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Lin J, Zhang S, Xin E, Liang M, Yang L, Chen J. Anterior cruciate ligament femoral footprint is oblong-ovate, triangular, or two-tears shaped in healthy young adults: three-dimensional MRI analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:5514-5523. [PMID: 37828405 DOI: 10.1007/s00167-023-07606-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE This study aimed to evaluate the morphology of the anterior cruciate ligament (ACL) femoral footprint with three-dimensional magnetic resonance imaging (3D MRI) in healthy knees. METHODS Fifty subjects with healthy knees were recruited, utilising 3D-SPACE sequences for ACL evaluation. The ACL was manually segmented, and the shape, size and location of the ACL femoral footprint were evaluated on a reformatted oblique-sagittal plane, which aligned closely with the ACL attachment. Statistical analysis included one-way ANOVA for continuous variables and Fisher's exact test for categorical variables, with a P value < 0.05 considered significant. RESULTS Three types of ACL femoral footprint shape were identified, namely, oblong-ovate (OO) in 33 knees (66%), triangular (Tr) in 12 knees (24%) and two-tears (TT) in 5 knees (10%), with the mean areas being 58, 47 and 68 mm2, respectively. Within group TT, regions with similar sizes but different locations were identified: high tear (TT-H) and low tear (TT-L). Notably, group OO demonstrated a larger notch height index, whilst group TT was characterised by a larger α angle and lateral femoral condyle index. A noticeable variation was observed in the location of the femoral footprint centre across groups, with group TT-L and group Tr showing a more distal position relative to the apex of the deep cartilage. According to the Bernard and Hertel (BH) grid, the ACL femoral footprint centres in group TT-L exhibited a shallower and higher position than other groups. Furthermore, compared to group OO and TT-H, group Tr showed a significantly higher position according to the BH grid. CONCLUSION In this study, the morphology of the ACL femoral footprint in healthy young adults was accurately evaluated using 3D MRI, revealing three distinct shapes: OO, Tr and TT. The different ACL femoral footprint types showed similar areas but markedly different locations. These findings emphasise the necessity of considering both the shape and precise location of the ACL femoral footprint during clinical assessments, which might help surgeons enhance patient-specific surgical plans before ACL reconstruction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jinrong Lin
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Shurong Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Enhui Xin
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Meng Liang
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Liqin Yang
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Jing'an District, Shanghai, 200040, People's Republic of China.
| | - Jiwu Chen
- Department of Sports Medicine, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 100 Haining Road, Hongkou District, Shanghai, 200080, People's Republic of China.
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Mao Y, Zhang K, Li J, Fu W. Transtibial Versus Anteromedial Portal Technique for Femoral Tunnel Drilling in Primary Single-Bundle Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Level 1 and 2 Evidence of Clinical, Revision, and Radiological Outcomes. Am J Sports Med 2023; 51:250-262. [PMID: 34652233 DOI: 10.1177/03635465211044476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although numerous clinical studies have compared transtibial (TT) and anteromedial portal (AMP) drilling of femoral tunnels during anterior cruciate ligament reconstruction (ACLR), there is no high-quality, evidence-based consensus regarding which technique affords the best outcome. HYPOTHESIS There would be no difference between the TT and AMP techniques in terms of knee stability, patient-reported outcomes, incidence of revision, and radiological results. STUDY DESIGN Meta-analysis; Level of evidence, 2. METHODS The PubMed and EMBASE databases were searched from inception to February 1, 2021. Level 1 and 2 clinical trials that compared TT and AM techniques were included. Data were meta-analyzed for the outcome measures of knee stability, patient-reported functional outcomes, incidence of revision, and radiological results. Dichotomous variables were presented as odds ratios (ORs), and continuous variables were presented as mean differences (MDs) and standard mean differences (SMDs). RESULTS The meta-analysis included 18 clinical studies, level of evidence 1 or 2, that involved 53,888 patients. Pooled data showed that the AMP group had a lower side-to-side difference (SMD, 0.22; 95% CI, 0.06 to 0.39; P = .009), a lower incidence of pivot-shift phenomenon (OR, 3.69; 95% CI, 1.26 to 10.79; P = .02), and a higher postoperative Lysholm score (SMD, -0.26; 95% CI, -0.44 to -0.08; P = .005) than the TT group. However, no statistically significant differences were seen in other outcomes, including subjective International Knee Documentation Committee scores (SMD, -0.11; 95% CI, -0.30 to 0.09; P = .30) or grades (OR, 0.93; 95% CI, 0.35 to 2.49; P = .89), postoperative activity level (MD, -0.14; 95% CI, -0.42 to 0.15; P = .35), and incidence of revision ACLR (OR, 1.04; 95% CI, 0.93 to 1.16; P = .45). The TT technique was more likely to create longer (SMD, 1.05; 95% CI, 0.05 to 2.06; P = .04) and more oblique (SMD, 0.81; 95% CI, 0.51 to 1.11; P < .001) femoral tunnels than the AMP technique, and a higher height ratio of the aperture position was detected with the TT technique (SMD, -3.51; 95% CI, -5.54 to -1.49; P < .001). CONCLUSION The AMP technique for ACLR may be more likely to produce better knee stability and improved clinical outcomes than the TT technique, but no difference was found in the incidence of revision between the 2 groups.
