1
|
Khan ZA, Kerzner B, Kaplan DJ, Riff AJ, Chahla J, Bach BR. A Single-Surgeon 35-Year Experience With ACL Reconstruction Using Patellar Tendon Auto- and Allografts With the Transtibial Technique. Orthop J Sports Med 2024; 12:23259671241265074. [PMID: 39286523 PMCID: PMC11403700 DOI: 10.1177/23259671241265074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 02/23/2024] [Indexed: 09/19/2024] Open
Abstract
Background Long-term follow-up for anterior cruciate ligament reconstruction (ACLR) is limited due to heterogeneity in the number of techniques utilized, the number of surgeons included, and attrition bias. Purpose To analyze a single surgeon's 35-year experience with ACLR using the transtibial technique, with an emphasis on temporal trends in graft selection and subanalyses on rates of revision surgery, contralateral ACLR, and nonrevision reoperation among different demographic cohorts of patients. Study Design Case series; Level of evidence, 4. Methods All patients who underwent arthroscopically assisted single-bundle ACLR between 1986 and 2021 were identified from a prospectively maintained single-surgeon registry. Outcomes of interest included revision, reoperation, and contralateral rupture rates. Results A total of 2915 ACLRs were performed during the senior surgeon's career. The mean age for primary ACLR was 29.4 ± 14.8 years. During primary ACLR, 98.4% of patients received a central-third bone-patellar tendon-bone (BPTB) graft. Increasing patient age was associated with increasing allograft usage (P < .01), with a significant temporal increase in allograft usage over the senior surgeon's career (P < .01). There was a higher revision rate among younger patients (P < .01), female patients aged 21 to 25 years (P = .01), and patients who received an allograft during the primary procedure (P = .04). The contralateral rupture rate showed no difference between sexes (P = .34); however, patients who underwent ACLR with autograft had a greater rate of contralateral injury compared with those with allograft (P < .01). The contralateral rupture rate was greater than the revision rate (P < .01). The most common causes of nonrevision reoperation were failed meniscal repair, new meniscal tears, arthrofibrosis, and painful hardware removal. Conclusion The findings of this single-surgeon registry reveal temporal trends in ACLR over a 35-year career. There was a trend toward increasing BPTB allograft use in ACLR, especially in older patients and revision cases. A greater revision rate was observed among younger patients, female patients, and those receiving allografts during primary surgery. Contralateral ACLR was more common than revision surgery.
Collapse
Affiliation(s)
| | - Benjamin Kerzner
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Daniel J Kaplan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Andrew J Riff
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Bernard R Bach
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
2
|
Zhu S, Li R. All-Inside Anterior Cruciate Ligament Reconstruction Had Clinical Outcome Similar to the Transtibial Technique Except for Improved Side-to-Side Difference and Tegner Activity Scale: A Systematic Review and Meta-analysis. Arthroscopy 2024; 40:2276-2288. [PMID: 38354760 DOI: 10.1016/j.arthro.2024.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024]
Abstract
PURPOSE To compare clinical outcomes of the all-inside technique with the transtibial technique in anterior cruciate ligament reconstruction based on available literature on this topic. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, we conducted a systematic search for randomized controlled trials and cohort studies. Our comprehensive search encompassed PubMed, Embase, Cochrane Library, and Web of Science. We included randomized controlled trials (RCTs) and cohort studies that compared the 2 techniques with a minimal 1-year follow-up. Two independent authors assessed RCTs using the risk of bias tool developed by the Cochrane Collaboration and evaluated the quality of cohort studies using the Newcastle-Ottawa Scale for Assessing the Quality of Nonrandomized Comparative Trials. The subjective and objective outcomes, complications, and graft failure were obtained. R software was used to perform the analysis. RESULTS The present analysis enrolled 9 RCTs (n = 687) and 11 cohort studies (n = 910). After a minimal 1-year follow-up in RCTs, functional outcomes such as International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity scale, Knee Society Score, and hop test were found to be similar between 2 techniques. The laxity outcomes, including the IKDC objective grade and pivot-shift test, were suggested to be comparable. There was a significant difference favoring the transtibial technique in terms of side-to-side difference (P = .04; 95% confidence interval [CI], 0.08-0.90). The pooled data from cohort studies indicated equivalent results in terms of IKDC subjective score, Lysholm score, side-to-side difference, IKDC objective grade, complications, and graft failure, with the exception of statistical difference in the Tegner activity scale (P = .03; 95% CI, -0.50 to -0.04). CONCLUSIONS Our findings suggest that there is no difference in most outcome scores between the all-inside and transtibial techniques for anterior cruciate ligament reconstruction. There are statistically significant differences in side-to-side difference and Tegner activity scale favoring the all-inside technique. LEVEL OF EVIDENCE Level IV, meta-analysis of Level I to IV studies.
