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Early medial reconstruction combined with severely injured medial collateral ligaments can decrease residual medial laxity in anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2022; 142:2791-2799. [PMID: 34731315 DOI: 10.1007/s00402-021-04211-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/29/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study aimed to describe an anatomic medial knee reconstruction technique for combined anterior cruciate ligament (ACL) and grade III medial collateral ligament (MCL) injuries and to assess knee function and stability restoration in patients who underwent primary MCL reconstruction compared with primary repair. METHODS A total of 105 patients who had undergone anatomic ACL reconstruction between 2008 and 2017 were enrolled in this retrospective study and divided into two groups according to concomitant MCL ruptures. Group A included patients with isolated ACL ruptures without MCL injuries. Group B included patients with both ACL and MCL injuries, and it was subdivided into three groups according to the severity of the MCL injury and treatment modality: B-1, grade I or II MCL injury treated conservatively; B-2: grade III MCL injury treated by primary MCL repair; and B-3: grade III MCL injury treated by primary reconstruction. Knee stability was measured via Telos valgus radiography at 6-month and 2-year postoperative. The Lysholm score, Tegner activity level, Likert scales (satisfaction), and return to previous sports were evaluated at 2-year postoperative. RESULTS At 6-month postoperative, there was no significant difference in medial laxity between the B-2 and B-3 groups. However, at 2-year postoperative, medial laxity were significantly higher both at 30° of flexion (5.2° versus 2.2°, p = 0.020) and at full extension (3.4° versus 1.1°, p < 0.001) in patients in B-2 group compared to those in B-3 group. There were no statistically significant differences between the two groups with respect to Lysholm scores, Tegner activity levels, Likert scales (satisfaction), and returning to previous sports at the 2-year follow-up. CONCLUSION Primary medial reconstruction combined with severely injured MCL in ACL reconstruction may decrease residual medial laxity more than primary repair. LEVEL OF EVIDENCE Retrospective observational study, IV.
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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.
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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
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3
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Takahashi T, Watanabe S, Ito T. Current and future of anterior cruciate ligament reconstruction techniques. World J Meta-Anal 2021; 9:411-437. [DOI: 10.13105/wjma.v9.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Ehime University, Matsuyama 790-8577, Ehime, Japan
| | - Seiji Watanabe
- Department of Orthopedic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Ehime, Japan
| | - Toshio Ito
- Department of Orthopaedic Surgery, Murakami Memorial Hospital, Saijo 793-0030, Ehime, Japan
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Trofa DP, Saltzman BM, Corpus KT, Connor PM, Fleischli JE, Piasecki DP. A Hybrid Transtibial Technique Combines the Advantages of Anteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial. Am J Sports Med 2020; 48:3200-3207. [PMID: 33017169 DOI: 10.1177/0363546520956645] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND The anteromedial (AM) portal and transtibial (TT) approaches are 2 common anterior cruciate ligament (ACL) femoral tunnel drilling techniques, each with unique benefits and disadvantages. A hybrid TT (HTT) technique using medial portal guidance of a flexible TT guide wire has recently been described that may combine the strengths of both the AM portal and the TT approaches. HYPOTHESIS The HTT technique will achieve anatomic femoral tunnel apertures similar to the AM portal technique, with improved femoral tunnel length and orientation. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS A total of 30 consecutive patients with primary ACL tears were randomized to undergo the TT, AM portal, or HTT technique for femoral tunnel positioning at the time of reconstruction. All patients underwent 3-dimensional computed tomography of the operative knee at 6 weeks postoperatively. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as graft bending angles in the sagittal and coronal planes, were measured. RESULTS Tibial tunnel lengths and aperture positions were identical between the 3 groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regard to both height (P = .629) and depth (P = .582). By contrast, compared with the AM portal and HTT techniques, femoral apertures created with the TT technique were significantly higher (P < .001 and P < .001, respectively) and shallower (P = .014 and P = .022, respectively) in the notch. The mean femoral tunnel length varied significantly between the groups, measuring 35.2, 41.6, and 54.1 mm for the AM portal, HTT, and TT groups, respectively (P < .001). Last, there was no difference between the mean coronal (P = .190) and sagittal (P = .358) graft bending angles between the TT and HTT groups. By contrast, compared with the TT and HTT techniques, femoral tunnels created with the AM portal technique were significantly more angulated in the coronal plane (17.7° [P < .001] and 12.5° [P = .006], respectively) and sagittal plane (13.5° [P < .001] and 10.5° [P = .013], respectively). CONCLUSION This prospective randomized controlled trial found that the HTT technique achieved femoral aperture positions equally as anatomic as the AM portal technique but produced longer, less angulated femoral tunnels, which may help reduce graft strain and mismatch. As such, this hybrid approach may represent a beneficial combination of both the TT and the AM portal techniques. REGISTRATION NCT02795247 (ClinicalTrials.gov identifier).