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Affiliation(s)
- Yunhe Mao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Kaibo Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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The Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Finite Element Analysis Model of Graft Bending Angles and Peak Graft Stresses in Comparison With Transtibial and Anteromedial Portal Techniques. J Am Acad Orthop Surg 2022; 30:e1195-e1206. [PMID: 36001883 DOI: 10.5435/jaaos-d-21-00883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/05/2022] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The purpose of this finite element analysis was to compare femoral tunnel length; anterior cruciate ligament reconstruction graft bending angle; and peak graft stress, contact force, and contact area created by the transtibial, anteromedial portal (AMP), and hybrid transtibial techniques. METHODS Finite element analysis modeling was used to examine anterior cruciate ligament reconstruction models based on transtibial, AMP, and hybrid transtibial femoral tunnel drilling techniques. An evaluation of femoral tunnel length, graft bending angle, peak graft stress, contact force, and contact area was done in comparison of these techniques. RESULTS The femoral tunnel created with the hybrid transtibial technique was 45.3 mm, which was 13.3% longer than that achieved with the AMP technique but 15.2% shorter than that with the transtibial technique. The femoral graft bending angle with the hybrid transtibial technique (105°) was less acute than that with the AMP technique (102°), but more acute than that with the transtibial technique (109°). At 11° knee flexion, the hybrid transtibial technique had 22% less femoral contact force, 21% less tibial contact force, 21% less graft tension than the AMP technique. Yet, the hybrid transtibial technique had 41% greater femoral contact force, 39% greater tibial contact force, 33% greater graft tension, and 6% greater graft von Mises stress than the transtibial technique. A similar trend was found for the anterior knee drawer test. At both 6-mm anterior tibial displacement and 11° knee flexion, the hybrid transtibial and AMP techniques had at least 51% more femoral contact area than the transtibial technique. CONCLUSION This finite element analysis highlights that the hybrid transtibial technique is a true hybrid between the AMP and transtibial techniques for femoral tunnel drilling regarding femoral tunnel length, graft bending angle, and peak graft stress.
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Truong CD, Kha TD, Vuong TH, Zakzouk A, Dung NM, Tran TDX, Makram AM, Huy NT. A Simplified Double-Bundle Anterior Cruciate Ligament Reconstruction by the Three-Inside Technique With Two Suspension Buttons and One Interference Screw. Arthrosc Tech 2021; 11:e43-e52. [PMID: 35127428 PMCID: PMC8807718 DOI: 10.1016/j.eats.2021.08.037] [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: 06/22/2021] [Accepted: 08/30/2021] [Indexed: 02/03/2023] Open
Abstract
In comparison with the single-bundle technique, double-bundle anterior cruciate ligament (ACL) reconstruction has proven its superiority regarding biomechanical studies and clinical outcomes in both rotational knee stability and anterior translation function. However, the complexity and risk of complications remain a great concern for the orthopaedic surgeon performing double-bundle ACL reconstruction. We present a simplified double-bundle ACL reconstruction by the 3-inside technique with 2 suspension buttons and 1 interference screw. The semitendinosus tendon is tripled to be the anteromedial (AM) bundle, whereas the gracilis is doubled for the posterolateral (PL) bundle. We perform a 3-socket approach with an inside-out femoral tunnel for the AM bundle, an outside-in femoral tunnel for the PL bundle, and a retrograde tibial socket for the tibial bundle. Thus, this technique is, simply, a combination of 2 procedures: one single all-inside method (for the AM bundle) and one outside-in method (for the PL bundle), with which most arthroscopic surgeons are familiar. The AM and PL bundles are fixed at 30° and 45°, respectively, using 2 suspension buttons and 1 interference screw. Our simplified technique could reduce surgical costs and minimize complications while maintaining isometric position and appropriate graft size for each patient.
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Affiliation(s)
| | - To Dong Kha
- School of Medicine, Vietnam National University Ho Chi Minh City, Ho Chi Minh City, Vietnam,Vietnam National University Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Thanh Huan Vuong
- Faculty of Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh city, Vietnam
| | | | | | - Tung Dang Xuan Tran
- Van Hanh Private Hospital, Ho Chi Minh City, Vietnam,School of Dentistry, Taipei Medical University, Taipei City, Taiwan
| | | | - Nguyen Tien Huy
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan,Address correspondence to Cong Dung Truong, M.D., Van Hanh Private Hospital, Ho Chi Minh City, Vietnam. E-mail: ; or Nguyen Tien Huy, M.D., Ph.D., School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki 852-8523, Japan.