Collapse
Affiliation(s)
- Shuang Zhu
- Department of Orthopaedics, Southern Medical University Zhujiang University, Guangzhou, China
| | - Renbin Li
- Department of Orthopaedics, Southern Medical University Zhujiang University, Guangzhou, China.
| |
Collapse
|
3
|
Mueller MM, Tenfelde O, Hinz N, Pagenstert G, Frosch KH, Hoeher J, Akoto R. App-based analysis of the femoral tunnel position in ACL reconstruction using the quadrant method. Arch Orthop Trauma Surg 2024; 144:3137-3144. [PMID: 38795188 DOI: 10.1007/s00402-024-05380-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/09/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE The purpose of this study was to examine the intra- and interobserver variability of an app-based analysis of the femoral tunnel position using the quadrant method in primary anterior cruciate ligament reconstruction. MATERIALS AND METHODS Between 12/2020 und 12/2021 50 patients who underwent primary anterior cruciate ligament reconstruction were included in this retrospective study. Intraoperative strictly lateral fluoroscopic images of the knee with marked femoral tunnel were analyzed by four observers using the quadrant method. For retest reliability analysis, measurements were repeated once by 2 observers after 4 weeks. RESULTS The femoral tunnel position of all included patients averaged 27.86% in the depth relation and 15.61% in the height relation. Statistical analysis showed an almost perfect intra- and interobserver reliability in the depth and height relation. The ICC was 0.92 in the depth relation and 0.84 in the height relation. The Pearson's correlation coefficient in the depth and height relation of observer 1 (0.94/0.81) was only slightly different from the Pearson's correlation coefficient of observer 2 (0.92/0.85). The app-based tunnel analysis took on average 59 ± 16 s per measurement. CONCLUSION The femoral tunnel analysis with the app-based quadrant method has an almost perfect intra- and interobserver reliability. By smartphone camera, a fast and highly accurate, if necessary also intraoperative, control of the tunnel position can be performed. LEVEL OF EVIDENCE Level 3-diagnostic retrospective cohort study.
Collapse
Affiliation(s)
- Maximilian M Mueller
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany.
| | - Oliver Tenfelde
- Department of Orthopaedic Surgery, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
- Sportsclinic Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Nico Hinz
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
| | - Geert Pagenstert
- Clarahof Clinic of Orthopaedic Surgery, University of Basel, Clarahofweg 19a, 4058, Basel, Switzerland
| | - Karl-Heinz Frosch
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Juergen Hoeher
- Department of Orthopaedic Surgery, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
- Sportsclinic Cologne, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Ralph Akoto
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
- Department of Orthopaedic Surgery, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| |
Collapse
|
4
|
Dadoo S, Benvegnu N, Herman ZJ, Yamamoto T, Hughes JD, Musahl V. Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures. Clin Sports Med 2024; 43:449-464. [PMID: 38811121 DOI: 10.1016/j.csm.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.
Collapse
Affiliation(s)
- Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA.
| | - Neilen Benvegnu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA
| | - Zachary J Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA
| | - Tetsuya Yamamoto
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA; Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
5
|
Inclan PM, Brophy RH. Revision anterior cruciate ligament reconstruction. Bone Joint J 2023; 105-B:474-480. [PMID: 37121594 DOI: 10.1302/0301-620x.105b5.bjj-2022-1064.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.
