID: 29850508 PMCID: PMC5911328 DOI: 10.1155/2018/3762580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/17/2018] [Accepted: 02/27/2018] [Indexed: 01/19/2023]
Abstract
This study aimed to identify the staining pattern of ACL attachment blended with cartilage of the medial tibial plateau at the tibial insertion and histologically characterize the tibial footprint. Sixteen fresh frozen cadaveric knees (mean age: 52.0 ± 6.2 years) were used for this study. The specimens were bisected in the coronal plane, in accordance with the fiber orientation of the ACL tibial attachment. Adjacent sections were then stained with hematoxylin and eosin (H&E) to observe the morphology of the ACL insertion and with fast green and Safranin-O protocols to evaluate for collagen and proteoglycans (PG). The insertion area on the tibial footprint was divided into five zones in the medial to lateral direction, which was determined by division of the section from most prominent medial tibial spine to most lateral margin of ACL attachment. Then rectangular area with a vertical length that is twice the width of respective five zones was set. Stained areas of all images were quantified positively by using ImageJ software, and the value for staining area measured was defined in percentage by multiplying whole image area by 100. The mean proportion of Safranin-O staining is significantly greater nearer to the medial tibial spine (59% in zone 1, 32% in zone 2, 13% in zone 3, 13% in zone 4, and 4% in zone 5, P < 0.001). The medial section of the tibial insertion area grew in size and increased in PG staining with more densely organized collagen arrangement with more fibrocartilage cells. The ACL tibial insertion showed a medially eccentric staining pattern by histological evaluation of the ACL attachment to cartilage. Our histological results of the eccentric biomaterial property in the medial tibial spine of ACL insertion area can be considered in making a more functional anatomic tibial tunnel placement.
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Three-dimensional isotropic magnetic resonance imaging can provide a reliable estimate of the native anterior cruciate ligament insertion site anatomy. Knee Surg Sports Traumatol Arthrosc 2018; 26:1311-1318. [PMID: 28612204 PMCID: PMC5729064 DOI: 10.1007/s00167-017-4560-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 04/26/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE This study quantified the error in anterior cruciate ligament (ACL) insertion site location and area estimated from three-dimensional (3D) isotropic magnetic resonance imaging (MRI) by comparing to native insertion sites determined via 3D laser scanning. METHODS Isotropic 3D DESS MRI was acquired from twelve fresh-frozen, ACL-intact cadaver knees. ACL insertion sites were manually outlined in each MRI slice, and the resulting contours combined to determine the 3D insertion site shape. Specimens were then disarticulated, and the boundaries of the ACL insertion sites were digitized using a high-accuracy laser scanner. MRI and laser scan insertion sites were co-registered to determine the percent overlapping area and difference in insertion centroid location. RESULTS Femoral ACL insertion site area averaged 112.7 ± 17.9 mm2 from MRI and 109.7 ± 10.9 mm2 from laser scan (p = 0.345). Tibial insertion area was 134.7 ± 22.9 mm2 from MRI and 135.2 ± 15.1 mm2 from laser scan (p = 0.881). Percentages of overlapping area between modalities were 82.2 ± 10.2% for femurs and 81.0 ± 9.0% for tibias. The root-mean-square differences for ACL insertion site centroids were 1.87 mm for femurs and 2.49 mm for tibias. The MRI-estimated ACL insertion site centroids were biased on average 0.6 ± 1.6 mm proximally and 0.3 ± 1.9 mm posteriorly for femurs, and 0.3 ± 1.1 mm laterally and 0.5 ± 1.5 mm anteriorly for tibias. CONCLUSION Errors in ACL insertion site location and area estimated from 3D-MRI were determined via comparison with a high-accuracy 3D laser scanning. Results indicate that MRI can provide estimates of ACL insertion site area and centroid location with clinically applicable accuracy. MRI-based assessment can provide a reliable estimate of the native ACL anatomy, which can be helpful for surgical planning as well as assessment of graft tunnel placement.
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