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5
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Iriuchishima T, Goto B. Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction. J Knee Surg 2021; 34:1531-1538. [PMID: 32480416 DOI: 10.1055/s-0040-1710521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms "anterior cruciate ligament reconstruction," "anatomic or anatomical," and "single bundle." Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow-deep direction (32.3%) and in a high-low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.
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Affiliation(s)
| | - Bunsei Goto
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
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6
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Mediavilla I, Aramberri M, Tiso G, Margalet E, MargAbat F. "Y" Graft Double Bundle Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2021; 10:e2135-e2141. [PMID: 34504753 PMCID: PMC8417341 DOI: 10.1016/j.eats.2021.05.015] [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: 03/19/2021] [Accepted: 05/18/2021] [Indexed: 02/03/2023] Open
Abstract
UNLABELLED Single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been a standard procedure. However, residual rotary instability in approximately 20% of the cases (irrespective of the graft choice and the surgical technique) forces the surgeon to improve the biomechanical quality of the reconstruction. In parallel, adjustable suspensory fixation (ASF) devices have arisen. Biomechanics has defined (both anatomical and functional) the anteromedial (AM) and posterolateral (PL) bundles that work synergistically. In the unsymmetrical "anatomic" SB ACL reconstruction, the distribution of the ACL graft fibers (for AM or PL behavior) is not under the control of the surgeon. Furthermore, different sizes of the original footprints (depending on height) suggest the need to customize the graft footprint. This customization is only possible if distances are measured during surgical procedures. We present an inside-out technique for DB ACL reconstruction ("all-inside" also possible). Semitendinosus is folded to obtain a Y-shaped trifurcate configuration graft, distributing their bundles in two different areas. Used as measuring instruments, we used the "offset" guides as measuring instruments, allowing the surgeon to know the distance between the centers of the AM and PL tunnels. It may be carried out by means of common "offset" guides and any marketed ASF devices, while generating customized footprints. CLASSIFICATION I: knee; II: ACL.
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Affiliation(s)
- Iñaki Mediavilla
- University Hospital of Basurto, Bilbao, Spain,Address correspondence to Iñaki Mediavilla, M.D., Ph.D., University Hospital of Basurto, Montevideo Avenue, 18 48013 Bilbao, Spain.
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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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Jennings JK, Leas DP, Fleischli JE, D'Alessandro DF, Peindl RD, Piasecki DP. Transtibial Versus Anteromedial Portal ACL Reconstruction: Is a Hybrid Approach the Best? Orthop J Sports Med 2017; 5:2325967117719857. [PMID: 28840144 PMCID: PMC5549878 DOI: 10.1177/2325967117719857] [Citation(s) in RCA: 16] [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: 11/15/2022] Open
Abstract
BACKGROUND Improved biomechanical and clinical outcomes are seen when the femoral tunnels of the anterior cruciate ligament (ACL) are placed in the center of the femoral insertion. The transtibial (TT) technique has been shown to be less capable of this than an anteromedial (AM) portal approach but is more familiar to surgeons and less technically challenging. A hybrid transtibial (HTT) technique using medial portal guidance of a transtibial guide wire without knee hyperflexion may offer anatomic tunnel placement while maintaining the relative ease of a TT technique. PURPOSE To evaluate the anatomic and biomechanical performance of the HTT technique compared with TT and AM approaches. STUDY DESIGN Controlled laboratory study. METHODS Thirty-six paired, fresh-frozen human knees were used. Twenty-four knees (12 pairs) underwent all 3 techniques (TT, AM, HTT) for femoral tunnel placement, with direct measurement of femoral insertional overlap and femoral tunnel length. The remaining 12 knees (6 pairs) underwent completed reconstructions to evaluate graft anisometry and tunnel orientation, with each technique performed in 4 specimens and tested using motion sensors with a quad-load induced model. Graft length changes and graft/femoral tunnel angle were measured at varying degrees of flexion. RESULTS Percentage overlap of the femoral insertion averaged 37.0% ± 28.6% for TT, 93.9% ± 5.6% for HTT, and 79.7% ± 7.7% for AM, with HTT significantly greater than both TT (P = .007) and AM (P = .001) approaches. Graft length change during knee flexion (anisometry) was 30.1% for HTT, 12.8% for AM, and 8.5% for TT. When compared with the TT approach, HTT constructs exhibited comparable graft-femoral tunnel angulation (TT, 150° ± 3° vs HTT, 142° ± 2.3°; P < .001) and length (TT, 42.6 ± 2.8 mm vs HTT, 38.5 ± 2.0 mm; P = .12), while AM portal tunnels were significantly shorter (31.6 ± 1.6 mm; P = .001) and more angulated (121° ± 6.5°; P < .001). CONCLUSION The HTT technique avoids hyperflexion and maintains femoral tunnel orientation and length, similar to the TT technique, but simultaneously achieves anatomic graft positioning. CLINICAL RELEVANCE The HTT technique offers an anatomic alternative to an AM portal approach while maintaining the technical advantages of a traditional TT reconstruction.