Collapse
Affiliation(s)
- Paul M Inclan
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| |
Collapse
|
6
|
Haroun HK, Abouelsoud MM, Allam MR, Abdelwahab MM. Transtibial versus independent femoral tunnel drilling techniques for anterior cruciate ligament reconstruction: evaluation of femoral aperture positioning. J Orthop Surg Res 2022; 17:166. [PMID: 35303903 PMCID: PMC8931956 DOI: 10.1186/s13018-022-03040-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Femoral tunnel can be drilled through tibial tunnel (TT), or independent of it (TI) by out-in (OI) technique or by anteromedial (AM) technique. No consensus has been reached on which technique achieves more proper femoral aperture position because there have been evolving concepts in the ideal place for femoral aperture placement. This meta-analysis was performed to analyze the current literature comparing femoral aperture placement by TI versus TT techniques in ACL reconstruction. Methods We performed a comprehensive systematic review and meta-analysis of English-language literature in PubMed, Cochrane, and Web of Science databases for articles comparing femoral aperture placement by TI versus TT techniques with aperture position assessed by direct measurement or by postoperative imaging, PXR and/or CT and/or MRI. Results We included 55 articles with study population of 2401 knees of whom 1252 underwent TI and 1149 underwent TT techniques. The relevant baseline characteristics, whenever compared, were comparable between both groups. There was nonsignificant difference between TI and TT techniques in the distance from aperture center to footprint center and both techniques were unable to accurately recreate the anatomic footprint position. TI technique significantly placed aperture at more posterior position than TT technique. TI technique significantly lowered position of placed aperture perpendicular to Blumensaat’s line (BL) than TT technique, and modifications to TT technique had significant effect on this intervention effect. Regarding sagittal plane aperture placement along both AP anatomical axis and BL, there was nonsignificant difference between both techniques. Conclusion Modifications to TT technique could overcome limitations in aperture placement perpendicular to BL. The more anterior placement of femoral aperture by TT technique might be considered, to some extent, a proper position according to recent concept of functional anatomical ACL reconstruction. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03040-5.
Collapse
Affiliation(s)
- Haitham K Haroun
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt.
| | - Maged M Abouelsoud
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt
| | | | - Mahmoud M Abdelwahab
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt
| |
Collapse
|
7
|
Anterior Cruciate Ligament Revision Reconstruction. J Am Acad Orthop Surg 2021; 29:723-731. [PMID: 34096902 DOI: 10.5435/jaaos-d-21-00088] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/03/2021] [Indexed: 02/01/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction is used in patients with recurrent instability after primary ACL reconstruction. Identifying the etiology of graft failure is critical to the success of revision reconstruction. The most common etiologies include technical errors, trauma, failure to recognize concomitant injuries, young age, incomplete rehabilitation, and hardware failure. Patients should undergo a complete history and physical examination with a specific focus on previous injury mechanism and surgical procedures. A revision ACL reconstruction is a technically demanding procedure, and the surgeon should be prepared to address bone tunnel osteolysis, concurrent meniscal, ligamentous, or cartilage lesions, and limb malalignment. Surgical techniques described in this article include both single-stage and two-stage reconstruction procedures. Rates of return to sport after a revision reconstruction are lower than after primary reconstruction. Future research should be focused on improving both single-stage and two-stage revision techniques, as well as concomitant procedures to address limb malalignment and associated injuries.
Collapse
|
8
|
Schützenberger S, Grabner S, Schallmayer D, Kontic D, Keller F, Fialka C. The risk of graft impingement still exists in modern ACL surgery and correlates with degenerative MRI signal changes. Knee Surg Sports Traumatol Arthrosc 2021; 29:2880-2888. [PMID: 33009942 DOI: 10.1007/s00167-020-06300-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Anatomic tunnel placement in ACL reconstruction is crucial to restore knee function. The aims of this study were to (i) evaluate the accuracy of tunnel placement for primary state-of-the-art ACL reconstruction, and (ii) examine the correlation between incorrect tunnel placement, graft appearance, and notch impingement. METHODS In this retrospective study, all patients underwent primary single-bundle ACL reconstruction with independent drilling of the femoral and tibial tunnels according to anatomical landmarks. The accuracy of tunnel placement and the rate of notch impingement were analysed with MRI. The study cohort was subdivided according to the morphology of the graft: intact, degeneration, and re-rupture. The objective outcome was evaluated with the IKDC objective score, and the subjective outcomes were evaluated with the IKDC subjective score, the Lysholm knee score, the KOOS, and the Tegner activity scale score. RESULTS Eighty-seven consecutive patients with a mean follow-up of 3.8 ± 1.4 years were evaluated. There was no significant difference among the groups concerning the baseline characteristics. The re-rupture rate was 9.2%. The position of the femoral tunnel was correct in 92% of the patients, and the position of the tibial tunnel was correct in 93% of the patients. In the intact group, impingement was not found in any of the cases, whereas the rate of impingement in the degeneration (65%) and re-rupture (80%) groups was significantly higher than that in the intact group (p < 0.001). The risk of impingement was more likely with femoral (71% vs. 13%, p < 0.001) or tibial (100% vs. 11%, p < 0.001) malpositioning. The objective IKDC score was A in 52 patients (60%), B in 26 patients (30%), and C in 9 patients (10%). The average subjective IKDC score, Lysholm score, and KOOS were comparable in the intact and degeneration groups but significantly lower in the patient group with newly diagnosed re-ruptures (p = 0.05). The Tegner activity scale score was comparable in all three groups. CONCLUSION Even though the accuracy of femoral tunnel placement in modern single-bundle ACL reconstruction is greater, the risk of malpositioning and graft impingement remains. In our patient cohort, there was a clear correlation between ACL graft impingement, degenerative changes in MRI, and incorrect tunnel positioning. The surgeon must focus on accurate tunnel placement specific to individual patient anatomy. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- S Schützenberger
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Vienna, Austria.
