1
|
Ryu DJ, Kim S, Kim M, Kim JH, Kim WJ, Lim D, Wang JH. It is challenging to reproduce both anatomical and functional aspects of anterolateral reconstruction: postoperative 3D-CT analysis of the femoral tunnel position. Knee Surg Relat Res 2024; 36:26. [PMID: 39210443 PMCID: PMC11360883 DOI: 10.1186/s43019-024-00230-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 08/05/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the femoral tunnel position and fiber length of the anterolateral ligament (ALL) reconstruction compared with the natural anatomy of the ALL. We also evaluated whether the femoral tunnel position would affect residual pivot shift. METHODS This study was a retrospective review of 55 knees that underwent ALL reconstruction considering the anatomical and functional aspects, during primary anterior cruciate ligament (ACL) reconstruction in the presence of a high-grade pivot shift or revisional ACL reconstruction. We determined the position of the femoral tunnel and the length of graft using a three-dimensional (3D)-computed tomography (CT) model after ALL reconstruction. We also measured graft excursion during surgery and examined pivot shift 2 years after surgery. We conducted a subgroup analysis of femoral tunnel position, fiber length, isometricity, and residual pivot shift depending on whether the tunnel was anterior or posterior to the lateral epicondyle (LE). We also performed a subgroup analysis depending on whether the ACL reconstruction was primary or revisional. RESULTS The mean femoral tunnel position was 2.04 mm posterior and 14.5 mm proximal from the center of the LE. The mean lengths of the anterior and posterior fibers were 66.6 and 63.4 mm, respectively. The femoral tunnel was positioned more proximally than the anatomical position, and both anterior and posterior ALL fibers were longer than the natural anatomy. The anteroposterior femoral tunnel position was significantly correlated with anterior (p = 0.045) and posterior (p = 0.037) fiber excursion. In the subgroup analysis, there was no significant difference in the residual pivot shift between the posterior and anterior tunnel positions. However, there were significant differences for proximal position (p < 0.001) and fiber length (p = 0.006). There was no significant difference between primary and revisional ACL regarding femoral tunnel position and fiber lengths. CONCLUSION It is challenging to reproduce both anatomical and functional aspects of ALL reconstruction in both primary and revision ACL reconstruction. Especially for functional reconstruction, the femoral tunnel tended to be positioned more proximally than the anatomical position. However, the femoral tunnel position did not affect functional clinical outcomes at the 2-year follow-up. LEVEL OF EVIDENCE Level IV Case series.
Collapse
Affiliation(s)
- Dong Jin Ryu
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea
| | - Seoyeong Kim
- Department of Mechanical Engineering, Sejong University, Seoul, South Korea
| | - Minji Kim
- Department of Mechanical Engineering, Sejong University, Seoul, South Korea
| | - Joo Hwan Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, South Korea
| | - Won Jae Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, South Korea
| | - Dohyung Lim
- Department of Mechanical Engineering, Sejong University, Seoul, South Korea.
- RNX Co., Ltd, Seoul, South Korea.
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, South Korea.
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, 06351, South Korea.
- Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, 06351, South Korea.
| |
Collapse
|
2
|
Kim MJ, Moon SG, Kang JH, Lee DW. Usefulness of 3-Dimensional Computed Tomography Assessment of Femoral Tunnel after Anterior Cruciate Ligament Reconstruction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1716. [PMID: 37893436 PMCID: PMC10608529 DOI: 10.3390/medicina59101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
Positioning of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction is the most crucial factor for successful procedure. Owing to the inter-individual variability in the intra-articular anatomy, it can be challenging to obtain precise tunnel placement and ensure consistent results. Currently, the three-dimensional (3D) reconstruction of computed tomography (CT) scans is considered the best method for determining whether femoral tunnels are positioned correctly. Postoperative 3D-CT feedback can improve the accuracy of femoral tunnel placement. Precise tunnel formation obtained through feedback has a positive effect on graft maturation, graft failure, and clinical outcomes after surgery. However, even if femoral tunnel placement on 3D CT is appropriate, we should recognize that acute graft bending negatively affects surgical results. This review aimed to discuss the implementation of 3D-CT evaluation for predicting postoperative outcomes following ACL re-construction. Reviewing research that has performed 3D CT evaluations after ACL reconstruction can provide clinically significant evidence of the formation of ideal tunnels following anatomic ACL reconstruction.
Collapse
Affiliation(s)
- Min-Jeong Kim
- Department of Radiology, Incheon Sarang Hospital, Incheon 22135, Republic of Korea;
| | - Sung-Gyu Moon
- Department of Radiology, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea; (S.-G.M.); (J.-H.K.)
| | - Ji-Hee Kang
- Department of Radiology, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea; (S.-G.M.); (J.-H.K.)
| | - Dhong-Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
| |
Collapse
|
3
|
Nakanishi Y, Nagai K, Kay J, Zakharia A, Nukuto K, Hoshino Y, Matsushita T, Kuroda R, de Sa D. The incidence of tibial tunnel coalition is higher than femoral tunnel coalition in double-bundle anterior cruciate ligament reconstruction using hamstring autografts: A systematic review. Orthop Traumatol Surg Res 2022; 108:103407. [PMID: 36122878 DOI: 10.1016/j.otsr.2022.103407] [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: 05/12/2021] [Revised: 01/30/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Intra-operative and postoperative coalition of tunnels may occur in double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). However, the incidence and effect on clinical outcomes of tunnel coalition following primary DB ACLR using a hamstring autograft has yet be analyzed, and thus remains unknown. The objective of this systematic review was to identify the incidence of tunnel coalition upon DB ACLR using hamstring autografts and to elucidate any clinical outcomes and/or complications that tunnel coalition may have postoperatively. HYPOTHESIS The incidence of tunnel coalition would increase in respect to time from the index surgery, and that tunnel coalition would be related to poorer clinical outcomes compared to non-coalition cases. METHODS Three databases (PubMed, EMBASE, Cochrane Library) were searched in accordance with PRISMA and R-AMSTAR guidelines on June 15, 2020. Relevant studies were screened in duplicate and data regarding patient demographics, incidence of femoral and tibial tunnel coalition, and outcomes were extracted. Coalition rate was also compared between follow up at 1 month or less defined as "shorter-term", and 6 months or greater as "longer-term". Coalition is defined as the missing of a bony bridge between the two tunnels. RESULTS Thirty-six studies examining 1,574 patients, mean age 29.1 years, were included in this study. 29 studies (1,110 knees) reported the incidence of femoral coalition with a pooled rate of coalition of 8% (95% CI=4-12%). 28 studies (1,129 knees) reported an incidence of tibial coalition with a pooled rate of coalition of 21% (95% CI=13-30%). The incidence of tibial coalition was significantly higher than the incidence of femoral coalition across 21 comparative studies (OR=3.37, 95% CI=1.41-8.09, p=0.0065). Only two studies (111 knees) compared tunnel coalition and non-coalition groups for clinical outcome and no significant differences were observed with regards to Lysholm score, Tegner activity scale, and knee laxity measured with a KT-1000 arthrometer. DISCUSSION The rate of tibial tunnel coalition in DB ACLR is higher than femoral tunnel coalition, particularly at longer-term follow-up. Despite the higher radiographic evidence of coalition, the clinical effects of such remain to be ascertained, and further comparative studies are required to facilitate this understanding. LEVEL OF EVIDENCE IV, systematic review.
Collapse
Affiliation(s)
- Yuta Nakanishi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | | | - Koji Nukuto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Selim NM, Badawy ER, Youssef K. Freehand Anatomic Transtibial Single-Bundle Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2022; 11:e229-e239. [PMID: 35155118 PMCID: PMC8821723 DOI: 10.1016/j.eats.2021.10.013] [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: 05/23/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023] Open
Abstract
Creation of the femoral tunnel for single-bundle anterior cruciate ligament (ACL) reconstruction has a high rate of nonanatomic placement with the transtibial (TT) technique but yields better restoration with the anteromedial portal technique and close restoration of the anatomic femoral footprint with the outside-in technique. Modifications of the traditional (TT) technique have been described to restore the native femoral ACL footprint and to simulate double-bundle reconstruction. Modified TT techniques try to capture the anatomic femoral footprint through an anatomic tibial tunnel. In the technique described in this article, the anatomic femoral footprint is drilled first by the use of a 2.5-mm Kirschner wire through the parapatellar anteromedial portal, making an angle 30° to the sagittal plane and 20° to the horizontal plane. The wire is drilled while the knee is hyperflexed and then withdrawn from outside until its distal end reaches the intercondylar notch. The wire is then advanced in an antegrade manner while the knee is flexed 90° until it reaches the center of the marked tibial footprint. The angle of knee flexion may be slightly increased or decreased around 90° with or without slight internal rotation to capture the anatomic tibial footprint. The procedure is completed as a TT single-bundle ACL reconstruction.
Collapse
Affiliation(s)
- Naser M. Selim
- Address correspondence to Naser M. Selim, M.D., Knee Surgery–Arthroscopy and Sports Injuries Unit, Faculty of Medicine, Mansoura University Hospital, Gomhorrya Street, Mansoura city, Dakahellia Governorate, Egypt.
| | | | | |
Collapse
|
6
|
Yoon KH, Kim YS, Park JY, Kim SG, Lee JH, Choi SH, Kim SJ. Ideal Combination of Anatomic Tibial and Femoral Tunnel Positions for Single-Bundle ACL Reconstruction. Orthop J Sports Med 2022; 10:23259671211069960. [PMID: 35071661 PMCID: PMC8777344 DOI: 10.1177/23259671211069960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/07/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Anatomic anterior cruciate ligament reconstruction (ACLR) is preferred over
nonanatomic ACLR. However, there is no consensus on which point the tunnels
should be positioned among the broad anatomic footprints. Purpose/Hypothesis: To identify the ideal combination of tibial and femoral tunnel positions
according to the femoral and tibial footprints of the anteromedial (AM) and
posterolateral (PL) anterior cruciate ligament bundles. It was hypothesized
that patients with anteromedially positioned tunnels would have better
clinical scores, knee joint stability, and graft signal intensity on
follow-up magnetic resonance imaging (MRI) than those with posterolaterally
positioned tunnels. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 119 patients who underwent isolated single-bundle ACLR with a
hamstring autograft from July 2013 to September 2018 were retrospectively
investigated. Included were patients with clinical scores and knee joint
stability test results at 2-year follow-up and postoperative 3-dimensional
computed tomography and 1-year postoperative MRI findings. The cohort was
divided into 4 groups, named according to the bundle positions in the tibial
and femoral tunnels: AM-AM (n = 33), AM-PL (n = 26), PL-AM (n = 29), and
PL-PL (n = 31). Results: There were no statistically significant differences among the 4 groups in
preoperative demographic data or postoperative clinical scores (Lysholm,
Tegner, and International Knee Documentation Committee subjective scores);
knee joint stability (anterior drawer, Lachman, and pivot-shift tests and
Telos stress radiographic measurement of the side-to-side difference in
anterior tibial translation); graft signal intensity on follow-up MRI; or
graft failure. Conclusion: No significant differences in clinical scores, knee joint stability, or graft
signal intensity on follow-up MRI were identified between the patients with
anteromedially and posterolaterally positioned tunnels.
Collapse
Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Yoon-Seok Kim
- Department of Orthopaedic Surgery, Armed Forces Hongcheon Hospital, Hongcheon, Republic of Korea
| | - Jae-Young Park
- Department of Orthopaedic Surgery, Uijeongbu Eulji Medical Center, School of Medicine, Eulji University, Uijeongbu-si, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopaedic Surgery, National Medical Center, Seoul, Republic of Korea
| | - Jong-Hwan Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sun Hwan Choi
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sang Jin Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| |
Collapse
|
7
|
Bhimani R, Shahriarirad R, Ranjbar K, Erfani A, Ashkani-Esfahani S. Transportal versus all-inside techniques of anterior cruciate ligament reconstruction: a systematic review. J Orthop Surg Res 2021; 16:734. [PMID: 34949188 PMCID: PMC8705139 DOI: 10.1186/s13018-021-02872-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/05/2021] [Indexed: 01/10/2023] Open
Abstract
Background Transportal (TP) and all-inside techniques (AIT) are the most commonly used anterior cruciate ligament (ACL) reconstruction procedures in current clinical practice. However, there is an ongoing debate over which procedure is superior. Therefore, the purpose of this systematic review was to evaluate and compare the clinical outcomes and complications of these two techniques to propose recommendations for future application. Our primary hypothesis was that AIT is a superior ACLR technique compared to TP. Methods A systematic literature review, using PRISMA guidelines, was conducted using PubMed, Medline, Google Scholar, and EMBASE, up to February 2021 to identify studies focusing on AIT and TP techniques of ACL reconstruction. We excluded animal experiments, cadaveric studies, retrospective studies, case reports, technical notes, and studies without quantitative data. Patients’ characteristics, surgical technical features, along with postoperative follow-up and complications were extracted and reported accordingly. Methodological quality of the included studies was assessed using the Modified Coleman Methodology Score (MCMS). Results A total of 44 studies were selected for this review, of which four were comparative studies. A total of 923 patients underwent AIT and 1678 patients underwent the TP technique for ACLR. A single semitendinosus graft was commonly used in the AIT compard to combined semitendinosus and gracilis graft in the TP group. The postoperative increase in International Knee Documentation Committee (IKDC), Lysholm, KT-1000, and Short Form-12 (physical and mental) scores were similar in the AIT group and the TP group. Contrastingly, the VAS pain score was significantly lower in the AIT group compared to the TP group. Furthermore, the pooled complication rates from all studies were similar between the two groups (AIT: 54 patients, 8.26% vs. PT: 55 patients, 6.62%). However, the four studies that prospectively compared AIT and TP techniques showed lesser complications in the AIT group than the TP group. Conclusion Since the future trend in orthopedic surgery is toward less invasive and patients’ satisfaction with good outcomes, AIT is a good alternative method considering preserving bony tissue and gracilis tendon with less post-operative pain, along with more knee flexor strength and equal outcomes compared to conventional ACL reconstruction surgery. Level of Evidence II. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02872-x.