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Affiliation(s)
| | - Daniel P Leas
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - James E Fleischli
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
| | | | - Richard D Peindl
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dana P Piasecki
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
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Variation in the shape of the tibial insertion site of the anterior cruciate ligament: classification is required. Knee Surg Sports Traumatol Arthrosc 2017; 25:2428-2432. [PMID: 26658565 DOI: 10.1007/s00167-015-3891-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To propose a classification system for the shape of the tibial insertion site (TIS) of the anterior cruciate ligament (ACL) and to demonstrate the intra- and inter-rater agreement of this system. Due to variation in shape and size, different surgical approaches may be feasible to improve reconstruction of the TIS. METHODS One hundred patients with a mean age of 26 ± 11 years were included. The ACL was cut arthroscopically at the base of the tibial insertion site. Arthroscopic images were taken from the lateral and medial portal. Images were de-identified and duplicated. Two blinded observers classified the tibial insertion site according to a classification system. RESULTS The tibial insertion site was classified as type I (elliptical) in 51 knees (51 %), type II (triangular) in 33 knees (33 %) and type III (C-shaped) in 16 knees (16 %). There was good agreement between raters when viewing the insertion site from the lateral portal (κ = 0.65) as well as from the medial portal (κ = 0.66). Intra-rater reliability was good to excellent. Agreement in the description of the insertion site between the medial and lateral portals was good for rater 1 and good for rater 2 (κ = 0.74 and 0.77, respectively). CONCLUSION There is variation in the shape of the ACL TIS. The classification system is a repeatable and reliable tool to summarize the shape of the TIS using three common patterns. For clinical relevance, different shapes may require different types of reconstruction to ensure proper footprint restoration. Consideration of the individual TIS shape is required to prevent iatrogenic damage of adjacent structures like the menisci. LEVEL OF EVIDENCE III.
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10
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Current use of navigation system in ACL surgery: a historical review. Knee Surg Sports Traumatol Arthrosc 2016; 24:3396-3409. [PMID: 27744575 DOI: 10.1007/s00167-016-4356-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/07/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE The present review aims to analyse the available literature regarding the use of navigation systems in ACL reconstructive surgery underling the evolution during the years. METHODS A research of indexed scientific papers was performed on PubMed and Cochrane Library database. The research was performed in December 2015 with no publication year restriction. Only English-written papers and related to the terms ACL, NAVIGATION, CAOS and CAS were considered. Two reviewers independently selected only those manuscripts that presented at least the application of navigation system for ACL reconstructive surgery. RESULTS One hundred and forty-six of 394 articles were finally selected. In this analysis, it was possible to review the main uses of navigation system in ACL surgery including tunnel positioning for primary and revision surgery and kinematic assessment of knee laxity before and after different surgical procedures. In the early years, until 2006, navigation system was mainly used to improve tunnel positioning, but since the last decade, this tool has been principally used for kinematics evaluation. Increased accuracy of tunnel placement was observed using navigation surgery, especially, regarding femoral, 42 of 146 articles used navigation to guide tunnel positioning. During the following years, 82 of 146 articles have used navigation system to evaluate intraoperative knee kinematic. In particular, the importance of controlling rotatory laxity to achieve better surgical outcomes has been underlined. CONLUSIONS Several applications have been described and despite the contribution of navigation systems, its potential uses and theoretical advantages, there are still controversies about its clinical benefit. The present papers summarize the most relevant studies that have used navigation system in ACL reconstruction. In particular, the analysis identified four main applications of the navigation systems during ACL reconstructive surgery have been identified: (1) technical assistance for tunnel placement; (2) improvement in knowledge of the kinematic behaviour of ACL and other structures; (3) comparison of effectiveness of different surgical techniques in controlling laxities; (4) navigation system performance to improve the outcomes of ACL reconstruction and cost-effectiveness. LEVEL OF EVIDENCE IV.
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Tsoukas D, Fotopoulos V, Basdekis G, Makridis KG. No difference in osteoarthritis after surgical and non-surgical treatment of ACL-injured knees after 10 years. Knee Surg Sports Traumatol Arthrosc 2016; 24:2953-2959. [PMID: 25854500 DOI: 10.1007/s00167-015-3593-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/30/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE Aim of this study was to record and compare the functional and activity level as well as the manifestations of osteoarthritis after isolated ACL ruptures between patients with conservative treatment and ACL reconstruction with hamstrings tendon graft. METHODS Thirty-two patients diagnosed with ACL rupture were recorded. Clinical examination included the Tegner and Lysholm activity scale, the International Knee Documentation Committee Subjective Form and KT-1000 arthrometer. Narrowing of the medial and lateral joint spaces was assessed using the IKDC knee examination score. RESULTS Median follow-up was 10.3 years (range 10-11). Fifteen patients were conservatively treated (median age 33 years, range 25-39). Seventeen patients were operated (median age 31 years, range 20-36). There was significant difference between the mean values of IKDC scores in favour of the ACL-reconstruction group of patients, 86.8 (SD 6.5) versus 77.5 (SD 13.8), respectively (p = 0.04). The mean value of anteroposterior tibial translation was 1.5 mm (SD 0.2) for ACL-reconstruction group of patients, while the corresponding mean value for ACL-conservative group was 4.5 mm (SD 0.5), p = 0.03. Four patients in ACL-reconstruction group had radiological findings of grade C or D according to IKDC form. In ACL-conservative group, five patients presented similar signs (n.s.). CONCLUSIONS ACL reconstruction using hamstrings autograft resulted in better functional outcome and laxity measurements than ACL-conservative management. However, the incidence of radiological osteoarthritis was similar between the two groups and independent on the pre-operative grade of laxity and functional status of the patients. Equally, bone bruises were not found as a risk factor for the development of osteoarthritis after ACL rupture. LEVEL OF EVIDENCE Prospective randomized study, Level II.