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Affiliation(s)
- David P Trofa
- Department of Orthopedics, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Bryan M Saltzman
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Keith T Corpus
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Patrick M Connor
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - James E Fleischli
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Dana P Piasecki
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
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Ishibashi Y, Adachi N, Koga H, Kondo E, Kuroda R, Mae T, Uchio Y. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication. J Orthop Sci 2020; 25:6-45. [PMID: 31843222 DOI: 10.1016/j.jos.2019.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS). METHODS The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature. CONCLUSIONS This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Shimane University School of Medicine, Japan
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Pedneault C, Laverdière C, Hart A, Boily M, Burman M, Martineau PA. Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2019; 47:3187-3194. [PMID: 31513428 DOI: 10.1177/0363546519873633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic anterior cruciate ligament (ACL) reconstruction improves knee kinematics and joint stability in symptomatic patients who have ACL deficiency. Despite a concerted effort to place the graft within the ACL's native attachment sites, the accuracy of tunnel placement using contemporary techniques is not well established. PURPOSE To use 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate the accuracy of tibial tunnel placement after anatomic ACL reconstruction. STUDY DESIGN Case series; Level of evidence, 4. METHODS Forty patients with symptomatic, ACL-deficient knees were prospectively enrolled in the study and underwent 3D MRI of both their injured and uninjured knees before and after surgery through use of a validated imaging protocol. The root ligament of the anterior horn of the lateral meniscus was used as a radiographic reference, and the center of the reconstructed graft was compared with that of the contralateral normal knee. The tunnel angles and intra-articular graft angles were also measured, as was the percentage overlap between the native tibial footprint and tibial tunnel. RESULTS The reconstructed tibial footprint was placed at a mean ± SD of 2.14 ± 2.45 mm (P < .001) medial and 5.11 ± 3.57 mm (P < .001) posterior to the native ACL footprint. The mean distance between the center of the native and reconstructed ACL at the tibial attachment site was 6.24 mm. Of the 40 patients, 18 patients had a tibial tunnel that overlapped more than 50% of the native footprint, and 10 patients had maximal (100%) overlap. Further, 22 of the 40 patients had less than 50% overlap with the native footprint, and in 12 patients the footprint was missing completely. CONCLUSION Despite the use of contemporary surgical techniques to perform anatomic ACL reconstruction, a significant positioning error in tibial tunnel placement remains.