Collapse
Affiliation(s)
- Rohan Bhimani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirhossein Erfani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran. .,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Soheil Ashkani-Esfahani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
8
|
Lee DK, Kim JH, Lee BH, Kim H, Jang MJ, Lee SS, Wang JH. Influence of Graft Bending Angle on Femoral Tunnel Widening After Double-Bundle ACL Reconstruction: Comparison of Transportal and Outside-In Techniques. Orthop J Sports Med 2021; 9:23259671211035780. [PMID: 34708137 PMCID: PMC8543726 DOI: 10.1177/23259671211035780] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Previous studies have suggested that increased mechanical stress due to acute
graft bending angle (GBA) is associated with tunnel widening and graft
failure after anterior cruciate ligament (ACL) reconstruction. Few studies
have compared the GBA between the outside-in (OI) and the transportal (TP)
techniques. Purpose: To evaluate the influence of GBA on clinical outcomes and tunnel widening
after ACL reconstruction with OI versus TP technique. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the study were 56 patients who underwent double-bundle ACL
reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical
outcomes (Lysholm, International Knee Documentation Committee, Tegner score,
and knee laxity) 1 year postoperatively were evaluated. Computed tomography
scans at 5 days and 1 year postoperatively were used for imaging
measurements, and the femoral tunnel was divided into the proximal third,
middle, and aperture sections. The GBA and cross-sectional area (CSA) were
measured using image analysis software and were compared between groups. A
correlation analysis was performed to determine if the GBA affected clinical
outcomes or tunnel widening. Results: No significant difference was observed in clinical outcomes between the
groups. The GBA of both the anteromedial (AM) and posterolateral bundles
were more acute in the OI group compared with the TP group
(P < .05). The CSA at the AM tunnel aperture
increased significantly in the OI group (84.2% ± 64.3%) compared with the TP
group (51.4% ± 36.7%) (P = .04). However, there were no
differences in the other sections. In the Pearson correlation test, GBA was
not correlated with tunnel widening or clinical outcomes. Conclusion: Regardless of technique, the GBA did not have a significant influence on
tunnel widening or clinical outcomes. Considering a wider AM tunnel
aperture, a more proximal and posterior AM tunnel position might be
appropriate with the OI technique.
Collapse
Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, South Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Hyeonsoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Min Jae Jang
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Health Science and Technology and Department of Medical Device Management and Research, SAIHST (Samsung Advanced Institute for Health Sciences & Technology), Sungkyunkwan University, Seoul, South Korea
| |
Collapse
|
9
|
Moran TE, Ignozzi AJ, Werner BC. Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211035741. [PMID: 34631903 PMCID: PMC8493321 DOI: 10.1177/23259671211035741] [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: 03/25/2021] [Accepted: 04/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background Recent studies have suggested that femoral tunnel drilling during anterior cruciate ligament (ACL) reconstruction (ACLR) with the use of a flexible reaming system through a standard anteromedial portal (AM-FR) may result in a different tunnel geometry compared with a rigid reamer through an accessory anteromedial portal with hyperflexion (AM-RR). Purpose To summarize radiologic, anatomic, and clinical outcomes from available studies that directly compared the use of AM-FR versus AM-RR for independent femoral tunnel creation during ACLR. Study Design Systematic review; Level of evidence, 4. Methods A literature search was performed using the MEDLINE (PubMed) and Web of Science databases to identify all studies that directly compared radiologic, anatomic, and clinical outcomes between the use of AM-FR and AM-RR. The literature search, data recording, and methodological quality assessment was performed by 2 independent reviewers. The outcomes analyzed included resultant ACL graft positioning and graft bending angle; femoral tunnel positioning, aperture morphology, length, and widening; posterior wall breakage; and distance from various posterolateral knee structures. Results A total of 13 studies met the eligibility criteria for inclusion. There was no difference in femoral tunnel aperture location between techniques. There were conflicting findings among studies regarding which technique resulted in a more acute graft bending angle. One study reported greater femoral tunnel widening upon follow-up with the use of AM-FR. AM-FR produced longer and more anteverted femoral tunnels than did AM-RR. The difference in tunnel length was significant and more prominent in lesser degrees of knee flexion. With AM-FR, femoral tunnels were farther from the lateral collateral ligament and peroneal nerve, and 1 of 5 studies had fewer reports of posterior wall breakage. There has been no literature comparing the clinical or functional outcomes of these techniques. Conclusion Although no clinical studies exist comparing AM-FR and AM-RR for femoral tunnel creation during ACLR, both systems allow for reproducible positioning of an anatomic femoral tunnel aperture. The use of AM-FR results in longer and more anteverted femoral tunnels than using AM-RR, with exit points on the lateral femur that are different but safe. Surgeons should be aware of the technical differences with each method; however, further study is needed to identify any clinically important difference that results.
Collapse
Affiliation(s)
- Thomas E Moran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Anthony J Ignozzi
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| |
Collapse
|
10
|
Moon SW, Park S, Oh M, Wang JH. Outcomes of human umbilical cord blood-derived mesenchymal stem cells in enhancing tendon-graft healing in anterior cruciate ligament reconstruction: an exploratory study. Knee Surg Relat Res 2021; 33:32. [PMID: 34530924 PMCID: PMC8447562 DOI: 10.1186/s43019-021-00104-4] [Citation(s) in RCA: 3] [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: 10/29/2020] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
Background The study investigated whether allogeneic human umbilical cord blood-derived MSCs (hUCB-MSCs) could be safely used without treatment-related adverse events, reducing tunnel enlargement, and improve clinical results in human anterior cruciate ligament (ACL) reconstruction. Methods Thirty patients were enrolled consecutively. They were divided into three groups by randomization. In the negative control group, ACL reconstruction surgery without additional treatment was performed. In the experimental group, a hUCB-MSC and hyaluronic acid mixture was applied to the tendon-bone interface of the femoral tunnels during ACL reconstruction surgery. In the positive control group, only hyaluronic acid was applied. Finally, 27 patients were analyzed after the exclusion of three patients. The incidence of treatment-related adverse events, clinical outcomes, including second-look arthroscopic findings, and the amount of tunnel enlargement, were evaluated. Results There were no treatment-related adverse events in the treatment groups. Tunnel enlargement in the experimental group (579.74 ± 389.85 mm3) was not significantly different from those in the negative (641.97 ± 455.84 mm3) and positive control (421.96 ± 274.83 mm3) groups (p = 0.6468). There were no significant differences between the groups in clinical outcomes such as KT-2000 measurement (p = 0.793), pivot shift test (p = 0.9245), International Knee Documentation Committee subjective score (p = 0.9195), Tegner activity level (p = 0.9927), and second-look arthroscopic findings (synovial coverage of the graft, p = 0.7984; condition of the graft, p = 0.8402). Conclusions Allogeneic hUCB-MSCs were used safely for ACL reconstruction without treatment-related adverse event in a 2-year follow-up. However, our study did not suggest any evidence to show clinical advantage such as the prevention of tunnel enlargement postoperatively and a decrease in knee laxity or improvement of clinical outcomes. Trial registration CRIS, Registration Number: KCT0000917. Registered on 12 November 2013; https://cris.nih.go.kr/cris/index.jsp
Collapse
Affiliation(s)
- Sang Won Moon
- Department of Orthopaedic Surgery, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Sinhyung Park
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, Gyeonggi-do, Korea
| | - Minkyung Oh
- Clinical Trial Center, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea. .,Department of Health Sciences and Technology and Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, 06351, Korea.
| |
Collapse
|
11
|
Hodel S, Mania S, Vlachopoulos L, Fürnstahl P, Fucentese SF. Influence of femoral tunnel exit on the 3D graft bending angle in anterior cruciate ligament reconstruction. J Exp Orthop 2021; 8:44. [PMID: 34173071 PMCID: PMC8233443 DOI: 10.1186/s40634-021-00364-9] [Citation(s) in RCA: 3] [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: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To quantify the influence of the femoral tunnel exit (FTE) on the graft bending angle (GBA) and GBA-excursion throughout a full range of motion (ROM) in single-bundle anterior cruciate ligament (ACL) reconstruction. Methods Three-dimensional (3D) surface models of five healthy knees were generated from a weight-bearing CT obtained throughout a full ROM (0, 30, 60, 90, 120°) and femoral and tibial ACL insertions were computed. The FTE was simulated for 16 predefined positions, referenced to the Blumensaat's line, for each patient throughout a full ROM (0, 30, 60, 90, 120°) resulting in a total of 400 simulations. 3D GBA was calculated between the 3D directional vector of the ACL and the femoral tunnel, while the intra-articular ACL insertions remained unchanged. For each simulation the 3D GBA, GBA-excursion, tunnel length and posterior tunnel blow-out were analysed. Results Overall, mean GBA decreased with increasing knee flexion for each FTE (p < 0.001). A more distal location of the FTE along the Blumensaat's line resulted in an increase of GBA and GBA-excursion of 8.5 ± 0.6° and 17.6 ± 1.1° /cm respectively (p < 0.001), while a more anterior location resulted in a change of GBA and GBA-excursion of -2.3 ± 0.6° /cm (+ 0.6 ± 0.4°/ cm from 0–60° flexion) and 9.8 ± 1.1 /cm respectively (p < 0.001). Mean tunnel length was 38.5 ± 5.2 mm (range 29.6–50.5). Posterior tunnel blow-out did not occur for any FTE. Conclusion Aiming for a more proximal and posterior FTE, with respect to Blumensaat’s line, reliably reduces GBA and GBA-excursion, while preserving adequate tunnel length. This might aid to reduce excessive graft stress at the femoral tunnel aperture, decrease femoral tunnel widening and promote graft-healing. Level of Evidence IV
Collapse
Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Sylvano Mania
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| |
Collapse
|
12
|
Miyaji N, Araki D, Hoshino Y, Kanzaki N, Nagai K, Matsumoto T, Niikura T, Kuroda R, Matsushita T. The sagittal cutting plane affects evaluation of the femoral bone tunnel position on three-dimensional computed tomography after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:398-404. [PMID: 32266416 DOI: 10.1007/s00167-020-05963-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate how the femoral sagittal cutting plane affects evaluation of the bone tunnel position after anterior cruciate ligament (ACL) reconstruction using the quadrant method in three-dimensional computed tomography (CT) imaging. METHODS Thirty patients who underwent primary anatomic double-bundle ACL reconstruction and CT 2 weeks after surgery were enrolled. Three sagittal cutting planes with respect to the condylar axis were created using the CT images: at the top of the intercondylar notch (C-plane), 5% medial (M-plane), and 5% lateral (L-plane). The center of the bone tunnel position regarding depth and height of the anteromedial (AMB) and posterolateral bundle (PLB) were quantitatively evaluated using the quadrant method on the three different planes. RESULTS The mean depths of AMB and PLB were 27.4 ± 4.4% and 39.7 ± 5.1%, 27.0 ± 4.2% and 37.6 ± 4.9%, and 27.4 ± 4.5% and 38.5 ± 6.0%, at the M, C and L planes, respectively. The mean heights of AMB and PLB were 30.8 ± 6.3% and 56.2 ± 5.6%, 30.4 ± 6.2% and 56.6 ± 5.6%, and 25.4 ± 7.0% and 52.9 ± 6.9% at the M, C, and L planes, respectively. Both AMB and PLB bone tunnels were evaluated as higher positions in the L-plane than the C-plane (p < 0.01, p = 0.02, respectively) and M-plane (p < 0.01, p = 0.04, respectively), but there were no significant differences between the C-plane and M-plane (n.s.). There was no significant difference in the anteroposterior direction for all planes. CONCLUSION In evaluations of the bone tunnel position with the quadrant method using three-dimensional CT, the bone tunnel position depends on the femoral sagittal cutting plane. A consistent evaluation method should be used when evaluating the bone tunnel position after ACL reconstruction to enable correct evaluation clinically. LEVEL OF EVIDENCE Case-control study, Level III.