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Affiliation(s)
- Dimitrios Tsoukas
- Orthopaedic Sports Medicine Clinic, 1-3 Distomou Street, Maroussi, 15125, Athens, Greece
| | - Vasilios Fotopoulos
- Royal Sussex County Hospital, Eastern Road, Brighton, East Sussex, BN2 5BE, UK
| | - Georgios Basdekis
- Academic Department of Orthopaedic Surgery and Musculoskeletal Trauma, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Konstantinos G Makridis
- , Flat 155F, Block D, The Plaza, Claypit Lane, Leeds, LS2 8BN, UK.
- Centre Nollet (Teaching center - approved by ESSKA), Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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12
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Innocenti B, Salandra P, Pascale W, Pianigiani S. How accurate and reproducible are the identification of cruciate and collateral ligament insertions using MRI? Knee 2016; 23:575-81. [PMID: 27246728 DOI: 10.1016/j.knee.2015.07.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 07/15/2015] [Accepted: 07/28/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND At present, increasing the accuracy of identification of knee ligament insertions is fundamental in developing accurate patient-specific three-dimensional (3D) models for preoperative planning surgeries, designing patient-specific instrumentation or implants, and conducting biomechanical analyses. The accuracy and reproducibility of magnetic resonance imaging (MRI) scans in identifying cruciate and collateral ligament insertions have not been investigated thus far, despite their wide use. This study aimed to define and validate a method for this purpose. METHODS First, the femur and tibia bones were oriented. Then, the sites of cruciate and collateral ligament insertions were identified. The inter- and intra-class correlation coefficients (ICCs) were calculated after multiple operators were applied to the images of different patients. The effect of the quality of the available MRI scans on the accuracy of identifying ligament insertions was also investigated. Moreover, non-expert operators were also found to be capable of performing the procedure after a video tutorial, and its efficacy was tested. RESULTS The mean intra-observer variability was always <1.5mm for all landmarks, whereas the mean inter-observer variability was always <2.5mm except for the medial collateral ligament localized on the tibia (6.7mm). The ICCs showed good results, up to 0.99. A lower image quality had no noticeable effect on the procedure for identifying cruciate ligaments. Video tutorials were found to improve the ICCs up to 45%. CONCLUSIONS This procedure is suitable for the univocal and accurate identification of cruciate and lateral collateral ligaments on MRI scans. CLINICAL RELEVANCE This study demonstrates that MRI scans are highly suited to identifying cruciate ligament insertions.
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Affiliation(s)
- Bernardo Innocenti
- BEAMS Department (Bio Electro and Mechanical Systems), École Polytechnique de Bruxelles, Université Libre de Bruxelles, Av. F. Roosevelt 50, Brussels, Belgium
| | - Pasquale Salandra
- Università Politecnica delle Marche, Via Brecce Bianche, Ancona 60131, Italy
| | - Walter Pascale
- IRCCS Istituto Ortopedico Galeazzi, via R. Galeazzi 4, 20161 Milan, Italy
| | - Silvia Pianigiani
- IRCCS Istituto Ortopedico Galeazzi, via R. Galeazzi 4, 20161 Milan, Italy.