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Affiliation(s)
- Christopher Pedneault
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | | | - Adam Hart
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | - Mathieu Boily
- Department of Musculoskeletal Radiology, McGill University Health Center, Montreal, Québec, Canada
| | - Mark Burman
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
| | - Paul A Martineau
- Department of Orthopedic Surgery, McGill University Health Center, Montreal, Québec, Canada
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7
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Mehta A, Lin CC, Campbell RA, Chin G, McGarry MH, Lee TQ, Adamson GJ. Effects of Anteromedial Portal versus Transtibial ACL Tunnel Preparation on Contact Characteristics of the Graft and the Tibial Tunnel Aperture. Clin Orthop Surg 2019; 11:52-59. [PMID: 30838108 PMCID: PMC6389531 DOI: 10.4055/cios.2019.11.1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/27/2018] [Indexed: 12/24/2022] Open
Abstract
Background The purpose of this study was to compare the tibial tunnel aperture contact characteristics simulating an anteromedial and transtibial anterior cruciate ligament (ACL) tunnel preparation. Methods Seven matched pairs of cadaveric knees were tested. From each knee, a 10-mm quadriceps ACL graft was prepared. The native ACL was arthroscopically removed and tibial tunnels were drilled. In one knee, a transtibial technique was performed with femoral tunnel drilling approached through the tibial tunnel. For the anteromedial technique on the contralateral knee, the posterior tibial tunnel was chamfered with a rasp. The knees were then disarticulated and tibial tunnel aperture geometry was measured. A pressure sensor was placed between the graft and the posterior aspect of the tibial tunnel and the graft was secured with an interference screw. Contact force, contact area, contact pressure, peak contact pressure, hysteresis and stiffness were measured at cyclic loads of 50 N, 100 N, 150 N, and 200 N. Results Tibial tunnel aperture area, diameter and deviation from a circle were significantly larger with the transtibial technique (p < 0.05). There was no significant difference in hysteresis, stiffness, contact area, contact force and mean contact pressure. The peak contact pressure between the ACL graft and the tibial tunnel was significantly higher with the anteromedial technique for 100 N (p = 0.04), 150 N (p = 0.01), and 200 N (p = 0.002) cyclic loading. Conclusions Increased peak contact pressure on the graft at the tibial aperture with the anteromedial technique may increase the stress on the graft and possibly lead to failure following ACL reconstruction.
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Affiliation(s)
- Akshay Mehta
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Charles C Lin
- Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Ronald A Campbell
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Garwin Chin
- Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA.,Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA.,Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA.,Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA.,Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Gregory J Adamson
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
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Song X, Li Q, Wu Z, Xu Q, Chen D, Jiang Q. Predicting the graft diameter of the peroneus longus tendon for anterior cruciate ligament reconstruction. Medicine (Baltimore) 2018; 97:e12672. [PMID: 30383628 PMCID: PMC6221677 DOI: 10.1097/md.0000000000012672] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to evaluate the correlation between various anthropometric parameters and the graft diameter of the peroneus longus tendon (PLT).We retrospectively analyzed the data of 156 patients who underwent anterior cruciate ligament reconstruction (ACLR) with the PLT graft at our institution. Anthropometric parameters, including height, weight, gender, age, duration of injury, and preinjury activity levels, were recorded. t tests, correlation coefficients (Pearson r), and a multiple linear regression analysis were used to evaluate the influence of these anthropometric variables on the diameter of the graft obtained.The mean PLT graft diameter was 8.3 mm, and 21 patients (13.5%) had a diameter less than 8 mm; 85 patients (54.5%) had a diameter between 8 and 9 mm, and 50 patients (32.0%) had a diameter greater than or equal to 9 mm. The correlation analysis showed that height (P < .001), weight (P < .001), and duration of injury (P = .012) were significantly related to graft diameter. On the basis of these 3 predictors, the following regression equation was obtained: Diameter = 2.28 + 0.028*height (cm) + 0.013*weight (kg) + 0.289*duration of injury (0 or 1). Patients who were short and shin were more likely to own smaller graft diameters (<8 mm), especially the one ruptured his or her anterior cruciate ligament (ACL) over 3 months.Height, weight, and duration of injury were associated with the diameter of PLT. They are important preoperative information for surgeon about the size of PLT and can be used for alternative graft source planning and patient counseling.Level of evidence: IV.