Collapse
Affiliation(s)
- Nobuaki Miyaji
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Daisuke Araki
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yuichi Hoshino
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Noriyuki Kanzaki
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kanto Nagai
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takahiro Niikura
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| |
Collapse
|
13
|
Kim JH, Oh E, Yoon YC, Lee DK, Lee SS, Wang JH. Remnant-Tensioning Single-Bundle Anterior Cruciate Ligament Reconstruction Provides Comparable Stability to and Better Graft Vascularity Than Double-Bundle Anterior Cruciate Ligament Reconstruction in Acute or Subacute Injury: A Prospective Randomized Controlled Study Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging. Arthroscopy 2021; 37:209-221. [PMID: 33221428 DOI: 10.1016/j.arthro.2020.08.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical, second-look arthroscopic, magnetic resonance imaging (MRI), and dynamic-contrast-enhanced MRI (DCE-MRI) findings between remnant-tensioning single-bundle (RT-SB) and double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). METHODS Sixty-seven patients with acute or subacute anterior cruciate ligament (ACL) injury were randomized to undergo RT-SB or DB ACLR. Twenty-six patients in the RT-SB group and 28 in the DB group were evaluated using stability tests (Lachman test, pivot-shift test, and KT-2000 arthrometer) and multiple clinical scores. One year postoperatively, all 54 patients underwent MRI for evaluation of graft continuity and graft signal/noise quotient and DCE-MRI for the calculation of normalized area under the curve (nAUC) as a marker of graft vascularity. Among them, 41 patients underwent second-look arthroscopy for the evaluation of graft continuity, graft tension, and synovialization. The results were compared between the 2 groups. RESULTS At the minimum 2-year follow-up (28.7 ± 6.4 months), the stability tests, clinical scores, second-look arthroscopic findings, and MRI findings were not significantly different between the groups. However, the mean nAUC values on DCE-MRI for the ACL graft were significantly higher in the RT-SB group than those in the DB group in all 3 zones (nAUCproximal, P = .005; nAUCmiddle, P = .021; nAUCdistal, P = .027; and nAUCaverage, P = .008). CONCLUSION For acute or subacute ACL injury, the RT-SB ACLR showed an outcome comparable to that of DB ACLR in terms of knee stability, clinical scores, MRI findings, and second-look arthroscopic findings. Moreover, RT-SB ACLR showed better graft vascularity 1 year postoperatively than DB ACLR using DCE-MRI. LEVEL OF EVIDENCE II, prospective randomized controlled trial.
Collapse
Affiliation(s)
- Jun Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Eunsun Oh
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Young Cheol Yoon
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea; Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Do Kyung Lee
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, South Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea; Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea; Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
| |
Collapse
|
14
|
Graft bending angle of the reconstructed posterior cruciate ligament gradually decreases as knee flexion increases. Knee Surg Sports Traumatol Arthrosc 2020; 28:2626-2633. [PMID: 32062684 DOI: 10.1007/s00167-020-05899-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 02/03/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of the study was to determine the change in the graft bending angles at the femoral and tibial tunnel aperture in single-bundle posterior cruciate ligament (PCL) reconstruction. It was hypothesized that different knee flexion and different tunnel directions may affect changes of the femoral and tibial graft bending angle. METHODS The right knees of 12 male subjects were scanned with a high-resolution computed tomography scanner at 4 different knee flexion angles (0°, 45°, 90° and 135°). To begin with, the 3D knee models were created and manipulated with the use of several modeling programs. Single-bundle PCL reconstruction was then virtually conducted in a 90° flexion model: The femoral and tibial graft bending angle, according to the various knee flexion angles, was calculated using a special software program. RESULTS The femoral graft bending angle significantly decreased as the knee flexion increased between 0° and 135° (all p < 0.001). The femoral graft bending angle of the AL graft showed the most obtuse angles among the three types of the graft beyond 45° of knee flexion. For the tibial graft bending angle, the anteromedial tunnel group showed significantly more acute tibial graft bending angle than the anterolateral tunnel group in all three types of the graft at all flexion angles (all p < 0.001). CONCLUSION Changes in the femoral graft bending angle were generally affected by different knee flexion angles. The effect of tibial tunnel direction on the tibial graft bending angle was found to be significant. The clinical relevance is that a mostly obtuse femoral graft bending angle was shown by the AL graft among three types of the graft.
Collapse
|
15
|
Wang N, Zhu Z, Wu Z, He H, Wang H, Li W, Xie D, Wang Y. Comparative risk-benefit profiles of different femoral drilling techniques in anterior cruciate ligament reconstruction: A protocol for a systematic review and network meta-analysis. Medicine (Baltimore) 2020; 99:e20544. [PMID: 32502016 PMCID: PMC7306331 DOI: 10.1097/md.0000000000020544] [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] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injury experiences about 200,000 isolated cases annually, and ACL reconstruction has become the gold standard for the restoration of stability and functionality. In view of that incorrect graft placement is a common cause of ACL reconstruction failure, it is critically important to ensure that the tibial and femoral tunnels are properly placed during the operation. Therefore, we intend to conduct a network meta-analysis to comparatively evaluate the clinical outcomes among the different surgical techniques in ACL reconstruction. METHODS Embase, PubMed, and Cochrane Library will be searched through to retrieve the relevant literature up to April 2020. The outcomes include the International Knee Documentation Committee subjective/objective score, Lachman test, Lysholm score, laxity of knee joint, pivot-shift test, Tegner activity scale, and the number of adverse events. A Bayesian hierarchical framework will be used to evaluate the comparative efficacy among different fixation devices. Cochrane Q test and I statistics will be applied to evaluate the heterogeneity, and the Cochrane risk of bias assessment tool will be employed to evaluate the study quality and the risk of bias. RESULTS The comparative risk-benefit profiles of different femoral drilling techniques will be evaluated based on the existing evidence, in order to summarize a prioritization regimen. CONCLUSION Findings from this network meta-analysis will provide useful reference to patients, surgeons, and guideline makers in the related fields. REGISTRATION Open Science Framework (OSF) Preregistration. April 20, 2020. osf.io/uzahs.
Collapse
|
16
|
Yoon KH, Kim JH, Kwon YB, Kim EJ, Lee SH, Kim SG. A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2020; 140:383-390. [PMID: 31970504 DOI: 10.1007/s00402-020-03343-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Indexed: 01/14/2023]
Abstract
INTRODUCTION A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry. METHODS This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2 days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes. RESULTS The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5 mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%). CONCLUSIONS The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR. LEVEL OF EVIDENCE Retrospective case series; level of evidence, 4.
Collapse
Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Jae Ho Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Yoo Beom Kwon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Eung Ju Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang Hyeon Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, South Korea.
| |
Collapse
|
17
|
Nakamura K, Nakamura T, Horie M, Katagiri H, Otabe K, Nakagawa Y, Amemiya M, Sekiya I, Muneta T, Koga H. Anatomic femoral tunnel placement is difficult by the transtibial technique: comparison of three different femoral tunnel drilling techniques in double-bundle anterior cruciate ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 2020; 28:584-593. [PMID: 31612263 DOI: 10.1007/s00167-019-05740-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/30/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare the position and direction of femoral and tibial tunnels for both the anteromedial bundle (AMB) and posterolateral bundle (PLB) among three different femoral tunnel drilling techniques, transtibial (TT), transportal (TP), and outside-in (OI) techniques, in anatomic double-bundle ACL reconstruction to clarify advantages and disadvantages of each technique. METHODS One-hundred and thirty-nine patients underwent primary ACL reconstruction with an autologous semitendinosus tendon in our institution between 2014 and 2016. Thirteen patients were excluded according to the exclusion criteria. Of the 126 patients, 98 patients agreed to be included in this study. Patients were then randomized into three groups according to the femoral tunnel drilling technique; the TT, TP, and OI groups. Femoral and tibial tunnel angles and positions were measured using three-dimensional computed tomography. RESULTS Of patients who agreed to be included in this study, eight patients (seven in TT and one in OI) were excluded since the femoral tunnel could not be created at the intended position. Eighty-six patients (29 in TT, 29 in TP, and 28 in OI) were included for the analyses. Tunnel angles, as well as tunnel lengths, had significant differences among different techniques depending on each technique's characteristics. In terms of tunnel position, femoral tunnel positions of both the AMB and PLB in the TT group were significantly higher than those in the TP group (AMB: p = 0.003, PLB: p = 0.001), and the PLB tunnel position in the TP group had significantly smaller vaciance than that in the TT group (p = 0.004) and OI group (0.002). CONCLUSIONS The femoral tunnel positions created by the TT technique were significantly higher, with larger variance, than the TP technique in double-bundle ACL reconstruction, although the positions seemed to be within anatomical footprint. In addition, there were several cases in which femoral tunnels could not be created at the intended position by the TT technique. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Kaori Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masafumi Horie
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Koji Otabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masaki Amemiya
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takeshi Muneta
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| |
Collapse
|
18
|
Tejpal T, Gupta A, Shanmugaraj A, Horner NS, Simunovic N, Peterson DC, Ayeni OR. Anteromedial Portal Double-Bundle Anterior Cruciate Ligament Reconstruction Yields Similar Outcomes to Non-AMP Femoral Drilling Double-Bundle Techniques: A Systematic Review of Comparative Studies. Orthop J Sports Med 2019; 7:2325967119888140. [PMID: 31853457 PMCID: PMC6906356 DOI: 10.1177/2325967119888140] [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: 01/14/2023] Open
Abstract
Background Biomechanical studies have shown double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) to have increased anterior and rotational stability as compared with single-bundle ACLR. Various techniques exist to drill the femoral tunnel, such as anteromedial portal (AMP), outside-in (OI), and transtibial (TT) drilling. However, it is unclear whether one drilling technique is superior to others when a DB graft is used. Purpose To systematically assess the outcomes and complications in patients undergoing DB ACLR through an AMP technique as compared with other femoral drilling techniques. Study Design Systematic review; Level of evidence, 3. Methods PubMed, Medline, and EMBASE databases were searched in April 2018. Nonrandomized studies were assessed with the MINORS (Methodological Index for Nonrandomized Studies), whereas randomized studies were assessed with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Results Ten studies comprising 722 patients satisfied the inclusion criteria. A total of 351 patients underwent DB ACLR with AMP drilling (mean ± SD age, 32.7 ± 4.7 years); 318 patients had DB ACLR with OI drilling (age, 31.9 ± 4.1 years); and 53 received a DB ACLR with TT drilling (age, 26.5 ± 2.0 years). Graft types used included hamstring autograft (74.1%; n = 247), tibialis anterior autograft (6.0%; n = 20) and unspecified grafts (19.8%; n = 66). No significant difference in postoperative Tegner and Lysholm scores was found between the AMP and OI groups postoperatively. The AMP group had a lower anterior and posterior graft bending angle as compared with the OI group. Four patients (1.1%) in the AMP group had graft reruptures, as compared with 9 reruptures (2.8%) in the OI group. There were no reports of rerupture in the TT group. Conclusion DB AMP ACLR results in significantly improved functional outcome scores postoperatively. AMP techniques yield similar functional outcomes to OI ACLR. No direct comparison in functional outcomes scores were available between the AMP and TT techniques. Low overall complication and revision rates were observed for patients undergoing DB AMP ACLR and were found to be similar to those of other femoral drilling techniques. Owing to a steeper graft bending angle in patients undergoing OI or TT ACLR relative to AMP ACLR, patients treated with OI or TT femoral drilling may have increased strain placed on the graft. Based on the various limitations in the available literature, it is not currently possible to make a definite conclusion of whether AMP is superior to non-AMP techniques in the setting of DB ACLR.
Collapse
Affiliation(s)
- Tushar Tejpal
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Arnav Gupta
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nolan S Horner
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Devin C Peterson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
19
|
Li H, Liu S, Sun Y, Li H, Chen S, Chen J. Influence of Graft Bending Angle on Graft Maturation, the Femoral Tunnel, and Functional Outcomes by 12 Months After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2019; 7:2325967119882663. [PMID: 31807603 PMCID: PMC6880034 DOI: 10.1177/2325967119882663] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: The graft bending angle (GBA), the angle between the femoral bone tunnel and
the line connecting the femoral and tibial tunnel apertures, has been proven
to influence stress within the graft and could be an important factor in
graft healing within the joint and bone tunnel. However, the influence of
the GBA on functional outcomes, particularly on return to sports (RTS), is
rarely reported. Purpose/Hypothesis: The purpose of this study was to investigate the influence of the GBA on
graft maturation, the femoral tunnel, and functional outcomes at 12 months
after anterior cruciate ligament reconstruction (ACLR). We hypothesized that
a greater GBA might be related to bone tunnel widening, poor graft healing,
and inferior functional outcomes after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 43 consecutive patients who underwent unilateral ACLR with
hamstring tendon autografts participated in this study. Their knees were
evaluated using functional scores (International Knee Documentation
Committee [IKDC] score, Lysholm knee activity score, Tegner activity scale,
RTS) and the anterior tibial translation side-to-side difference (ATTD), as
measured using a KT-1000 arthrometer and 3.0-T magnetic resonance imaging
(MRI), at 12 months after surgery. Based on MRI, the signal/noise quotient
(SNQ) of the graft, the GBA, and the femoral tunnel diameter were
measured. Results: The mean GBA was 56° (range, 41°-69°). The GBA had a significant positive
correlation with the SNQ (rho, 0.45; P = .003) and bone
tunnel diameter (rho, 0.35; P = .02), but it had no
significant correlation with any functional scores. Patients were divided
into 3 groups based on GBA values: low GBA (LGBA; 40° < GBA ≤ 50°),
middle GBA (MGBA; 50° < GBA ≤ 60°), and high GBA (HGBA; 60° < GBA ≤
70°). The HGBA group had a significantly higher mean SNQ than both the LGBA
(P = .01) and MGBA groups (P = .02).
It also had a greater mean tunnel diameter than the LGBA group
(P = .04). There was no significant difference in IKDC
scores, Lysholm scores, ATTD, Tegner scores, or rates of RTS among
groups. Conclusion: The GBA did not affect functional outcomes at 12 months after ACLR, although
it affected the SNQ of the graft and the femoral tunnel diameter.