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A systematic review of single- versus double-bundle ACL reconstruction using the anatomic anterior cruciate ligament reconstruction scoring checklist. Knee Surg Sports Traumatol Arthrosc 2016; 24:862-72. [PMID: 25344803 DOI: 10.1007/s00167-014-3393-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/15/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this systematic review was to apply the anatomic ACL reconstruction scoring checklist (AARSC) and to evaluate the degree to which clinical studies comparing single-bundle (SB) and double-bundle (DB) ACL reconstructions are anatomic. METHODS A systematic electronic search was performed using the databases PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to January 2014 comparing SB and DB ACL reconstructions with clinical outcome measurements were included. The items from the AARSC were recorded for both the SB and DB groups in each study. RESULTS Eight-thousand nine-hundred and ninety-four studies were analysed, 77 were included. Randomized clinical trials (29; 38%) and prospective comparative studies (29; 38%) were the most frequent study type. Most studies were published in 2011 (19; 25%). The most commonly reported items for both SB and DB groups were as follows: graft type (152; 99%), femoral and tibial fixation method (149; 97% respectively), knee flexion angle during graft tensioning (124; 8%) and placement of the tibial tunnel at the ACL insertion site (101; 66%). The highest level of documentation used for ACL tunnel position for both groups was often one dimensional, e.g. drawing, operative notes or o'clock reference. The DB reconstruction was in general more thoroughly reported. The means for the AARSC were 6.9 ± 2.8 for the SB group and 8.3 ± 2.8 for the DB group. Both means were below a proposed required minimum score of 10 for anatomic ACL reconstruction. CONCLUSIONS There was substantial underreporting of surgical data for both the SB and DB groups in clinical studies. This underreporting creates difficulties when analysing, comparing and pooling results of scientific studies on this subject.
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Is double-bundle anterior cruciate ligament reconstruction superior to single-bundle? A comprehensive systematic review. Knee Surg Sports Traumatol Arthrosc 2015; 23:696-739. [PMID: 24037314 DOI: 10.1007/s00167-013-2666-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 08/31/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe current evidence on single- and double-bundle anterior cruciate ligament (ACL) reconstruction, in terms of differences in knee kinematics, functional outcomes, patient-reported outcomes and graft failures. METHODS An electronic search was made using PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to August 2011 were included, and an updated search was made in PubMed in July 2012. Therapeutic studies, level of evidence I-III, for isolated primary ACL tears written in English comparing single- and double-bundle reconstruction reporting clinical outcome were included. Quality appraisal based on Cochrane Collaboration's tool for assessing risk of bias was performed. RESULTS Of 7,154 potentially eligible studies, 60 papers were included (25 randomised controlled trials, 21 prospective comparative studies, 14 retrospective comparative studies), comprising 4,146 patients (2,072 single-bundle, 2,074 double-bundle). Minor differences were found between study types. An analysis of graft failures revealed fewer re-ruptures in double-bundle reconstruction than single-bundle, 19 and 44, respectively. Up to 45 % of the studies reported a superior outcome in double-bundle reconstruction in terms of antero-posterior laxity, measured with the Lachman, anterior drawer, KT-1000/2000 and navigation. Measurements of rotatory laxity revealed superior results in double-bundle reconstruction measured with pivot shift and navigation in 18/42 (8/15 anatomically reconstructed) and 9/20 studies, respectively. Patient-reported outcome measures and functional outcomes did not differ to a large extent; however, differences when identified were almost exclusively in favour of double-bundle reconstruction. CONCLUSION Based on current evidence, double-bundle reconstruction appears to have fewer re-ruptures and less antero-posterior and rotatory laxity. Furthermore, no differences were found in short-term patient-reported outcome measures or objective findings. However, detailed statistical analyses of the included studies divided into homogeneous groups are needed to avoid reporting bias and to confirm any statistical difference.
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Kassam AM, Tillotson L, Schranz PJ, Mandalia VI. The Lateral Meniscus as a Guide to Anatomical Tibial Tunnel Placement During Anterior Cruciate Ligament Reconstruction. Open Orthop J 2015; 9:542-7. [PMID: 26962379 PMCID: PMC4763962 DOI: 10.2174/1874325001509010542] [Citation(s) in RCA: 9] [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: 03/18/2015] [Revised: 08/27/2015] [Accepted: 10/19/2015] [Indexed: 12/02/2022] Open
Abstract
Purpose: The aim of the study is to show, on an MRI scan, that the posterior border of the anterior horn of the
lateral meniscus (AHLM) could guide tibial tunnel position in the sagittal plane and provide anatomical graft position. Method: One hundred MRI scans were analysed with normal cruciate ligaments and no evidence of meniscal injury. We
measured the distance between the posterior border of the AHLM and the midpoint of the ACL by superimposing sagittal
images. Results: The mean distance between the posterior border of the AHLM and the ACL midpoint was -0.1mm (i.e. 0.1mm
posterior to the ACL midpoint). The range was 5mm to -4.6mm. The median value was 0.0mm. 95% confidence interval
was from -0.5 to 0.3mm.
A normal, parametric distribution was observed and Intra- and inter-observer variability showed significant correlation
(p<0.05) using Pearsons Correlation test (intra-observer) and Interclass correlation (inter-observer). Conclusion: Using the posterior border of the AHLM is a reproducible and anatomical marker for the midpoint of the
ACL footprint in the majority of cases. It can be used intra-operatively as a guide for tibial tunnel insertion and graft
placement allowing anatomical reconstruction. There will inevitably be some anatomical variation. Pre-operative MRI
assessment of the relationship between AHLM and ACL footprint is advised to improve surgical planning. Level of Evidence: Level 4.