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Affiliation(s)
- Xiaoxiao Song
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine
| | - Qiangqiang Li
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower, Hospital, Nanjing Medical University
| | - Zongfang Wu
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower, Hospital, Nanjing Medical University
| | - Qian Xu
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine
| | - Dongyang Chen
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine
- Laboratory for Bone and Joint Diseases, Model Animal Research Center, Nanjing, University, Nanjing, Jiangsu, PR China
| | - Qing Jiang
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital, School of Medicine
- Laboratory for Bone and Joint Diseases, Model Animal Research Center, Nanjing, University, Nanjing, Jiangsu, PR China
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Sim JA, Kim JM, Lee S, Song EK, Seon JK. No difference in graft healing or clinical outcome between trans-portal and outside-in techniques after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:2338-2344. [PMID: 28756467 DOI: 10.1007/s00167-017-4655-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 07/19/2017] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of this study was to compare femoral tunnel geometry including tunnel position, length, and graft bending angle between trans-portal and outside-in techniques in anterior cruciate ligament (ACL) reconstruction and discover whether such differences in tunnel geometry could influence graft healing or clinical outcome. METHODS Sixty-four patients with anatomical single-bundle ACL reconstruction performed with either trans-portal technique (32 patients, one centre) or outside-in technique (32 patients, the other centre) were included in this retrospective study. Femoral tunnel location and length, and graft bending angle at the femoral tunnel were analysed on 3D CT knee model. The location and length of the femoral tunnel and graft bending angle were compared between the two techniques. All patients underwent MRI scans at around 1 year following ACL reconstruction. It was found that all patients had intact ACL graft on MRI images. On oblique axial image taken after ACL reconstruction to determine graft healing at femoral and tibial tunnels and the intra-articular portion, graft signal intensity ratio was calculated by dividing signal intensity (SI) of the reconstructed ACL by that of posterior cruciate ligament (PCL) in the region of interest selected with Marosis software. Clinical outcomes regarding Tegner activity scores, the International Knee Documentation Committee (IKDC) evaluation scores, Lachman test, and pivot shift test results were also compared between the two groups. RESULTS While the location of femoral tunnel was similar to each other in both groups, the femoral tunnel length was longer in the outside-in technique (37.0 vs. 32.4 mm, p = .02). Meanwhile, the outside-in technique showed significantly more acute graft tunnel angle than the trans-portal technique (106.7° vs. 113.8°, p = .01). However, signal intensity ratios of grafts (compared with SI of PCL) were similar in femoral and tibial tunnels and intra-articular portions. Moreover, there were no statistically significant differences in terms of IKDC scores (89.4 vs. 90.5, n.s.) or Tegner activity scores (6.2 vs. 6.4, n.s.) between the two groups. There was no significant difference in measurement of Lachman or Pivot shift test either between the two groups. CONCLUSION Even though the outside-in technique in ACL reconstruction created a more acute femoral graft bending angle and a longer femoral tunnel length than the trans-portal technique, these had no negative effect on graft healing. In addition, trans-portal and outside-in techniques in ACL reconstruction showed similar femoral tunnel positions and clinical outcomes. Acceptable graft healing and clinical outcomes can be obtained for both trans-portal and outside-in techniques in ACL reconstruction. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jae-Ang Sim
- Department of Orthopaedic Surgery, Gil Hospital, Gachon University of Medicine and Science, Inchon, Korea
| | - Jong-Min Kim
- Department of Orthopaedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - SahngHoon Lee
- Department of Orthopaedic Surgery, Seoul University Hospital, Seoul, Korea
| | - Eun-Kyoo Song
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 519-763, Korea
| | - Jong-Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 519-763, Korea.
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10
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Ni J, Li D, Mao M, Dang X, Wang K, He J, Shi Z. A Method of Accurate Bone Tunnel Placement for Anterior Cruciate Ligament Reconstruction Based on 3-Dimensional Printing Technology: A Cadaveric Study. Arthroscopy 2018; 34:546-556. [PMID: 29122434 DOI: 10.1016/j.arthro.2017.08.288] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To explore a method of bone tunnel placement for anterior cruciate ligament (ACL) reconstruction based on 3-dimensional (3D) printing technology and to assess its accuracy. METHODS Twenty human cadaveric knees were scanned by thin-layer computed tomography (CT). To obtain data on bones used to establish a knee joint model by computer software, customized bone anchors were installed before CT. The reference point was determined at the femoral and tibial footprint areas of the ACL. The site and direction of the bone tunnels of the femur and tibia were designed and calibrated on the knee joint model according to the reference point. The resin template was designed and printed by 3D printing. Placement of the bone tunnels was accomplished by use of templates, and the cadaveric knees were scanned again to compare the concordance of the internal opening of the bone tunnels and reference points. RESULTS The twenty 3D printing templates were designed and printed successfully. CT data analysis between the planned and actual drilled tunnel positions showed mean deviations of 0.57 mm (range, 0-1.5 mm; standard deviation, 0.42 mm) at the femur and 0.58 mm (range, 0-1.5 mm; standard deviation, 0.47 mm) at the tibia. CONCLUSIONS The accuracy of bone tunnel placement for ACL reconstruction in cadaveric adult knees based on 3D printing technology is high. CLINICAL RELEVANCE This method can improve the accuracy of bone tunnel placement for ACL reconstruction in clinical sports medicine.