Collapse
Affiliation(s)
- Hong Li
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shaohua Liu
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yaying Sun
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Kusano M, Kazui A, Uchida R, Mae T, Tsuda T, Toritsuka Y. Loop Length Change of an Adjustable-Length Femoral Cortical Suspension Device in Anatomic Rectangular Tunnel Anterior Cruciate Ligament Reconstruction With a Bone-Patellar Tendon-Bone Graft and Associated Clinical Outcomes. Arthroscopy 2018; 34:3063-3070. [PMID: 30301633 DOI: 10.1016/j.arthro.2018.06.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 06/07/2018] [Accepted: 06/10/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate loop length changes of an adjustable femoral cortical suspensory fixation device and assess the clinical results after anatomic rectangular tunnel anterior cruciate ligament (ART-ACL) reconstruction with a bone-tendon-bone (BTB) graft. METHODS The study included 50 patients who underwent ART-ACL reconstruction with a BTB graft fixed using the adjustable-length device BTB TightRope for femoral fixation between July 2013 and December 2014. Computed tomography examinations were performed at 1 and 12 weeks after the surgery. Loop length was measured in the reconstructed plane just parallel to the femoral tunnel, including the bone plug and the button. Measurement was performed thrice, and the mean value was used. Loop length change was defined as the difference in loop length between 1 and 12 weeks after the surgery. A paired t test was conducted with the effect size for statistical analysis. At 2 years postoperatively, clinical evaluations, including subjective and objective assessments, were performed. RESULTS The mean loop lengths at 1 and 12 weeks were 25.77 ± 3.88 mm and 25.81 ± 3.89 mm, respectively, with a significant difference (P = .01). However, the effect size was 0.01, suggesting that the difference was not meaningful. The mean individual loop length change was 0.04 ± 0.13 mm. All individual loop length changes were within the measurement error range. At 2 years postoperatively, 49 patients (98%) were graded as normal or nearly normal according to the International Knee Documentation Committee form. The mean side-to-side difference in anterior laxity at manual maximum force was 0.2 ± 0.5 mm. CONCLUSIONS The loop length change of an adjustable-length femoral cortical suspension device was negligible after ART-ACL reconstruction with a BTB graft. This ART-ACL reconstruction with a BTB graft using an adjustable-length device could safely provide sufficient stability to the operated knee. LEVEL OF EVIDENCE Level Ⅳ, therapeutic case series.
Collapse
Affiliation(s)
- Masashi Kusano
- Department of Orthopaedic Sports Medicine, Kansai Rosai Hospital, Hyogo, Japan
| | - Arisa Kazui
- Department of Orthopaedic Surgery, Osaka General Medical Center, Osaka, Japan
| | - Ryohei Uchida
- Department of Orthopaedic Sports Medicine, Seifu Hospital, Osaka, Japan
| | - Tatsuo Mae
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takayuki Tsuda
- Department of Orthopaedic Sports Medicine, Kansai Rosai Hospital, Hyogo, Japan
| | - Yukiyoshi Toritsuka
- Department of Orthopaedic Sports Medicine, Kansai Rosai Hospital, Hyogo, Japan.
| |
Collapse
|
22
|
Comparison of Modified Transtibial and Outside-In Techniques in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy 2018; 34:2857-2870. [PMID: 30197202 DOI: 10.1016/j.arthro.2018.05.041] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 05/20/2018] [Accepted: 05/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the bending angle of anterior cruciate ligament (ACL) graft at femoral tunnel, graft maturation, and tunnel positions and the clinical outcomes of the modified transtibial (mTT) and outside-in (OI) techniques. METHODS Patients who met the inclusion criteria were divided into the mTT group (n = 50) and the OI group (n = 50). Using 3-dimensional computed tomography (3-D CT), tunnel placement and femoral tunnel bending angle were analyzed. The 3.0-T magnetic resonance imaging (MRI) was used to assess the graft signal intensity (indicative of maturation) with signal/noise quotient (SNQ). Graft tension and synovialization were evaluated with second-look arthroscopy in all cases. Clinical and functional tests were completed at 36 months of follow-up. RESULTS When tunnel placements were analyzed using the quadrant method, no significant differences were found between the mTT group and the OI group. The femoral graft bending angle was reduced in the mTT group, and the total mean of SNQ values and mean SNQ values at the femoral intraosseous and proximal graft of the mTT group were significantly lower than in the OI group (P < .001), respectively. The femoral graft bending angle on the coronal and axial planes showed moderate-to-strong correlation with the SNQ values at the femoral intraosseous and proximal graft. Second-look arthroscopy revealed better synovialization in the mTT group than in the OI group (P = .040), with no significant difference in graft tension between the 2 groups (P = .328). CONCLUSIONS Anatomic tunnel placements did not vary between the mTT group and the OI group. However, the mTT group had more benefits in femoral graft bending angle and showed higher graft maturity and better synovial coverage than the OI group, although there were no significant differences in clinical outcomes. The acute femoral graft bending angle might negatively affect the maturation of proximal graft. LEVEL OF EVIDENCE: Level III, retrospective comparative study.
Collapse
|
23
|
Kim JG, Kang SH, Kim JH, Lim CO, Wang JH. Comparison of Clinical Results, Second-Look Arthroscopic Findings, and MRI Findings Between the Transportal and Outside-In Techniques for Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Trial With a Minimum 2-Year Follow-up. Am J Sports Med 2018; 46:544-556. [PMID: 29293362 DOI: 10.1177/0363546517744535] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques. PURPOSE To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups. RESULTS No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05). CONCLUSION With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.
Collapse
Affiliation(s)
- Jae Gyoon Kim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Seung Hoon Kang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Chae Ouk Lim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| |
Collapse
|
24
|
Van Der Bracht H, Tampere T, Beekman P, Schepens A, Devriendt W, Cromheecke M, Verdonk P, Victor J. Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis. Knee Surg Sports Traumatol Arthrosc 2018; 26:508-517. [PMID: 29124289 DOI: 10.1007/s00167-017-4739-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 10/02/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft. METHODS Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12®. 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations. RESULTS In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture. CONCLUSION In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture. CLINICAL RELEVANCE the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Hans Van Der Bracht
- Department of Orthopaedic Surgery and Traumatology, AZ Sint-Lucas Gent, Groenebriel 1, 9000, Ghent, Belgium
| | - Thomas Tampere
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
| | - Pieter Beekman
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium.
| | - Alexander Schepens
- Department of Orthopaedic Surgery and Traumatology, AZ Sint-Lucas Gent, Groenebriel 1, 9000, Ghent, Belgium
| | - Wouter Devriendt
- Department of Biofluid, Tissue and Solid Mechanics for Medical Applications, bioMMeda, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Michiel Cromheecke
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
| | - Peter Verdonk
- Department of Orthopaedics and Traumatology, AZ Monica, Harmoniestraat 68, 2018, Antwerp, Belgium
| | - Jan Victor
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
| |
Collapse
|
25
|
Hiramatsu K, Mae T, Tachibana Y, Nakagawa S, Shino K. Contact area between femoral tunnel and interference screw in anatomic rectangular tunnel ACL reconstruction: a comparison of outside-in and trans-portal inside-out techniques. Knee Surg Sports Traumatol Arthrosc 2018; 26:519-525. [PMID: 29058021 DOI: 10.1007/s00167-017-4732-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/25/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE The purpose of this study was to compare the femoral tunnel length, the femoral graft bending angle at the femoral tunnel aperture, and the contact area between the femoral tunnel wall and an interference screw used for fixation in anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction (ART ACLR). METHODS The study included 149 patients with primary ACL injury who underwent ART ACLR. Preoperatively, flexion angle of the index knee was checked under general anaesthesia. Those of less than 130° of passive flexion were assigned to the outside-in (OI) technique (78 patients), while the others to the trans-portal inside-out (TP) technique (71 patients). The patients underwent computed tomography with multiplanar reconstruction at 3-5 weeks post-operatively. Femoral tunnel length, graft bending angle, and contact ratio between the IFS and femoral tunnel were assessed. P < 0.05 was considered statistically significant. RESULTS The femoral tunnel length in the OI technique was significantly longer than that in the TP technique (P < 0.001). The femoral graft bending angle in the OI technique was significantly more acute than that in the TP technique (P < 0.001). The contact ratio in the OI technique was significantly larger than that in the TP technique at every point in the femoral tunnel (P < 0.001). CONCLUSIONS The OI technique resulted in a more acute femoral graft bending angle, longer mean femoral tunnel length, and larger contact ratio than the TP technique after ART ACLR. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
Collapse
Affiliation(s)
- Kunihiko Hiramatsu
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yuta Tachibana
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Shigeto Nakagawa
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| |
Collapse
|
26
|
Choi CH, Kim SJ, Chun YM, Kim SH, Lee SK, Eom NK, Jung M. Influence of knee flexion angle and transverse drill angle on creation of femoral tunnels in double-bundle anterior cruciate ligament reconstruction using the transportal technique: Three-dimensional computed tomography simulation analysis. Knee 2018; 25:99-108. [PMID: 28978459 DOI: 10.1016/j.knee.2017.09.005] [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: 05/02/2017] [Revised: 07/19/2017] [Accepted: 09/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to find appropriate flexion angle and transverse drill angle for optimal femoral tunnels of anteromedial (AM) bundle and posterolateral (PL) bundle in double-bundle ACL reconstruction using transportal technique. METHODS Thirty three-dimensional knee models were reconstructed. Knee flexion angles were altered from 100° to 130° at intervals of 10°. Maximum transverse drill angle (MTA), MTA minus 10° and 20° were set up. Twelve different tunnels were determined by four flexion angles and three transverse drill angles for each bundle. Tunnel length, wall breakage, inter-tunnel communication and graft-bending angle were assessed. RESULTS Mean tunnel length of AM bundle was >30mm at 120° and 130° of flexion in all transverse drill angles. Mean tunnel length of PL bundle was >30mm during every condition. There were ≥1 cases of wall breakage except at 120° and 130° of flexion with MTA for AM bundle. There was no case of wall breakage for PL bundle. Considering inter-tunnel gap of >2mm without communication and obtuse graft-bending angle, 120° of flexion and MTA could be recommended as optimal condition for femoral tunnels of AM and PL bundles. CONCLUSION Flexion angle and transverse drill angle had combined effect on femoral tunnel in double-bundle ACL reconstruction using transportal technique. Achieving flexion angle of 120° and transverse drill angle close to the medial femoral condyle could be recommended as optimal condition for femoral tunnels of AM and PL bundles to avoid insufficient tunnel length, wall breakage, inter-tunnel communication and acute graft-bending angle.
Collapse
Affiliation(s)
- Chong Hyuk Choi
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Jae Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su-Keon Lee
- Department of Orthopaedic Surgery, Gwangmyung Sungae Hospital, Gyeonggi, Republic of Korea
| | - Nam-Kyu Eom
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
27
|
Rezende FC, Moraes VY, Franciozi CES, Debieux P, Luzo MV, Belloti JC. One-incision versus two-incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults. Cochrane Database Syst Rev 2017; 12:CD010875. [PMID: 29243827 PMCID: PMC6486027 DOI: 10.1002/14651858.cd010875.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are serious knee injuries that are frequently treated surgically in the form of arthroscopically assisted reconstruction with grafts from the patella or hamstrings tendons. We reviewed the evidence for the choice of arthroscopically assisted ACL reconstruction technique in terms of whether it should involve one incision (femoral tunnel drilled from inside the knee joint under arthroscopic visualisation) or two incisions (femoral tunnel drilled from outside to inside the knee joint). OBJECTIVES To assess the effects (benefits and harms) of one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American and Caribbean Health Sciences (LILACS), the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, reference lists, and conference abstracts. The date of the search was 16 August 2017. SELECTION CRITERIA Randomised and quasi-randomised controlled clinical trials evaluating one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults. DATA COLLECTION AND ANALYSIS Two review authors independently searched and selected studies, and extracted data and assessed the risk of bias of the eligible studies. We undertook limited pooling of data using the fixed-effect model. MAIN RESULTS We included five trials (four randomised and one quasi-randomised) evaluating a total of 320 participants who were mainly in their 20s. All participants underwent ACL reconstruction with patella tendon grafts. All five included trials were at a high risk of bias, particularly performance bias. Based on these limitations and the insufficiency of the available data resulting in imprecision of effect estimates, we judged the quality of the evidence as very low for all outcomes. This means that we are uncertain of the findings of the review.We found very low-quality evidence of no clinically important differences between the two techniques in self reported knee function, measured using the Lysholm knee score (scale 0 to 100: best outcome), at short-term (3 months) (mean difference (MD) 2.73 favours one-incision technique, 95% confidence interval (CI) -2.70 to 8.15; 79 participants, 2 studies), intermediate-term (12 months) (MD -3.68 favours two-incision technique, 95% CI -6.61 to -0.75; 79 participants, 2 studies), and long-term follow-up. The data available for long-term follow-up (2 to 5 years) was expressed in terms of the numbers of participants with excellent Lysholm scores (90 points or more); we found no difference between the two groups (42/45 versus 36/40; risk ratio (RR) 1.04, 95% CI 0.91 to 1.18; 1 study). There were no data for quality of life measures or for overall numbers of participants incurring an adverse event. We found very low-quality evidence of little between-group differences in individual adverse events such as infection, knee stiffness, reoperation, and graft failure.We found very low-quality evidence from one study (59 participants) of little difference between the two groups in activity levels measured using Tegner scores (scale 0 to 10: highest sport activity) at two years (MD -0.80 favours two-incision technique, 95% CI -1.90 to 0.30). There was very low-quality evidence from four studies of minimal between-group difference in the number of participants with normal or nearly normal objectively measured knee function (International Knee Documentation Committee objective assessment grading) at intermediate follow-up (means 12 to 28 months): 56/78 versus 63/89; RR 1.01, 95% CI 0.85 to 1.21; 167 participants). AUTHORS' CONCLUSIONS The very low-quality and often absent evidence means that we are uncertain whether one-incision arthroscopically assisted ACL reconstruction techniques yield better, worse, or equivalent results compared with two-incision techniques in terms of short-, intermediate-, or long-term subjective function, quality of life, adverse outcomes, activity levels, and objectively rated knee function. The evidence was available only for single-bundle ACL reconstruction using patella tendon grafts.When considering priorities for high-quality randomised trials on techniques for ACL reconstruction, it is important to note the insufficiency of the evidence available to inform this key comparison.
