Is intraoperative fluoroscopy necessary in anterior cruciate ligament double-bundle reconstruction? A prospective randomized controlled trial

Technology-assisted anterior cruciate ligament reconstruction improves tunnel placement but leads to no change in clinical outcomes: a systematic review and meta-analysis

PURPOSE

To investigate the effect of technology-assisted Anterior Cruciate Ligament Reconstruction (ACLR) on post-operative clinical outcomes and tunnel placement compared to conventional arthroscopic ACLR.

METHODS

CENTRAL, MEDLINE, and Embase were searched from January 2000 to November 17, 2022. Articles were included if there was intraoperative use of computer-assisted navigation, robotics, diagnostic imaging, computer simulations, or 3D printing (3DP). Two reviewers searched, screened, and evaluated the included studies for data quality. Data were abstracted using descriptive statistics and pooled using relative risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI), where appropriate.

RESULTS

Eleven studies were included with total 775 patients and majority male participants (70.7%). Ages ranged from 14 to 54 years (391 patients) and follow-up ranged from 12 to 60 months (775 patients). Subjective International Knee Documentation Committee (IKDC) scores increased in the technology-assisted surgery group (473 patients; P = 0.02; MD 1.97, 95% CI 0.27 to 3.66). There was no difference in objective IKDC scores (447 patients; RR 1.02, 95% CI 0.98 to 1.06), Lysholm scores (199 patients; MD 1.14, 95% CI - 1.03 to 3.30) or negative pivot-shift tests (278 patients; RR 1.07, 95% CI 0.97 to 1.18) between the two groups. When using technology-assisted surgery, 6 (351 patients) of 8 (451 patients) studies reported more accurate femoral tunnel placement and 6 (321 patients) of 10 (561 patients) studies reported more accurate tibial tunnel placement in at least one measure. One study (209 patients) demonstrated a significant increase in cost associated with use of computer-assisted navigation (mean 1158€) versus conventional surgery (mean 704€). Of the two studies using 3DP templates, production costs ranging from $10 to $42 USD were cited. There was no difference in adverse events between the two groups.

CONCLUSION

Clinical outcomes do not differ between technology-assisted surgery and conventional surgery. Computer-assisted navigation is more expensive and time consuming while 3DP is inexpensive and does not lead to greater operating times. ACLR tunnels can be more accurately located in radiologically ideal places by using technology, but anatomic placement is still undetermined because of variability and inaccuracy of the evaluation systems utilized.

LEVEL OF EVIDENCE

Level III.

The incidence of tibial tunnel coalition is higher than femoral tunnel coalition in double-bundle anterior cruciate ligament reconstruction using hamstring autografts: A systematic review

INTRODUCTION

Intra-operative and postoperative coalition of tunnels may occur in double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). However, the incidence and effect on clinical outcomes of tunnel coalition following primary DB ACLR using a hamstring autograft has yet be analyzed, and thus remains unknown. The objective of this systematic review was to identify the incidence of tunnel coalition upon DB ACLR using hamstring autografts and to elucidate any clinical outcomes and/or complications that tunnel coalition may have postoperatively.

HYPOTHESIS

The incidence of tunnel coalition would increase in respect to time from the index surgery, and that tunnel coalition would be related to poorer clinical outcomes compared to non-coalition cases.

METHODS

Three databases (PubMed, EMBASE, Cochrane Library) were searched in accordance with PRISMA and R-AMSTAR guidelines on June 15, 2020. Relevant studies were screened in duplicate and data regarding patient demographics, incidence of femoral and tibial tunnel coalition, and outcomes were extracted. Coalition rate was also compared between follow up at 1 month or less defined as "shorter-term", and 6 months or greater as "longer-term". Coalition is defined as the missing of a bony bridge between the two tunnels.

RESULTS

Thirty-six studies examining 1,574 patients, mean age 29.1 years, were included in this study. 29 studies (1,110 knees) reported the incidence of femoral coalition with a pooled rate of coalition of 8% (95% CI=4-12%). 28 studies (1,129 knees) reported an incidence of tibial coalition with a pooled rate of coalition of 21% (95% CI=13-30%). The incidence of tibial coalition was significantly higher than the incidence of femoral coalition across 21 comparative studies (OR=3.37, 95% CI=1.41-8.09, p=0.0065). Only two studies (111 knees) compared tunnel coalition and non-coalition groups for clinical outcome and no significant differences were observed with regards to Lysholm score, Tegner activity scale, and knee laxity measured with a KT-1000 arthrometer.

DISCUSSION

The rate of tibial tunnel coalition in DB ACLR is higher than femoral tunnel coalition, particularly at longer-term follow-up. Despite the higher radiographic evidence of coalition, the clinical effects of such remain to be ascertained, and further comparative studies are required to facilitate this understanding.

LEVEL OF EVIDENCE

IV, systematic review.

Reconstruction of the Anterior Cruciate Ligament Using Ruler-Assisted Positioning of the Femoral Tunnel Relative to the Posterior Apex of the Deep Cartilage: A Single-Center Case Series

The techniques available to locate the femoral tunnel during anterior cruciate ligament (ACL) reconstruction have notable limitations. To evaluate whether the femoral tunnel center could be located intraoperatively with a ruler, using the posterior apex of the deep cartilage (ADC) as a landmark. This retrospective case series included consecutive patients with ACL rupture who underwent arthroscopic single-bundle ACL reconstruction at the Department of Orthopedics, Beijing Tongren Hospital between January 2014 and May 2018. During surgery, the ADC of the femoral lateral condyle was used as a landmark to locate the femoral tunnel center with a ruler. Three-dimensional computed tomography (CT) was performed within 3 days after surgery to measure the femoral tunnel position by the quadrant method. Arthroscopy was performed 1 year after surgery to evaluate the intra-articular conditions. Lysholm and International Knee Documentation Committee (IKDC) scores were determined before and 1 year after surgery. The final analysis included 82 knees of 82 patients (age = 31.7 ± 6.1 years; 70 males). The femoral tunnel center was 26 ± 1.5% in the deep-shallow (x-axis) direction and 31 ± 3.1% in the high-low (y-axis) direction, close to the "ideal" values of 27 and 34%. Lysholm score increased significantly from 38.5 (33.5-47) before surgery to 89 (86-92) at 1 year after surgery (p < 0.001). IKDC score increased significantly from 42.5 (37-47) before surgery to 87 (83.75-90) after surgery (p < 0.001). Using the ADC as a landmark, the femoral tunnel position can be accurately selected using a ruler.