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Affiliation(s)
- A M Kassam
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - L Tillotson
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - P J Schranz
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - V I Mandalia
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
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Smith JO, Yasen S, Risebury MJ, Wilson AJ. Femoral and tibial tunnel positioning on graft isometry in anterior cruciate ligament reconstruction: a cadaveric study. J Orthop Surg (Hong Kong) 2014; 22:318-24. [PMID: 25550010 DOI: 10.1177/230949901402200310] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To assess distance changes between the femoral and tibial attachment points of 3 different anterior cruciate ligament (ACL) tunnel entry positions throughout the range of knee motion in cadaveric knees. METHODS The ACLs of 11 fresh-frozen cadaveric knees (from 6 men and 5 women) were removed using radiofrequency. Three tibial tunnel placements were made using a cannulated awl, and three 2.4-mm pilot tunnels were drilled on the lateral femoral condyle. One end of an inelastic suture was inserted from each of the 3 femoral holes and fixed on the femoral cortex using a suture button in turn, whereas the other end of the suture was passed through the cannulated awl and fixed on each of the 3 tibial placements in turn, with constant tension. Distance changes of the suture throughout the range of knee movement (0º, 90º, and 135º of knee flexion) were measured for each combination of tibial and femoral positions. RESULTS The distance was minimum when the knee was in full extension (p < 0.0001). Most of the distance changes occurred during initial flexion (0º-90º). The most isometric position (mean ± standard deviation [SD] distance change, 2.78 ± 0.93 mm; p < 0.0001) was noted when the suture was at the anteromedial bundle placement in the femur and anterior in the tibia. The least isometric position (mean ± SD distance change, 10.37 ± 2.08 mm; p < 0.0001) was noted when the suture was at the mid-bundle position in the femur and at the posterolateral bundle insertion in the tibia. The anatomic position resulted in a mean ± SD distance change of 7.63 ± 2.01 mm (p < 0.0001). The femoral position had a greater influence on distance change than the tibial position. CONCLUSION None of the ACL graft positions was isometric. Anatomic ACL positioning resulted in comparable anisometry to the native ACL. The minimum distance for all graft positions was noted in full extension, in which position the graft should be fixed during anatomic ACL reconstruction.
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Affiliation(s)
- James O Smith
- Department of Orthopaedics, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, United Kingdom
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Zheng L, Harner CD, Zhang X. The morphometry of soft tissue insertions on the tibial plateau: data acquisition and statistical shape analysis. PLoS One 2014; 9:e96515. [PMID: 24788908 PMCID: PMC4008582 DOI: 10.1371/journal.pone.0096515] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/09/2014] [Indexed: 01/29/2023] Open
Abstract
This study characterized the soft tissue insertion morphometrics on the tibial plateau and their inter-relationships as well as variabilities. The outlines of the cruciate ligament and meniscal root insertions along with the medial and lateral cartilage on 20 cadaveric tibias (10 left and 10 right knees) were digitized and co-registered with corresponding CT-based 3D bone models. Generalized Procrustes Analysis was employed in conjunction with Principal Components Analysis to first create a geometric consensus based on tibial cartilage and then determine the means and variations of insertion morphometrics including shape, size, location, and inter-relationship measures. Step-wise regression analysis was conducted in search of parsimonious models relating the morphometric measures to the tibial plateau width and depth, and basic anthropometric and gender factors. The analyses resulted in statistical morphometric representations for Procrustes-superimposed cruciate ligament and meniscus insertions, and identified only a few moderate correlations (R2: 0.37-0.49). The study provided evidence challenging the isometric scaling based on a single dimension frequently employed in related morphometric studies, and data for evaluating cruciate ligament reconstruction strategies in terms of re-creating the native anatomy and minimizing the risk of iatrogenic injury. It paved the way for future development of computer-aided personalized orthopaedic surgery applications improving the quality of care and patient safety, and biomechanical models with a better population or average representation.
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Affiliation(s)
- Liying Zheng
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Christopher D Harner
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Xudong Zhang
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America; Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America; Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Yasen SK, Logan JS, Smith JO, Nancoo T, Risebury MJ, Wilson AJ. TriLink: Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2013; 3:e13-20. [PMID: 24749016 PMCID: PMC3986474 DOI: 10.1016/j.eats.2013.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/08/2013] [Indexed: 02/03/2023] Open
Abstract
Cadaveric and clinical biomechanical studies show improved kinematic restoration using double-bundle anterior cruciate ligament (ACL) reconstruction techniques. These have been criticized in the past for being technically challenging. We present a novel 3-socket approach for anatomic "all-inside" double-bundle reconstruction using a single hamstring tendon fashioned to create a trifurcate graft: the TriLink technique. The semitendinosus alone is harvested, quadrupled, and attached to 3 suspensory fixation devices in a Y-shaped configuration, creating a 4-stranded tibial limb and 2 double-stranded femoral limbs. A medial viewing/lateral working arthroscopic approach is adopted using specifically designed instrumentation. Anatomic placement of the 2 femoral tunnels is performed by a validated direct measurement technique. A single mid-bundle position is used on the tibia. Both femoral and tibial sockets are created in a retrograde manner using outside-to-in drilling. This is a simplified operative technique for anatomic double-bundle ACL reconstruction that maximizes bone preservation. The TriLink construct replicates the 2 bundles of the ACL, conferring native functional anisometry and improving femoral footprint coverage while avoiding the complexities and pitfalls of double-tibial tunnel techniques. Preservation of the gracilis reduces the morbidity of hamstring harvest and allows greater flexibility in graft choice in cases requiring multiligament reconstruction.