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Affiliation(s)
- Jianlong Ni
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Dichen Li
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Mao Mao
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Xiaoqian Dang
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Kunzheng Wang
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiankang He
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Zhibin Shi
- Department of Orthopedic Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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11
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Patel KA, Chhabra A, Makovicka JL, Bingham J, Piasecki DP, Hartigan DE. Anterior Cruciate Ligament Tunnel Placement Using the Pathfinder Guide. Arthrosc Tech 2017; 6:e1291-e1296. [PMID: 29354431 PMCID: PMC5622279 DOI: 10.1016/j.eats.2017.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 05/11/2017] [Indexed: 02/03/2023] Open
Abstract
Reconstruction techniques for the anterior cruciate ligament (ACL) have evolved considerably over the past 3 decades. The femoral tunnel is most commonly made via a transtibial or separate anteromedial portal approach. Benefits and drawbacks for each of these techniques exist. Improper tunnel placement is the cause of failure for ACL reconstruction 70% of the time. We present a hybrid technique for femoral tunnel placement using the Pathfinder ACL guide, which attempts to give the surgeon many of the benefits of both the transtibial and anteromedial portal techniques without the drawbacks.
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Affiliation(s)
- Karan A. Patel
- Department of Orthopedics, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - Anikar Chhabra
- Department of Orthopedics, Mayo Clinic, Phoenix, Arizona, U.S.A
| | | | - Joshua Bingham
- Department of Orthopedics, Mayo Clinic, Phoenix, Arizona, U.S.A
| | | | - David E. Hartigan
- Department of Orthopedics, Mayo Clinic, Phoenix, Arizona, U.S.A.,Address correspondence to David E. Hartigan, M.D., Department of Orthopedics, Mayo Clinic, Phoenix, AZ 85054, U.S.A.Department of OrthopedicsMayo ClinicPhoenixAZ85054U.S.A.
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Tanksley JA, Werner BC, Conte EJ, Lustenberger DP, Burrus MT, Brockmeier SF, Gwathmey FW, Miller MD. ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels? Orthop J Sports Med 2017; 5:2325967117704152. [PMID: 28567428 PMCID: PMC5439652 DOI: 10.1177/2325967117704152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Anatomic femoral tunnel placement for single-bundle anterior cruciate ligament (ACL) reconstruction is now well accepted. The ideal location for the tibial tunnel has not been studied extensively, although some biomechanical and clinical studies suggest that placement of the tibial tunnel in the anterior part of the ACL tibial attachment site may be desirable. However, the concern for intercondylar roof impingement has tempered enthusiasm for anterior tibial tunnel placement. Purpose: To compare the potential for intercondylar roof impingement of ACL grafts with anteriorly positioned tibial tunnels after either transtibial (TT) or independent femoral (IF) tunnel drilling. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaver knees were randomized to either a TT or IF drilling technique. Tibial guide pins were drilled in the anterior third of the native ACL tibial attachment site after debridement. All efforts were made to drill the femoral tunnel anatomically in the center of the attachment site, and the surrogate ACL graft was visualized using 3-dimensional computed tomography. Reformatting was used to evaluate for roof impingement. Tunnel dimensions, knee flexion angles, and intra-articular sagittal graft angles were also measured. The Impingement Review Index (IRI) was used to evaluate for graft impingement. Results: Two grafts (2/6, 33.3%) in the TT group impinged upon the intercondylar roof and demonstrated angular deformity (IRI type 1). No grafts in the IF group impinged, although 2 of 6 (66.7%) IF grafts touched the roof without deformation (IRI type 2). The presence or absence of impingement was not statistically significant. The mean sagittal tibial tunnel guide pin position prior to drilling was 27.6% of the sagittal diameter of the tibia (range, 22%-33.9%). However, computed tomography performed postdrilling detected substantial posterior enlargement in 2 TT specimens. A significant difference in the sagittal graft angle was noted between the 2 groups. TT grafts were more vertical, leading to angular convergence with the roof, whereas IF grafts were more horizontal and universally diverged from the roof. Conclusion: The IF technique had no specimens with roof impingement despite an anterior tibial tunnel position, likely due to a more horizontal graft trajectory and anatomic placement of the ACL femoral tunnel. Roof impingement remains a concern after TT ACL reconstruction in the setting of anterior tibial tunnel placement, although statistical significance was not found. Future clinical studies are planned to develop better recommendations for ACL tibial tunnel placement. Clinical Relevance: Graft impingement due to excessively anterior tibial tunnel placement using a TT drilling technique has been previously demonstrated; however, this may not be a concern when using an IF tunnel drilling technique. There may also be biomechanical advantages to a more anterior tibial tunnel in IF tunnel ACL reconstruction.