Collapse
Affiliation(s)
- Fernando C Rezende
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Vinícius Y Moraes
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Carlos ES Franciozi
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Pedro Debieux
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - Marcus V Luzo
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | - João Carlos Belloti
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyBorges Lagoa Street, 778São PauloBrazil04045001
| | | |
Collapse
|
28
|
Taketomi S, Inui H, Tahara K, Shirakawa N, Tanaka S, Nakagawa T. Effects of initial graft tension on femoral tunnel widening after anatomic anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft. Arch Orthop Trauma Surg 2017; 137:1285-1291. [PMID: 28616652 DOI: 10.1007/s00402-017-2728-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The effects of initial graft tension upon tunnel widening (TW) following anatomic anterior cruciate ligament (ACL) reconstruction have not been elucidated. The purpose of this study was to retrospectively investigate the effect of two different graft-tensioning protocols upon femoral TW following anatomic ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft and a three-dimensional (3D) computed tomography (CT) model. METHODS Forty-three patients who underwent isolated ACL reconstruction using BPTB grafts were included in this study. In 18 out of the 43 patients, the graft was fixed at full knee extension with manual maximum pull (Group H). These patients were compared with 25 patients in whom the BPTB graft was fixed at full knee extension with 80-N pull (Group L). Tunnel aperture area was measured using 3D CT 1 week and 1 year postoperatively, thus enabling us to calculate the percentage change in the area of femoral tunnel aperture. Clinical assessment was performed 1 year postoperatively, corresponding to the time period of CT assessment, and involved the evaluation of Lysholm score, anterior knee stability using a KneeLax3 arthrometer, and the pivot-shift test. RESULTS When measured at 1 year postoperatively, the mean area of the femoral tunnel aperture had increased by 78.6 ± 36.8% in Group H when compared with at 1 week postoperatively, whereas that of Group L had increased by 27.7 ± 32.3%. Furthermore, TW (%) in Group H was significantly greater than that of Group L (P < 0.001). No significant differences were detected between the two groups with regard to any of the clinical outcomes evaluated. CONCLUSION High levels of initial graft tension resulted in greater TW of the femoral tunnel aperture following anatomical ACL reconstruction using BPTB grafts. However, such levels of graft tension did not affect clinical outcome.
Collapse
Affiliation(s)
- Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroshi Inui
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keitaro Tahara
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuyuki Shirakawa
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takumi Nakagawa
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| |
Collapse
|
29
|
Tashiro Y, Gale T, Sundaram V, Nagai K, Irrgang JJ, Anderst W, Nakashima Y, Tashman S, Fu FH. The Graft Bending Angle Can Affect Early Graft Healing After Anterior Cruciate Ligament Reconstruction: In Vivo Analysis With 2 Years' Follow-up. Am J Sports Med 2017; 45:1829-1836. [PMID: 28402758 DOI: 10.1177/0363546517698676] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A high graft bending angle (GBA) after anterior cruciate ligament (ACL) reconstruction has been suggested to cause stress on the graft. Nevertheless, evidence about its effect on graft healing in vivo is limited. HYPOTHESIS The signal intensity on magnetic resonance imaging (MRI) would be higher in the proximal region of the ACL graft, and higher signals would be correlated to a higher GBA. STUDY DESIGN Descriptive laboratory study. METHODS Anatomic single-bundle ACL reconstruction was performed on 24 patients (mean age, 20 ± 4 years) using the transportal technique. A quadriceps tendon autograft with a bone plug was harvested. To evaluate graft healing, the signal/noise quotient (SNQ) was measured in 3 regions of interest (ROIs) of the proximal, midsubstance, and distal ACL graft using high-resolution MRI (0.45 × 0.45 × 0.70 mm), with decreased signals suggesting improved healing. Dynamic knee motion was examined during treadmill walking and running to assess the in vivo GBA. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors at each motion frame, based on tibiofemoral kinematics determined from dynamic stereo X-ray analysis. Graft healing and GBAs were assessed at 6 and 24 months postoperatively. Repeated-measures analysis of variance was used to compare the SNQ in the 3 ROIs at 2 time points. Pearson correlations were used to analyze the relationship between the SNQ and mean GBA during 0% to 15% of the gait cycle. RESULTS The SNQ of the ACL graft in the proximal region was significantly higher than in the midsubstance ( P = .022) and distal regions ( P < .001) at 6 months. The SNQ in the proximal region was highly correlated with the GBA during standing ( R = 0.64, P < .001), walking ( R = 0.65, P = .002), and running ( R = 0.54, P = .015) but not in the other regions. At 24 months, signals in the proximal and midsubstance regions decreased significantly compared with 6 months ( P < .001 and P = .008, respectively), with no difference across the graft area. CONCLUSION The signal intensity was highest in the proximal region and lowest in the distal region of the reconstructed graft at 6 months postoperatively. A steep GBA was significantly correlated with high signal intensities of the proximal graft in this early period. A steep GBA may negatively affect proximal graft healing after ACL reconstruction.
Collapse
Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vani Sundaram
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kanto Nagai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
30
|
Tashiro Y, Sundaram V, Thorhauer E, Gale T, Anderst W, Irrgang JJ, Fu FH, Tashman S. In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament-Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique. Arthroscopy 2017; 33:1393-1402. [PMID: 28343809 PMCID: PMC5495610 DOI: 10.1016/j.arthro.2017.01.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the in vivo dynamic graft bending angle (GBA) in anterior cruciate ligament (ACL)-reconstructed knees, correlate the angle to tunnel positions and tunnel widening, and evaluate the effects of 2 femoral tunnel drilling techniques on GBA. METHODS Patients with an isolated ACL injury undergoing reconstruction from 2011 to 2012 were included. Transportal techniques were used to create femoral tunnels. Tunnel locations were determined by 3-dimensional computed tomography. Tibiofemoral kinematics during treadmill walking and running were assessed by dynamic stereo x-ray analysis 6 months and 2 years postoperatively. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors on each motion frame. The cross-sectional areas of femoral tunnels were measured at 6 months and compared with the initial size to assess tunnel widening. RESULTS A total of 54 patients were included. Use of flexible drills resulted in significantly higher GBAs during walking (80.6° ± 7.8°, P < .001) and running (80.5° ± 9.0°, P = .025) than rigid drills (walking, 67.5° ± 9.3°; running, 74.1° ± 9.6°). Their use led to greater tunnel widening of 113.9% ± 17.6%, as compared with 97.7% ± 17.5% for rigid drills (P = .003). The femoral and tibial apertures were located in similar anatomic positions in both groups, but the femoral tunnel exits were located more anteriorly (P < .001) in the flexible drill group. A higher GBA was highly correlated with anterior location of femoral exits (r = 0.63, P < .001) and moderately correlated with greater tunnel widening (r = 0.48, P < .001). CONCLUSIONS High GBAs were identified during dynamic activities after anatomic ACL reconstruction with a transportal femoral tunnel drilling technique. The GBA was greater when flexible drills were used. The high bending angle resulted from the more anterior location of the femoral tunnel exits, and it correlated with early bone tunnel widening at 6 months. These results suggest that a high GBA may increase stress at the bone-graft interface and contribute to greater tunnel widening after anatomic ACL reconstruction, although the clinical impact should be further investigated. LEVEL OF EVIDENCE Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Ysutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Vani Sundaram
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Eric Thorhauer
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - James J. Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Freddie H. Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| |
Collapse
|
31
|
Pula D. Editorial Commentary: Angle Versus Anatomy: Sacrificing Graft Bending Angle for Anatomic Anterior Cruciate Ligament Reconstruction. Arthroscopy 2017; 33:1403-1404. [PMID: 28669474 DOI: 10.1016/j.arthro.2017.02.021] [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: 02/21/2017] [Accepted: 02/21/2017] [Indexed: 02/02/2023]
Abstract
Graft bending angle (GBA) is the angle created by the intra-articular anterior cruciate ligament (ACL) graft and the femoral tunnel. By definition then, it is affected by the angle at which the surgeon drills the femoral tunnel. In an attempt to create a more anatomic ACL, different techniques have been described to put the femoral tunnel in the anatomic footprint. If you can get past each author's unique description of GBA, whether they are referring to the graft, the tunnel angle, or using adjectives such as acute or higher GBA, you see that attempting to create more anatomic ACL reconstructions has resulted in a sharper turn for our grafts. The million-dollar question is: what does that mean? For now, the answer is unknown.
Collapse
|
32
|
Wang JH, Lee DK, Chung ST, Lee BH. Influence of change of tunnel axis angle on tunnel length during double-bundle ACL reconstruction via the transportal technique. BMC Musculoskelet Disord 2017; 18:237. [PMID: 28569166 PMCID: PMC5452363 DOI: 10.1186/s12891-017-1599-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/22/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Commercially available flexible reamer and curved guide systems allow a certain degree of control over intra-articular tunnel orientation, therefore allows a wide range of intra-osseous femoral tunnel orientations, contrary to the femoral tunneling technique using a straight guide pin, which are determined by knee flexion angle. We sought to find the clinical relevance of intra-osseous femoral tunnel orientations in the respect of tunnel length. To evaluate the relationship between the tunnel axis angle in three orthogonal planes and tunnel length in the anteromedial (AM) and posterolateral (PL) femoral tunnels in patients who underwent anatomic double-bundle anterior cruciate ligament reconstruction (DB-ACLR) using the transportal (TP) technique with a 42o curved guide. METHODS A total of 40 patients who underwent primary DB-ACLR with the TP technique using a curved guide were evaluated retrospectively. The tunnel axis angle in three orthogonal planes were evaluated on a three-dimensional surface model constructed using an axial computed tomography scan obtained after reconstruction. Then, correlations with tunnel length were analyzed. RESULTS In the AM tunnel, tunnel axis angles in the coronal (β = 0.0252, p = 0.022) and sagittal (β = 0.0168, p = 0.029) plane showed significant correlations with tunnel length, while the axial plane did not (p = 0.493) (adjusted R2 = 0.801). In the PL tunnel, only tunnel axis angles in the axial plane (β = 0.0262, p = 0.008) showed a significant relationship with tunnel length (adjusted R2 = 0.700). CONCLUSION Drilling at a higher angle in the coronal and sagittal planes in AM tunnels and at a higher angle in the axial plane in PL tunnels decreases the incidence of short femoral tunnels.
Collapse
Affiliation(s)
- Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, South Korea.,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, 06351, South Korea.,Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, 06351, South Korea
| | - Do Kyung Lee
- Department of Orthopaedic Surgery, Konyang University Hospital, 158, Gwanjeodong-ro, Seo-gu, Daejeon, South Korea
| | - Sung Taek Chung
- Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Gil-dong, Seoul, 134-701, South Korea
| | - Byung Hoon Lee
- Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Gil-dong, Seoul, 134-701, South Korea.
| |
Collapse
|
33
|
Niki Y, Nagai K, Harato K, Suda Y, Nakamura M, Matsumoto M. Effects of femoral bone tunnel characteristics on graft-bending angle in double-bundle anterior cruciate ligament reconstruction: a comparison of the outside-in and transportal techniques. Knee Surg Sports Traumatol Arthrosc 2017; 25:1191-1198. [PMID: 26294057 DOI: 10.1007/s00167-015-3761-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 08/11/2015] [Indexed: 01/10/2023]
Abstract
PURPOSE Bone tunnel creation techniques influence the 3-dimensional (3D) position of bone tunnels and graft-bending angle in anterior cruciate ligament (ACL) reconstruction. This study assessed graft-bending angle and 3D characteristics of femoral bone tunnels and compared them between outside-in (OI) and transportal (TP) techniques. METHODS Participants comprised 64 patients who underwent anatomic double-bundle ACL reconstruction, allocated to OI and TP groups (n = 32 each). The graft orientation plane exhibiting the largest graft-bending angle at the femoral tunnel aperture with the knee in extension was reconstructed from CT data using 3D imaging software. In this plane, graft-bending angle was compared between the OI and TP techniques. RESULTS Although positionings of the intra-articular apertures of the femoral and tibial bone tunnels were similar, several spatial parameters of bone tunnels differed between techniques. Graft-bending angles of both anteromedial and posterolateral bundles were significantly more acute with the OI technique than with the TP technique. On coronal-plane CT, angle of the bone tunnel axis relative to the distal condylar axis correlated negatively with graft-bending angle, while in the axial plane, angle of the bone tunnel axis relative to the posterior condylar axis correlated positively with graft-bending angle. Lysholm score, pivot shift test, and anteroposterior laxity at >2.5-year follow-up demonstrated no significant differences between techniques. DISCUSSION Different bone tunnel directions in OI and TP techniques substantially affected graft-bending angle , despite similar positionings of the intra-articular apertures. Graft-bending angle with the OI technique was acute, but risk of posterior blowout of the lateral femoral condyle was decreased. Surgeons should create the femoral tunnel while considering an obtuse graft-bending angle without increasing the risk of posterior blowout. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Yasuo Niki
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Katsuya Nagai
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kengo Harato
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yasunori Suda
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| |
Collapse
|
34
|
Kang K, Bae TS. Effect of femoral tunnel positions on graft stress in outside-in ACL reconstruction surgery during continuous knee motion: A simulation study. Int J Med Robot 2017; 13. [PMID: 28370840 DOI: 10.1002/rcs.1817] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/07/2017] [Accepted: 02/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Previous studies regarding the optimal femoral tunnel location for an anterior cruciate ligament (ACL) reconstruction were based on static experiments at specific angles, and did not consider continuous motion of the knee. METHODS Twenty-four surgical sites were set and continuous kinematic data, obtained from motion analysis, was used to describe knee movement. The bending angle and stress of the ACL graft as well as the length of the femoral tunnel was calculated through multi-flexible body dynamics analysis. RESULTS The lowest stress was found at both 5 mm and 10 mm radius at a proximal posterior of 45°, and the highest stress was also found at a distal 15 mm radius. Relatively high stresses were also identified between the distal and anterior regions as well as the distal and posterior regions at 15 mm radius. CONCLUSION Considering the availability of surgery, it was identified that the optimum femoral tunnel location is at 10 mm radius locations at a proximal posterior of 45°.