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Affiliation(s)
- Sam K. Yasen
- Address correspondence to Sam K. Yasen, M.B.B.S., B.Sc.(Hons), M.R.C.S., Department of Orthopaedics, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, England.
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Chae IJ, Bae JH, Wang JH, Jeon J, Park JH. Double-bundle anterior cruciate ligament reconstruction with split Achilles allograft and single tibia tunnel for small ACL tibial footprint : technical note with clinical results. Arch Orthop Trauma Surg 2013; 133:819-25. [PMID: 23589061 DOI: 10.1007/s00402-013-1734-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE We describe a surgical technique of double-bundle ACL reconstruction with a single tibia tunnel and report the clinical outcome. METHODS The Achilles tendon portion was split longitudinally into two separate bundles, namely, an anteromedial (AM) bundle with 7-8 mm diameter and a posterolateral (PL) bundle with 4-6 mm diameter. The central portion of the calcaneal bone plug was prepared with a diameter of 10 mm and a length of 30 mm. For the femoral tunnel preparation, we preferred inside out target through an accessory anteromedial portal for an approach to native ACL footprint and outside in reaming through separate incision on the lateral aspect of distal thigh to prevent cartilage injury of medial femoral condyle. 10 mm diameter of single tibia tunnel was prepared at the central portion of ACL tibial footprint. After graft passage from tibia to femoral side, fixation of calcaneal bone plug within the tibia tunnel was performed using two bioabsorbable cross pins. Then, AM bundle was first fixed at 45° of flexion while the PL bundle was fixed at 10° of flexion using bioabsorbable interference screws and augmented staples. Clinical results of 22 patients (18 males and 4 females, average age 30.7 years) who underwent double-bundle anterior cruciate ligament (ACL) reconstruction with this technique were evaluated. RESULTS At an average follow-up of 30 months, there was significant improvement of the Lysholm knee score, the 2,000 IKDC subjective knee score, the median Tegner activity score and the side-to-side difference. According to the 2,000 IKDC knee examination form, the grade rated as normal in seven patients, nearly normal in 14 patients and abnormal in one patient at the latest follow-up. There were no postoperative complications and revisional surgeries. CONCLUSIONS Split Achilles allograft and single tibia tunnel technique for double-bundle ACL reconstruction can be an alternative option for patients with small tibial insertion sites. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- In-Jung Chae
- Department of Orthopaedic Surgery, Korea University College of Medicine, Anam Hospital Seoul, Seoul, Republic of Korea
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Lopomo N, Zaffagnini S, Amis AA. Quantifying the pivot shift test: a systematic review. Knee Surg Sports Traumatol Arthrosc 2013; 21:767-83. [PMID: 23455384 DOI: 10.1007/s00167-013-2435-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/23/2013] [Indexed: 01/13/2023]
Abstract
PURPOSE This study aims to identify and summarize the evidence on the biomechanical parameters and the corresponding technologies which have been used to quantify the pivot shift test during the clinical and functional assessment of anterior cruciate ligament (ACL) injury and surgical reconstruction. METHODS Search strategy Internet search of indexed scientific articles on the PubMed database, Web of Science and references on published manuscripts. No year restriction was used. Selection criteria Articles included were written only in English and related to search terms: "pivot shift" AND (OR "ACL"). The reviewers independently selected only those studies that included at least one quantitative parameter for the analysis of the pivot shift test, including both in vitro and in vivo analyses performed on human joint. Those studies that analysed only clinical grading were excluded from the analysis. Analysis After evaluating the methodological quality of the articles, the parameters found were summarized. RESULTS Six hundred and eight studies met the inclusion criteria, and finally, 68 unique studies were available for the systematic review. Quantitative results were heterogeneous. The pivot shift test has been quantified by means of 25 parameters, but most of the studies focused on anterior-posterior translations, internal-external rotation and acceleration in anterior-posterior direction. CONCLUSION Several methodologies have been identified and developed to quantify pivot shift test. However, clinical professionals are still lacking a 'gold standard' method for the quantification of knee joint dynamic laxity. A widespread adoption of a standardized pivot shift manoeuvre and measurement method to allow objective comparison of the results of ACL reconstructions is therefore desirable. Further development of measurement methods is indeed required to achieve this goal in a routine clinical scenario.
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Affiliation(s)
- Nicola Lopomo
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136, Bologna, Italy.
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