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Affiliation(s)
- John A Tanksley
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Evan J Conte
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - David P Lustenberger
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - M Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Sim JA, Kim JM, Lee S, Bae JY, Seon JK. Comparison of tunnel variability between trans-portal and outside-in techniques in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:1227-1233. [PMID: 26713326 DOI: 10.1007/s00167-015-3950-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 12/15/2015] [Indexed: 01/02/2023]
Abstract
PURPOSE Although trans-portal and outside-in techniques are commonly used for anatomical ACL reconstruction, there is very little information on variability in tunnel placement between two techniques. METHODS A total of 103 patients who received ACL reconstruction using trans-portal (50 patients) and outside-in techniques (53 patients) were included in the study. The ACL tunnel location, length and graft-femoral tunnel angle were analyzed using the 3D CT knee models, and we compared the location and length of the femoral and tibial tunnels, and graft bending angle between the two techniques. The variability in each technique regarding the tunnel location, length and graft tunnel angle using the range values was also compared. RESULTS There were no differences in the average of femoral tunnel depth and height between the two groups. The ranges of femoral tunnel depth and height showed no difference between two groups (36 and 41 % in trans-portal technique vs. 32 and 41 % in outside-in technique). The average value and ranges of tibial tunnel location also showed similar results in two groups. The outside-in technique showed longer femoral tunnel than the trans-portal technique (34.0 vs. 36.8 mm, p = 0.001). The range of femoral tunnel was also wider in trans-portal technique than in outside-in technique. Although the outside-in technique showed significant acute graft bending angle than trans-portal technique in average values, the trans-portal technique showed wider ranges in graft bending angle than outside-in technique [ranges 73° (SD 13.6) vs. 53° (SD 10.7), respectively]. CONCLUSIONS Although both trans-portal and outside-in techniques in ACL reconstruction can provide relatively consistent in femoral and tibial tunnel locations, trans-portal technique showed high variability in femoral tunnel length and graft bending angles than outside-in technique. Therefore, the outside-in technique in ACL reconstruction is considered as the effective method for surgeons to make more consistent femoral tunnel. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jae-Ang Sim
- Department of Orthopaedic Surgery, Gil Hospital, Gachon University, Incheon, South Korea
| | - Jong-Min Kim
- Department of orthopaedic surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sahnghoon Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Ji-Yong Bae
- Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, 160 Ilsimri, Hwasun-eup, Hwasun-gun, Jeollanamdo, 519-809, South Korea
| | - Jong-Keun Seon
- Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, 160 Ilsimri, Hwasun-eup, Hwasun-gun, Jeollanamdo, 519-809, South Korea.