Collapse
Affiliation(s)
- Kyungmin Kang
- Dept. of Biomedical Engineering, Jungwon University, 85, Munmu-ro, Goesan-eup, Goesan-gun, Chungcheongbuk-do, 367-805, Korea
| | - Tae Soo Bae
- Dept. of Biomedical Engineering, Jungwon University, 85, Munmu-ro, Goesan-eup, Goesan-gun, Chungcheongbuk-do, 367-805, Korea
| |
Collapse
|
35
|
Lee SM, Yoon KH, Lee SH, Hur D. The Relationship Between ACL Femoral Tunnel Position and Postoperative MRI Signal Intensity. J Bone Joint Surg Am 2017; 99:379-387. [PMID: 28244908 DOI: 10.2106/jbjs.16.00241] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to find the ideal femoral tunnel position in single-bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT) by comparing clinical scores, stability of the knee joint, and graft signal intensity on follow-up magnetic resonance imaging (MRI). We hypothesized that positioning the femoral tunnel near the anteromedial bundle or center would lead to better results in terms of clinical outcomes and graft signal intensity on follow-up MRI than would positioning the tunnel near the posterolateral bundle. METHODS Two hundred patients underwent arthroscopic single-bundle ACL reconstruction with a soft-tissue graft; all patients had the same surgeon, surgical technique (anteromedial transportal technique), and rehabilitation protocol. Each patient underwent 3D-CT within 1 week after the operation and MRI at 1 year after the operation. Outcomes were evaluated in terms of clinical scores and the stability of the knee joint. We classified patients into three groups based on the femoral tunnel position: the anteromedial position group, the posterolateral position group, and the center position group. We evaluated graft signal intensity on follow-up MRI. RESULTS This study included 77 patients: 25 patients in the anteromedial position group, 15 patients in the posterolateral position group, and 33 patients in the center position group. Four patients had an eccentric tunnel position and were excluded. The 3 groups did not differ significantly (p > 0.05) in preoperative demographic characteristics. There were no significant differences (p > 0.05) between groups in clinical outcomes. However, patients in the anteromedial position group and in the center position group had better graft signal intensity on follow-up MRI than those in the posterolateral position group. CONCLUSIONS Positioning the femoral tunnel near the anteromedial bundle and center led to better graft signal intensity on follow-up MRI in anatomic single-bundle ACL reconstruction than did positioning the femoral tunnel near the posterolateral bundle. There were no differences in clinical scores or stability of the knee joint among the three groups. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Se Min Lee
- 1Department of Orthopaedic Surgery, Graduate School (S.M.L.), College of Medicine (K.H.Y. and D.H.), Kyung Hee University, Seoul, South Korea 2Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | | | | | | |
Collapse
|
36
|
Kim KI, Lee SH, Bae C, Bae SH. Three-Dimensional Reconstruction Computed Tomography Evaluation of the Tunnel Location and Angle in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction: A Comparison of the Anteromedial Portal and Outside-in Techniques. Knee Surg Relat Res 2017; 29:11-18. [PMID: 28231643 PMCID: PMC5336365 DOI: 10.5792/ksrr.16.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/12/2016] [Accepted: 01/02/2017] [Indexed: 02/08/2023] Open
Abstract
Purpose The purpose of this study was to compare the geometry and position of the femoral tunnel between the anteromedial portal (AMP) and outside-in (OI) techniques after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction. Materials and Methods We evaluated 82 patients undergoing single-bundle ACL reconstruction with hamstring autografts using either the AMP (n=40) or OI (n=42) technique. The locations of the tunnel apertures were assessed by postoperative 3-dimensional computed tomography imaging. The femoral graft bending angle, femoral tunnel aperture shape, femoral tunnel length, and posterior wall breakage were also measured. Results The mean femoral tunnel position parallel to the Blumensaat line was more caudally positioned in the AMP group than in the OI group (p=0.025) The mean femoral graft angle in the OI group (99.6°±7.1°) was significantly more acute than that of the AMP group (108.9°±10.2°, p<0.001). The mean height/width ratio of the AMP group (1.21±0.20) was significantly more ellipsoidal than that of the OI group (1.07±0.09, p<0.001). Conclusions The mean femoral tunnel position was significantly shallower in the AMP technique than in the OI technique. The OI technique might be more disadvantageous than the AMP technique in terms of the more acute bending angle.
Collapse
Affiliation(s)
- Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sang Hak Lee
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Chanil Bae
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sung Hae Bae
- Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| |
Collapse
|
37
|
Lee DW, Kim JG. Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction Using the Modified Transtibial Technique. Arthrosc Tech 2017; 6:e227-e232. [PMID: 28409105 PMCID: PMC5382429 DOI: 10.1016/j.eats.2016.09.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/12/2016] [Indexed: 02/03/2023] Open
Abstract
We present a technique for anterior cruciate ligament (ACL) reconstruction using hamstring tendon autograft with a modified transtibial technique. Our modified transtibial technique has the advantages of the conventional transtibial technique that is familiar to surgeons and that allows the press-fit fixing and enables us to make a relatively long femoral tunnel. To make the femoral tunnel at the anatomic position, the triangular, funnel-shaped bony trough was made to slip the eccentrically positioned guide pin into the anticipated anatomic center with a free-hand technique after marking the anatomic ACL footprint using a microfracture awl through the anteromedial portal. Gradual femoral reaming was performed with knee angle changes, which reduces the chances of posterior wall blowout, increases the femoral tunnel length, and avoids breakage of guide pin at the bending point. Our modified transtibial technique is anticipated to provide a more anatomic placement of the femoral tunnel during ACL reconstruction than the previous traditional transtibial techniques.
Collapse
Affiliation(s)
- Dhong Won Lee
- Department of Orthopaedic Surgery, Armed Forces Daejeon Hospital, Daejeon, Republic of Korea
| | - Jin Goo Kim
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Seoul, Republic of Korea,Address correspondence to Jin Goo Kim, M.D., Ph.D., Professor of Orthopaedics, Chief of Sports Medical Center, 120-1, Neungdong-ro, Gwangjin-gu, Department of Orthopaedic Surgery, Konkuk University Medical Center, Seoul 143-729, Republic of Korea.Professor of OrthopaedicsChief of Sports Medical Center120-1, Neungdong-ro, Gwangjin-guDepartment of Orthopaedic SurgeryKonkuk University Medical CenterSeoul143-729Republic of Korea
| |
Collapse
|
38
|
Tashiro Y, Irarrázaval S, Osaki K, Iwamoto Y, Fu FH. Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:129-137. [PMID: 27277192 DOI: 10.1007/s00167-016-4191-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/31/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine graft bending angle (GBA) during knee motion after anatomic anterior cruciate ligament (ACL) reconstruction and to clarify whether surgical techniques affect GBA. Our hypotheses were that the graft bending angle would be highest at knee extension and the difference of surgical techniques would affect the bending steepness. METHODS Eight healthy volunteers with a mean age of 29.3 ± 3.0 years were recruited and 3D MRI knee models were created at three flexion angles (0°, 90° and 130°). Surgical simulation of the tunnel drilling was performed with anatomic tunnel position using each outside-in (OI), trans-portal (TP) and trans-tibial (TT) techniques on the identical cases. The models were matched to other knee positions and the GBA in 3D was measured using computational software. Double-bundle ACL reconstruction was analysed first, and single-bundle reconstruction was also analysed to evaluate its effect to reduce GBA. A repeated-measures ANOVA was used to compare GBA difference at three flexion angles, by three techniques or of three bundles. RESULTS GBA changed substantially with knee motion, and it was highest at full extension (p < 0.001) in each surgical technique. OI technique exhibited highest GBA for anteromedial bundle (94.3° ± 5.2°) at extension, followed by TP (83.1° ± 6.5°) and TT (70.0° ± 5.2°) techniques (p < 0.01). GBA for posterolateral bundle at extension were also high in OI (84.6° ± 7.4°), TP (83.0° ± 6.3°) and TT (77.2° ± 7.0°) techniques (n.s.). Single-bundle grafts did not decrease GBA compared with double-bundle grafts. In OI technique, a more proximal location of the femoral exit reduced GBA of each bundle at extension and 90° flexion. CONCLUSION A significant GBA change with knee motion and considerably steep bending at full extension, especially with OI and TP techniques, were simulated. Although single-bundle technique did not reduce GBA as seen in double-bundle technique, proximal location of femoral exits by OI technique, with tunnels kept in anatomic position, was effective in decreasing GBA at knee extension and flexion. For clinical relevance, high stress on graft and bone interface has been suggested by steep GBA at full extension after anatomic ACL reconstruction. LEVEL OF EVIDENCE Therapeutic study (prospective comparative study), Level II.
Collapse
Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA. .,Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Sebastián Irarrázaval
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| |
Collapse
|
39
|
Figueroa D, Calvo R, Figueroa F, Paccot D, Izquierdo G, Morales N. Clinical and arthrometric outcomes of an anatomic outside-in single-bundle anterior cruciate ligament reconstruction using a retrodrill. Knee 2016; 23:1098-1105. [PMID: 27816290 DOI: 10.1016/j.knee.2016.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 05/28/2016] [Accepted: 07/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The main option to perform an anatomic anterior cruciate ligament (ACL) reconstruction is the anteromedial portal (AMP) technique. It has several reported complications (iatrogenic chondral injury, posterior-wall blowout, short sockets, increased risk of injury to common peroneal nerve). In an attempt to avoid these complications the outside-in (OI) technique was revived with the addition of a retrodrill. The aim of this study is to evaluate the clinical and arthrometric outcomes of a series of anatomical OI single bundle ACL reconstruction using a retrodrill. METHODS Prospective case series. KT-1000 and Pivot Shift Test were done at 24 months follow-up. International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores preoperatively and at final follow-up. Complications were reported. Statistical analysis was done with t-test. RESULTS 275 knees of 200 (73%) males and 75 (27%) females were enrolled in the study. Mean age 29.1 years (15-54). Mean follow-up 34.5 months (24-49). Mean preoperatively Lysholm Score 62 (25-95) versus 95 (76-100) at final follow-up (p<0.001) Mean preoperatively IKDC score 60 (26.4-90.8) versus 92 (59.8-100) at final follow-up (p<0.001) Mean Tegner activity Score pre injury 5 versus 5 at final follow-up. (p=0.59) Mean KT-1000 side-to-side difference 2mm (1-6). Pivot Shift test negative in 243 patients (90%); positive in 32 (10%) patients. 13 (5%) ACL re-ruptures. 2 (0.7%) infections. No other complications were reported. CONCLUSION OI single bundle anatomic ACL reconstruction using a retrodrill is a valid and safe option that avoids the complications reported with the AMP technique.
Collapse
Affiliation(s)
- David Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile.
| | - Rafael Calvo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Francisco Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Daniel Paccot
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Guillermo Izquierdo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Nelson Morales
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| |
Collapse
|
40
|
Zhang Y, Xu C, Dong S, Shen P, Su W, Zhao J. Systemic Review of Anatomic Single- Versus Double-Bundle Anterior Cruciate Ligament Reconstruction: Does Femoral Tunnel Drilling Technique Matter? Arthroscopy 2016; 32:1887-904. [PMID: 27184099 DOI: 10.1016/j.arthro.2016.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 02/29/2016] [Accepted: 03/04/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To provide an up-to-date assessment of the difference between anatomic double-bundle anterior cruciate ligament (ACL) reconstruction (DB-ACLR) and anatomic single-bundle ACL reconstruction (SB-ACLR). We hypothesized that anatomic SB-ACLR using independent femoral drilling technique would be able to achieve kinematic stability as with anatomic DB-ACLR. METHODS A comprehensive Internet search was performed to identify all therapeutic trials of anatomic DB-ACLR versus anatomic SB-ACLR. Only clinical studies of Level I and II evidence were included. The comparative outcomes were instrument-measured anterior laxity, Lachman test, pivot shift, clinical outcomes including objective/subjective International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale and complication rates of extension/flexion deficits, graft failure, and early osteoarthritis. Subgroup analyses were performed for femoral tunnel drilling techniques including independent drilling and transtibial (TT) drilling. RESULTS Twenty-two clinical trials of 2,261 anatomically ACL-reconstructed patients were included in the meta-analysis. Via TT drilling technique, anatomic DB-ACLR led to improved instrument-measured anterior laxity with a standard mean difference (SMD) of -0.42 (95% confidence interval [CI] = -0.81 to -0.02), less rotational instability measured by pivot shift (SMD = 2.76, 95% CI = 1.24 to 6.16), and higher objective IKDC score with odds ratio (OR) of 2.28 (95% CI = 1.19 to 4.36). Via independent drilling technique, anatomic DB-ACLR yielded better pivot shift (SMD = 2.04, 95% CI = 1.36 to 3.05). Anatomic DB-ACLR also revealed statistical significance in subjective IKDC score compared with anatomic SB-ACLR (SMD = 0.27, 95% CI = 0.05 to 0.49). CONCLUSIONS Anatomic DB-ACLR showed better anterior and rotational stability and higher objective IKDC score than anatomic SB-ACLR via TT drilling technique. Via independent drilling technique, however, anatomic DB-ACLR only showed superiority of rotational stability. All clinical function outcomes except subjective IKDC score were not significantly different between anatomic DB-ACLR and SB-ACLR. LEVEL OF EVIDENCE Level II, meta-analysis of Level I and II studies.
Collapse
Affiliation(s)
- Yang Zhang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shiqui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Peng Shen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| |
Collapse
|
41
|
Ahn JH, Jeong HJ, Lee YS, Park JH, Lee JH, Ko TS. Graft bending angle is correlated with femoral intraosseous graft signal intensity in anterior cruciate ligament reconstruction using the outside-in technique. Knee 2016; 23:666-73. [PMID: 26968485 DOI: 10.1016/j.knee.2015.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purposes of this study were as follows: 1) to determine the correlation between the bending angle of the anterior cruciate ligament (ACL) graft at the femoral tunnel and the magnetic resonance imaging (MRI) signal intensity of the ACL graft and 2) to analyze the difference in the MRI signal intensity of the reconstructed ACL graft in different areas of the graft after single-bundle hamstring autograft ACL (SB ACL) reconstruction using an outside-in (OI) technique with bone-sparing retro-reaming. METHODS Thirty-eight patients who underwent SB ACL reconstruction with the hamstring tendon autograft using the OI technique were enrolled in this study. All patients were assessed using three-dimensional computed tomography (CT) to evaluate femoral tunnel factors, including tunnel placement, tunnel length, tunnel diameter, and femoral tunnel bending angle. At a mean of 6.3±0.8months after surgery, 3.0-T MRI was used to evaluate the graft signal intensity using signal/noise quotient for high-signal-intensity lesions. RESULTS Among various femoral tunnel factors, only the femoral tunnel bending angle in the coronal plane was significantly (p=0.003) correlated with the signal/noise quotient of the femoral intraosseous graft. The femoral intraosseous graft had significantly (p=0.009) higher signal intensity than the other graft zone. Five cases (13.2%) showed high-signal-intensity zones around the femoral tunnel but not around the tibial tunnel. CONCLUSION After ACL reconstruction using the OI technique, the graft bending angle was found to be significantly correlated with the femoral intraosseous graft signal intensity, indicating that increased signal intensity by acute graft bending might be related to the maturation of the graft. LEVEL OF EVIDENCE This was a retrospective comparative study with Level III evidence.
Collapse
Affiliation(s)
- Jin Hwan Ahn
- Department of Orthopaedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 110-746, Republic of Korea.
| | - Hwa Jae Jeong
- Department of Orthopaedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 110-746, Republic of Korea.
| | - Yong Seuk Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Republic of Korea.
| | - Jai Hyung Park
- Department of Orthopaedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 110-746, Republic of Korea.
| | - Jin Ho Lee
- Department of Orthopaedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 110-746, Republic of Korea.
| | - Taeg Su Ko
- Department of Orthopaedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 110-746, Republic of Korea.
| |
Collapse
|
42
|
Jang KM, Park SC, Lee DH. Graft Bending Angle at the Intra-articular Femoral Tunnel Aperture After Single-Bundle Posterior Cruciate Ligament Reconstruction: Inside-Out Versus Outside-In Techniques. Am J Sports Med 2016; 44:1269-75. [PMID: 26847488 DOI: 10.1177/0363546515625046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND To date, no in vivo 3-dimensional computed tomography (3D-CT) studies have compared graft bending angles at the femoral tunnel aperture and femoral tunnel length in patients who underwent posterior cruciate ligament (PCL) reconstruction with outside-in (OI) and inside-out (IO) techniques. PURPOSE/HYPOTHESIS This study used in vivo 3D-CT analysis to compare graft bending angles at the femoral tunnel aperture and femoral tunnel lengths after OI and IO femoral drilling techniques in single-bundle PCL reconstruction. It was hypothesized that the graft bending angle at the femoral tunnel aperture would be less acute with the OI compared with the IO technique, with no difference in femoral tunnel lengths. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Immediate postoperative in vivo 3D-CT and curved planar reformation were used to assess the graft bending angles and femoral tunnel lengths in the sagittal, axial, and coronal planes in 67 patients who underwent single-bundle PCL reconstruction with the OI (n = 37) and IO (n = 30) techniques. RESULTS The mean graft bending angles on the sagittal and axial planes were 8.2° more acute (23.5° vs 15.3°, P = .011) and 5.3° more acute (49.0° vs 43.7°, P = .013), respectively, with the IO compared with the OI technique, but the difference in the coronal plane was not statistically significant (25.3° vs 24.8°, P = .623). Femoral tunnel length was similar in the 2 groups. CONCLUSION The graft bending angles in single-bundle PCL reconstruction were more acute in the sagittal and axial planes with the IO compared with the OI technique, but there was no difference in the coronal plane. In addition, femoral tunnel lengths did not differ significantly in patients who underwent OI and IO single-bundle PCL reconstructions. Although further biomechanical studies are needed to evaluate the effect on graft failure of a <10° difference in graft bending angle, the small magnitude of this difference would likely have little adverse effect on graft survival.
Collapse
Affiliation(s)
- Ki-Mo Jang
- Department of Orthopedic Surgery, Korea University, College of Medicine, Anam Hospital, Seoul, Korea
| | - Sung-Chul Park
- Department of Orthopedic Surgery, Korea University, College of Medicine, Anam Hospital, Seoul, Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
43
|
Lee BH, Seo DY, Bansal S, Kim JH, Ahn JH, Wang JH. Comparative Magnetic Resonance Imaging Study of Cross-Sectional Area of Anatomic Double Bundle Anterior Cruciate Ligament Reconstruction Grafts and the Contralateral Uninjured Knee. Arthroscopy 2016; 32:321-9.e1. [PMID: 26603824 DOI: 10.1016/j.arthro.2015.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 07/15/2015] [Accepted: 08/06/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the differences between cross-sectional area of the reconstructed graft by 2 anatomic double-bundle anterior cruciate ligament (ACL) reconstruction techniques, transportal and outside-in and contralateral uninjured knee. METHODS In prospective, randomized controlled trials, magnetic resonance imaging of both the reconstructed anatomic double-bundle ACL graft side and the contralateral uninjured knee of 92 patients (mean age, 34.7 ± 10.7 years) between November 2010 and January 2013 were compared. The 3-dimensional curved multiplanar reconstruction function of OsiriX v5.6 was used. Cross-sectional area was measured from the femoral insertion site to the tibial insertion site at 5 different locations, including the midsubstance. RESULTS A significant difference was observed between areas of the uninjured side and reconstructed side at the 5 locations. The area of the reconstructed graft at the femoral insertion site (64 ± 13 mm(2)) and midsubstance (62 ± 11 mm(2)) was larger that of the normal ACL (femoral insertion site; 60 ± 13 mm(2), P = .005 and midsubstance; 47 ± 13 mm(2), P = .0001), whereas at the tibial insertion site (71 ± 13 mm(2)) it was smaller than normal ACL (97 ± 22 mm(2), P = .0001). The measured area between the reconstructed graft and normal uninjured side at the femoral insertion site was relatively closer than that at midsubstance and the tibial insertion-site area. CONCLUSIONS A double-bundle anterior cruciate ligament reconstruction graft relatively closely restored the cross-sectional area of the femoral footprint area but was smaller than that of the tibial footprint area; however, the cross-sectional area of graft was much larger than that of the midsubstance.
Collapse
Affiliation(s)
- Byung Hoon Lee
- Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Dong Yeon Seo
- Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Samarjit Bansal
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jun Ho Kim
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Hwan Ahn
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
44
|
Lansdown DA, Allen C, Zaid M, Wu S, Subburaj K, Souza R, Feeley BT, Li X, Ma CB. A comprehensive in vivo kinematic, quantitative MRI and functional evaluation following ACL reconstruction--A comparison between mini-two incision and anteromedial portal femoral tunnel drilling. Knee 2015; 22:547-53. [PMID: 25982298 PMCID: PMC4472567 DOI: 10.1016/j.knee.2014.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/27/2014] [Accepted: 12/10/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Multiple techniques are used for femoral tunnel drilling in ACL reconstruction, including the Mini-two Incision Method (MT) and Anteromedial Portal Technique (AM). Both techniques allow for independent placement of the femoral tunnel, though there are no reports comparing kinematics and cartilage health after these reconstructions. We hypothesized that both techniques would result in the restoration of normal knee kinematics and show no evidence of early cartilage degeneration. METHODS A total of 20 patients were evaluated one year after ACL reconstruction, including 10 patients after MT and 10 patients after AM. MR-imaging was acquired bilaterally with the knee loaded in extension and flexion to evaluate the kinematics of the reconstructed knee compared with the normal knee. Quantitative cartilage imaging was obtained and compared with 10 matched control subjects. The Marx Activity Rating Scale and KOOS survey were administered. RESULTS The tibia was positioned significantly more anteriorly in extension and flexion relative to the contralateral knee for the MT group. The tibial position in the AM group was not significantly different from the patient's contralateral knee. T1ρ values in the central-medial tibia were significantly elevated in the MT group compared with the Control group. KOOS Symptom scores were significantly better for the MT group compared with the AM group. CONCLUSIONS We have observed in vivo differences in knee kinematics and early cartilage degeneration between patients following MT and AM ACL reconstructions. Both techniques allow for anatomic ACL reconstruction, though the MT group shows significant early differences compared with the patient's normal knee.
Collapse
Affiliation(s)
- Drew A. Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave., MU 320W Box 0728, San Francisco, CA, 94143, USA
| | - Christina Allen
- Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave., MU 320W Box 0728, San Francisco, CA, 94143, USA
| | - Musa Zaid
- University of California, San Francisco, School of Medicine, 521 Parnassus Ave., San Francisco, CA, 94117, USA
| | - Samuel Wu
- Musculoskeletal Quantitative Imaging Research (MQIR), Department of Radiology, University of California, San Francisco, 185 Berry St., Lobby 6, San Francisco, CA, 94107, USA
| | - Karupppasamy Subburaj
- Musculoskeletal Quantitative Imaging Research (MQIR), Department of Radiology, University of California, San Francisco, 185 Berry St., Lobby 6, San Francisco, CA, 94107, USA
| | - Richard Souza
- Musculoskeletal Quantitative Imaging Research (MQIR), Department of Radiology, University of California, San Francisco, 185 Berry St., Lobby 6, San Francisco, CA, 94107, USA
| | - Brian T. Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave., MU 320W Box 0728, San Francisco, CA, 94143, USA
| | - Xiaojuan Li
- Musculoskeletal Quantitative Imaging Research (MQIR), Department of Radiology, University of California, San Francisco, 185 Berry St., Lobby 6, San Francisco, CA, 94107, USA
| | - C. Benjamin Ma
- Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave., MU 320W Box 0728, San Francisco, CA, 94143, USA
| |
Collapse
|
45
|
Osti M, Krawinkel A, Ostermann M, Hoffelner T, Benedetto KP. Femoral and tibial graft tunnel parameters after transtibial, anteromedial portal, and outside-in single-bundle anterior cruciate ligament reconstruction. Am J Sports Med 2015; 43:2250-8. [PMID: 26138734 DOI: 10.1177/0363546515590221] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic graft tunnel placement is recommended in anterior cruciate ligament (ACL) reconstruction to restore knee joint stability and function. Transtibial (TT), anteromedial portal (AMP), and outside-in (OI) retrograde drilling surgical techniques have been described for tibial and femoral bone tunnel preparation. PURPOSE/HYPOTHESIS The purpose of this study was to evaluate the bone tunnel parameters and compare the ability of 3 different surgical techniques to achieve placement of the ACL femoral and tibial bone tunnels at the center of the native ACL femoral and tibial attachment sites. The hypothesis was that tunnel placement using an AMP or OI technique would result in optimized tunnel parameters and more closely reconstruct the center of the native ACL femoral attachment site. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study population consisted of 100 patients undergoing anatomic single-bundle ACL reconstruction using multiple-stranded hamstring tendon grafts. In group 1 (n = 36), the femoral tunnel was drilled using a TT surgical technique; in group 2 (n = 32), the femoral tunnel was drilled through an AMP; and in group 3 (n = 32), the femoral tunnel was created by use of an OI technique with retrograde drilling. Computed tomography (CT) scans were obtained postoperatively, and characteristics of femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. The position of the resulting tibial and femoral bone tunnels for each group was compared with the center of the native ACL attachment sites. RESULTS There were statistically significant differences (P < .05) for the ACL femoral tunnel between the 3 groups with respect to intercondylar height, total tunnel length, graft fixation length, tunnel axis, and tunnel entry angle. Statistically significant differences (P < .05) were found for the ACL tibial tunnel with respect to anteroposterior tunnel position and sagittal tunnel axis between the TT and both the OI and AMP techniques. The OI surgical technique produced more oblique and anatomically correct femoral tunnel apertures and longer femoral tunnel lengths compared with the AMP technique. Both AMP and OI techniques resulted in a more precise replication of intercondylar tunnel depth and height. There was no statistically significant difference for graft fixation length between the AMP and OI techniques. CONCLUSION The AMP and OI surgical techniques were superior in positioning the ACL femoral tunnel at the center of the native ACL attachment site compared with the TT technique. An acceptable graft fixation length was obtained for all 3 surgical techniques.