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Reid JC, Yonke B, Tompkins M. The angle of inclination of the native ACL in the coronal and sagittal planes. Knee Surg Sports Traumatol Arthrosc 2017; 25:1101-1105. [PMID: 28246878 DOI: 10.1007/s00167-017-4419-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 01/02/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE The purpose of this cross-sectional study was to evaluate the angle of inclination of the native anterior cruciate ligament (ACL) in both the sagittal and coronal planes and to evaluate these findings based on sex, height, BMI, and skeletal maturity. METHODS Inclusion criteria for the study included patients undergoing routine magnetic resonance imaging (MRI) of the knee at a single outpatient orthopedic center who had an intact ACL on MRI. Measurements of the angle of inclination were made on MRIs in both the sagittal and coronal planes. Patients were compared based on sex, height, BMI, and skeletal maturity. RESULTS One-hundred and eighty-eight patients were included (36 skeletally immature/152 skeletally mature; 98 male/90 female). The overall angle of inclination was 74.3° ± 4.8° in the coronal plane and 46.9° ± 4.9° in the sagittal plane. Skeletally immature patients (coronal: 71.8° ± 6.1°; sagittal: 44.7° ± 5.5°) were significantly different in both coronal and sagittal planes (P = 0.04 and 0.01, respectively) from skeletally mature patients (coronal: 75.3° ± 4.7°; sagittal: 47.4° ± 4.7°). There were no differences based on sex, height, or BMI. CONCLUSIONS There are differences between the angle of inclination findings in this study and other studies, which could be due to MRI and measurement techniques. Clinically, skeletal maturity may be important to account for when using the ACL angle of inclination to evaluate anatomic ACL reconstruction. LEVEL OF EVIDENCE Prognostic retrospective study, Level of evidence III.
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Affiliation(s)
- Jonathan C Reid
- University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Bret Yonke
- TRIA Orthopaedic Center, 8100 Northland Drive, Bloomington, MN, 55431, USA
| | - Marc Tompkins
- University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
- TRIA Orthopaedic Center, 8100 Northland Drive, Bloomington, MN, 55431, USA
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Guler O, Mahırogulları M, Mutlu S, Cercı MH, Seker A, Cakmak S. Graft position in arthroscopic anterior cruciate ligament reconstruction: anteromedial versus transtibial technique. Arch Orthop Trauma Surg 2016; 136:1571-1580. [PMID: 27484876 DOI: 10.1007/s00402-016-2532-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Indexed: 01/15/2023]
Abstract
INTRODUCTION When treating anterior cruciate ligament (ACL) injuries, the position of the ACL graft plays a key role in regaining postoperative knee function and physiologic kinematics. In this study, we aimed to compare graft angle, graft position in tibial tunnel, and tibial and femoral tunnel positions in patients operated with anteromedial (AM) and transtibial (TT) methods to those of contralateral healthy knees. MATERIALS AND METHODS Forty-eight patients who underwent arthroscopic ACL reconstruction with ipsilateral hamstring tendon autograft were included. Of these, 23 and 25 were treated by AM and TT techniques, respectively. MRI was performed at 18.4 and 19.7 months postoperatively in AM and TT groups. Graft angles, graft positions in the tibial tunnel and alignment of tibial and femoral tunnels were noted and compared in these two groups. The sagittal graft insertion tibia midpoint distance (SGON) has been used for evaluation of graft position in tunnel. RESULTS Sagittal ACL graft angles in operated and healthy knees of AM patients were 57.78° and 46.80° (p < 0.01). With respect to TT patients, ACL graft angle was 58.87° and 70.04° on sagittal and frontal planes in operated knees versus 47.38° and 61.82° in healthy knees (p < 0.001). ACL graft angle was significantly different between the groups on both sagittal and frontal planes (p < 0.001). Sagittal graft insertion tibia midpoint distance ratio was 0.51 and 0.48 % in the operated and healthy knees of AM group (p < 0.001) and 0.51 and 0.48 % in TT group (p < 0.001). Sagittal tibial tunnel midpoint distance ratio did not differ from sagittal graft insertion tibia midpoint distance of healthy knees in either group. Femoral tunnel clock position was better in AM [right knee 10:19 o'clock-face position (310° ± 4°); left knee 1:40 (50° ± 3°)] compared with TT group [right knee 10:48 (324° ± 5°); left knee 1:04 (32° ± 4°)]. With respect to the sagittal plane, the anterior-posterior position of femoral tunnel was better in AM patients. Lysholm scores and range of motion of operated knees in the AM and TT groups showed no significant difference (p > 0.05). CONCLUSIONS Precise reconstruction on sagittal plane cannot be obtained with either AM or TT technique. However, AM technique is superior to TT technique in terms of anatomical graft positioning. Posterior-placed grafts in tibial tunnel prevent ACL reconstruction, although tibial tunnel is drilled on sagittal plane.