Collapse
Affiliation(s)
- Michael Osti
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Alessa Krawinkel
- Department for Diagnostic and Interventional Radiology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Michael Ostermann
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Thomas Hoffelner
- Department for Trauma Surgery and Sports Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Karl Peter Benedetto
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| |
Collapse
|
46
|
Kim JG, Chang MH, Lim HC, Bae JH, Lee SY, Ahn JH, Wang JH. An in Vivo 3D Computed Tomographic Analysis of Femoral Tunnel Geometry and Aperture Morphology Between Rigid and Flexible Systems in Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal Technique. Arthroscopy 2015; 31:1318-29. [PMID: 25823674 DOI: 10.1016/j.arthro.2015.01.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 01/05/2015] [Accepted: 01/21/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to compare femoral tunnel length, femoral graft-bending angle, posterior wall breakage, and femoral aperture morphologic characteristics between rigid and flexible systems after double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using the transportal (TP) technique. METHODS We evaluated 3-dimensional computed tomography (3D-CT) results for 54 patients who underwent DB ACL reconstruction using the TP technique with either a flexible system (n = 27) or a rigid system (n = 27). The femoral tunnel length, femoral graft-bending angle, posterior wall breakage, femoral tunnel aperture height to width (H:W) ratio, aperture axis angle, and femoral tunnel position were assessed using OsiriX Imaging Software and Geomagic Qualify 2012 (Geomagic, Cary, NC). RESULTS The mean anteromedial (AM) femoral tunnel length of the flexible group was significantly longer than that of the rigid group (P = .009). The mean femoral graft-bending angles in the flexible group were significantly less acute than those in the rigid group (AM, P < .001; posterolateral [PL], P = .003]. Posterior wall breakage was observed in both groups (P = 1.00). The mean H:W ratios in the rigid group were significantly larger (more elliptical) than those of the flexible group (AM, P < .001; PL, P = .006). The mean aperture axis angle of the PL femoral tunnel in the rigid group was more parallel to the femoral shaft axis than that in the flexible group (P < .001). There were no significant differences in femoral tunnel position between the 2 groups. CONCLUSIONS The AM femoral tunnel length and the AM/PL femoral graft-bending angle of the flexible system were significantly longer and less acute than those of the rigid system. However, the aperture morphologic characteristics of the AM/PL femoral tunnel and the aperture axis angle of the PL femoral tunnel in the rigid system were significantly more elliptical and closer to parallel to the femoral shaft axis than those of the flexible system. LEVEL OF EVIDENCE Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Jae Gyoon Kim
- Department of Orthopaedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan, Gyeonggi-do, Republic of Korea
| | - Min Ho Chang
- School of Mechanical Engineering, Korea University, Seoul, Republic of Korea
| | - Hong Chul Lim
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Seoul, Republic of Korea
| | - Ji Hoon Bae
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Seoul, Republic of Korea
| | - Seung Yup Lee
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Seoul, Republic of Korea
| | - Jin Hwan Ahn
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
47
|
Relationship between femoral tunnel location and graft bending angle in outside-in and transportal technique for ACL double bundle reconstruction in 3D-CT study. Arch Orthop Trauma Surg 2015; 135:839-46. [PMID: 25940125 DOI: 10.1007/s00402-015-2226-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Indexed: 01/10/2023]
Abstract
INTRODUCTION In anterior cruciate ligament (ACL) reconstruction, sharp angulation of the graft at tunnel aperture increases local strain to the graft. The purpose of this study is to investigate the relationship between femoral tunnel location and femoral graft bending angle after ACL double bundle reconstruction (ACL-DBR) with two different drilling techniques. MATERIALS AND METHODS In ACL-DBR, femoral tunnel was created by two techniques; outside-in technique (26 patients, group A) and transportal technique (25 patients, group B). CT scan was taken at 1 week postoperatively. The position of femoral tunnel exit on the lateral femoral cortex, and intra-articular femoral and tibial tunnel aperture of the anteromedial bundle (AMB) and postero-lateral bundle (PLB) was measured using a rectangular frame on three-dimensional CT images. Femoral graft bending angle was measured using two-dimensional CT images. RESULTS Femoral tunnel exits of AMB and PLB in group A were significantly anterior and proximal than those in group B (p < 0.05), while there was no significant difference in intra-articular femoral and tibial tunnel apertures between group A and B. A mean femoral graft bending angle of AMB was 80.3° in group A and 69.2 degrees in group B, respectively (p < 0.05). A mean femoral graft bending angle of PLB was 66.3° in group A and 64.6° in group B, respectively. In both groups, a significant (p < 0.05) correlation (r < -0.4) was observed between the position of the femoral tunnel exit (anterior-posterior ratio from femoral anterior border line) and the femoral graft bending angle in AMB. CONCLUSIONS Since the femoral tunnel exit in outside-in technique was located more anterior and proximal, femoral graft bending angle of AMB in outside-in technique was greater than that in transportal technique. Anterior position of the femoral tunnel exit in AMB increased femoral graft bending angle in outside-in and transportal techniques.
Collapse
|
48
|
Lee BH, Bansal S, Park SH, Wang JH. Eccentric graft positioning within the femoral tunnel aperture in anatomic double-bundle anterior cruciate ligament reconstruction using the transportal and outside-in techniques. Am J Sports Med 2015; 43:1180-8. [PMID: 25670836 DOI: 10.1177/0363546514568278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ellipticity of the femoral tunnel aperture, which is considered to better restore the native anterior cruciate ligament (ACL) footprint after ACL reconstruction, is different according to the femoral tunneling technique used. How much of the femoral tunnel aperture is filled with graft in different tunneling techniques has yet to be evaluated. PURPOSE The aim of this study was to evaluate and compare the graft filling area and graft position within the femoral tunnel aperture in ACL reconstruction using the transportal (TP) and outside-in (OI) techniques. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 70 patients were randomized to undergo double-bundle ACL reconstruction using either the TP (n=35) or OI (n=35) technique. The aperture filling was evaluated by calculating the ratio of the cross-sectional area of the graft to that of the femoral tunnel, and the graft center position within the tunnel was assessed using immediate postoperative magnetic resonance imaging. RESULTS The cross-sectional area of the femoral anteromedial (AM) tunnel aperture in the TP group (605.5±112.7 mm2) was larger than that in the OI group (537.9±126.8 mm2). The cross-sectional area of the femoral posterolateral (PL) tunnel aperture in the TP group (369.9±88.3 mm2) did not differ significantly from that of the OI group (387.9±87.0 mm2). The grafts filled only 52.0% of the AM tunnel and 55.3% of the PL tunnel in the TP group, compared with 54.9% of the AM tunnel and 54.4% of the PL tunnel in the OI group, but there was no statistically significant difference (P>.05). The AM graft center was positioned 1.7±0.6 mm from the center of the tunnel aperture in the TP group and 1.6±0.5 mm in the OI group, and the PL graft center was positioned 1.4±0.4 mm from the center in the TP group and 1.3±0.4 mm in the OI group, with no significant intergroup differences (P=.406 and P=.629, respectively). In the OI group, the PL graft center was positioned more perpendicular to the Blumensaat line in relation to the tunnel aperture center (-10.8°±7.6°) compared with the TP group (-4.0°±11.8°) (P=.04). CONCLUSION The grafts did not fill the tunnel aperture area in either group, and the centers of the grafts differed slightly from the centers of the tunnel apertures. The finding of eccentric graft positioning in the tunnel with condensation in a particular direction in each technique might suggest the necessity of an underreamed femoral tunnel for graft. In addition, it may be useful to standardize the starting position of the femoral tunnel according to anatomic landmarks.
Collapse
Affiliation(s)
- Byung Hoon Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Samarjit Bansal
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sin Hyung Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
49
|
Abdelkafy A. Anatomic single-bundle anterior cruciate ligament reconstruction using the outside-in femoral tunnel drilling technique: a prospective study and short- to mid-term results. Arch Orthop Trauma Surg 2015; 135:383-92. [PMID: 25631248 DOI: 10.1007/s00402-015-2160-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Anatomic positioning of the femoral and tibial tunnels in the native ACL femoral and tibial footprints requires an independent drilling either via an accessory medial portal (trans-portal drilling) or using an outside-in drilling technique. Conventional trans-tibial drilling (dependant drilling) was found to lack the ability to accurately position the femoral tunnel in the native ACL footprint. The purpose of the current study was to evaluate the functional outcome results of anatomic single-bundle ACLR using the OI femoral tunnel drilling technique. MATERIALS AND METHODS Single surgeon single center prospective case series study. 64 patients having complete ACL tears were included in the current study. Average follow-up was 15.8 months (range 8-25). Objective and subjective IKDC scores, Lysholm knee score, SF-36 score, VAS for patients' satisfaction, VAS for pain and Kellgren and Lawrence (K/L) classification of osteoarthritis were used for follow-up evaluation. RESULTS Objective IKDC score revealed that 60 patients had grade ''A'' and 4 had grade ''B'', while no single patient had neither grade ''C'' nor ''D''. The average Lysholm Score was 92.4, average subjective IKDC was 91.5. Average SF-36 score was 96.7. The average VAS for operation satisfaction was 9.7. Average VAS for pain was 0.3. Forty-nine patients were classified as normal K/L classification, 7 were grade ''1'', 8 were grade ''2''. Comparing pre-operative and follow-up Objective IKDC, Subjective IKDC, Lysholm, SF-36 and VAS for pain scores revealed statistically significant differences (P value <0.05). CONCLUSION Arthroscopic-assisted ACL reconstruction using the outside-in femoral tunnel drilling technique shows a good and satisfactory functional outcome results at short- to mid-term follow-up. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Ashraf Abdelkafy
- Orthopaedic Surgery and Traumatology Department, Faculty of Medicine, Suez Canal University, Circular Road, Ismailia, 41522, Egypt,
| |
Collapse
|
50
|
Park SH, Moon SW, Lee BH, Chae SH, Ahn JH, Chang M, Wang JH. The sagittal plane angle and tunnel-related complications in double-bundle anterior cruciate ligament reconstruction using the transportal technique: an in vivo imaging study. Arthroscopy 2015; 31:283-92. [PMID: 25442665 DOI: 10.1016/j.arthro.2014.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 08/03/2014] [Accepted: 08/15/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the relation between the tunnel angle in the 3 orthogonal planes, especially the sagittal plane, which can be influenced by knee flexion during drilling, and the incidence of complications from the transportal technique using in vivo imaging data. METHODS Fifty-one patients who underwent anatomic double-bundle anterior cruciate ligament reconstruction by the transportal technique were evaluated retrospectively. A 3-dimensional surface model was made using an axial computed tomography scan obtained after anterior cruciate ligament reconstruction. The tunnel length, posterior cortical damage, proximity between the outer orifice of the tunnel and lateral collateral ligament (LCL) origin, and medial femoral condyle cartilage damage were evaluated on a 3-dimensional computed tomography scan and 3-T magnetic resonance imaging. Correlations between those parameters and the tunnel angle in the coronal, axial, and sagittal planes were analyzed. RESULTS A tunnel length of less than 30 mm developed in 4 cases (8%) in the anteromedial tunnel and in 1 case (2%) in the posterolateral (PL) tunnel. Posterior cortical damage developed in 12 cases (23%). A distance from the outer orifice of the tunnel to the LCL origin of less than 3 mm occurred in 18 cases (35.2%) in the PL tunnel. Medial femoral condyle cartilage damage was detected in 3 cases (6%). A positive correlation was observed between the sagittal angle and anteromedial tunnel length (P = .002, r = 0.547). The sagittal angle in the group with posterior cortical damage was lower than that in the group with no posterior cortical damage (P = .002). A negative correlation was observed between the distance from the outer orifice of the PL tunnel to the LCL origin and the sagittal angle (P = .002, r = -0.55). CONCLUSIONS Drilling at a higher angle in the sagittal plane decreased the incidence of posterior cortical damage and a short anteromedial tunnel. However, drilling at a higher angle shortened the distance to the LCL origin for the PL tunnel. LEVEL OF EVIDENCE Level IV, therapeutic case series.
Collapse
Affiliation(s)
- Sin Hyung Park
- Department of Orthopaedic Surgery, Soonchunhyang University School of Medicine, Bucheon Hospital, Bucheon, South Korea
| | - Sang Won Moon
- Department of Orthopaedic Surgery, Inje University School of Medicine, Haeundae Paik Hospital, Busan, South Korea
| | - Byung Hoon Lee
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea
| | - Sang Hoon Chae
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea
| | - Jin Hwan Ahn
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea
| | - Minho Chang
- School of Mechanical Engineering, Korea University, Seoul, South Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea.
| |
Collapse
|