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Affiliation(s)
- Olcay Guler
- Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey.
| | - Mahir Mahırogulları
- Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey
| | - Serhat Mutlu
- Orthopedics and Traumatology Department, Kanuni Sultan Suleyman Training Hospital, Istanbul, Turkey
| | - Mehmet H Cercı
- Orthopedics and Traumatology Department, Nisa Hospital, Istanbul, Turkey
| | - Ali Seker
- Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey
| | - Selami Cakmak
- Orthopedics and Traumatology Department, Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey
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Cruz AI, Lakomkin N, Fabricant PD, Lawrence JTR. Transphyseal ACL Reconstruction in Skeletally Immature Patients: Does Independent Femoral Tunnel Drilling Place the Physis at Greater Risk Compared With Transtibial Drilling? Orthop J Sports Med 2016; 4:2325967116650432. [PMID: 27331075 PMCID: PMC4900331 DOI: 10.1177/2325967116650432] [Citation(s) in RCA: 18] [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] [Indexed: 11/17/2022] Open
Abstract
Background: Most studies examining the safety and efficacy of transphyseal anterior cruciate ligament (ACL) reconstruction for skeletally immature patients utilize transtibial drilling. Independent femoral tunnel drilling may impart a different pattern of distal femoral physeal involvement. Purpose: To radiographically assess differences in distal femoral physeal disruption between transtibial and independent femoral tunnel drilling. We hypothesized that more oblique tunnels associated with independent drilling involve a significantly larger area of physeal disruption compared with vertically oriented tunnels. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We analyzed skeletally immature patients aged between 10 and 15 years who underwent transphyseal ACL reconstruction utilizing an independent femoral tunnel drilling technique between January 1, 2008, and March 31, 2011. These patients were matched with a transtibial technique cohort based on age and sex. Radiographic measurements were recorded from preoperative magnetic resonance imaging and postoperative radiographs. Results: Ten patients in each group were analyzed. There were significant differences between independent drilling and transtibial drilling cohorts in the estimated area of physeal disruption (1.64 vs 0.74 cm2; P < .001), femoral tunnel angles (32.1° vs 72.8°; P < .001), and medial/lateral location of the femoral tunnel (24.2 vs 36.1 mm from lateral cortex; P = .001), respectively. There was a significant inverse correlation between femoral tunnel angle and estimated area of distal femoral physeal disruption (r = –0.8255, P = .003). Conclusion: Femoral tunnels created with an independent tunnel drilling technique disrupt a larger area of the distal femoral physis and create more eccentric tunnels compared with a transtibial technique. Clinical Relevance: As most studies noting the safety of transphyseal ACL reconstruction have utilized a central, vertical femoral tunnel, surgeons should be aware that if an independent femoral tunnel technique is utilized during transphyseal ACL reconstruction, more physeal tissue is at risk and tunnels are more eccentrically placed across the physis when drilling at more horizontal angles. Prior studies have shown that greater physeal involvement and eccentric tunnels may increase the risk of growth disturbance.
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Affiliation(s)
| | - Nikita Lakomkin
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - J Todd R Lawrence
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Editorial Commentary: Posterior Cruciate Ligament Reconstruction--Do Not Abandon the C-Arm Quite Yet. Arthroscopy 2016; 32:493-4. [PMID: 26945956 DOI: 10.1016/j.arthro.2015.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 12/07/2015] [Indexed: 02/02/2023]
Abstract
Accurate tibial tunnel placement using the arthroscopically-assisted anatomic fovea landmark technique in transtibial posterior cruciate ligament reconstruction is possible without the use of fluoroscopic imaging. However, until a prospective, randomized controlled trial comparing the C-arm and anatomic fovea landmark techniques is completed, abandonment of the C-arm in posterior cruciate ligament reconstruction cannot be recommended.
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