| | - S Grabner
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Vienna, Austria
| | - D Schallmayer
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Vienna, Austria
| | - D Kontic
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Vienna, Austria
| | - F Keller
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Vienna, Austria
| | - C Fialka
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Vienna, Austria.,Department for Traumatology, Sigmund Freud Medical University, Vienna, Austria
| |
Collapse
|
9
|
One-Stage Anatomical Revision Anterior Cruciate Ligament Reconstruction: Results According to Tunnel Overlaps. Arthroscopy 2021; 37:1223-1232. [PMID: 33242629 DOI: 10.1016/j.arthro.2020.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To present clinical results according to tunnel overlap in 1-stage anatomical revision anterior cruciate ligament reconstruction (ACLR). METHODS All patients who underwent revision ACLR performed by a single surgeon (J.H.A.) from 2012 to 2017 and were followed up for >24 months were retrospectively evaluated. The exclusion criteria were concomitant ligament injury, including medial collateral ligament injury, modified Outerbridge grade ≥3 cartilage lesion, and severe meniscus defects. Tunnel overlap was measured on 3-dimensionally reconstructed computed tomography images. Patients in the nonoverlapped femoral tunnel group (group NO, n = 52) were treated with new tunnel drilling that completely avoided previous tunnels, and those in the overlapped femoral tunnel group (group O, n = 41) were treated with a new tunnel that overlapped with previous tunnels. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) and Lysholm scores. Knee joint stability was measured using the Lachman and pivot shift tests. Patients with femoral tunnel widening of ≥14 mm underwent 2-stage ACLR. RESULTS The mean follow-up duration of 93 patients was 46.9 months (range, 24-97 months). All preoperative subjective and objective IKDC (P<0.001) and Telos stress test scores (P = .016) were significantly improved at the last follow-up. Forty-one patients had overlapping femoral tunnels, whereas 87 had overlapping tibial tunnels. At the last follow-up, subjective IKDC and Lysholm scores (73.6 ± 15.3 vs 74.9 ± 12.1, P = .799 and 80.0 ± 19.2 vs 81.44 ± 13.5, P = .505, respectively) and objective pivot shift (IKDC grade) in the Lachman test (P = .183 and P = .450, respectively) did not differ significantly between groups NO and O, respectively. CONCLUSIONS One-stage anatomical revision ACLR significantly improved the clinical results. Most tibial tunnels (94%) and approximately one-half (44%) of the femoral tunnels overlapped. The overlapped femoral tunnel group did not show inferior outcomes or stability. LEVEL OF EVIDENCE Level III, cohort study.
Collapse
|
10
|
|
11
|
|
12
|
Jorge PB, Escudeiro D, Severino NR, Santili C, de Paula Leite Cury R, Junior AD, Guglielmetti LGB. Positioning of the femoral tunnel in anterior cruciate ligament reconstruction: functional anatomical reconstruction. BMJ Open Sport Exerc Med 2018; 4:e000420. [PMID: 30305927 PMCID: PMC6173259 DOI: 10.1136/bmjsem-2018-000420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 01/14/2023] Open
Abstract
The aim of this study was to review and update the literature in regard to the anatomy of the femoral origin of the ACL, the concept of the double band and its respective mechanical functions, and the concept of direct and indirect fibres in the ACL insertion. These topics will be used to help determine which might be the best place to position the femoral tunnel and how this should be achieved, based on the idea of functional positioning, that is, where the most important ACL fibres in terms of knee stability are positioned. Low positioning of the femoral tunnel, reproducing more of the posterolateral band, and positioning the tunnel away from the lateral intercondylar ridge, that is, in the indirect fibres, would theoretically rebuild a ligament that is less effective in relation to knee stability. The techniques described to determine the femoral tunnel's centre point all involve some degree of subjectivity; the point is defined manually and depends on the surgeon's expertise. The centre of the ACL insertion in the femur should be used as a parameter. Once the centre of the ligament in its footprint is marked, the centre of the tunnel must be defined, drawing the marking toward the intercondylar ridge and anteromedial band. This will allow the femoral tunnel to occupy the region containing the most important original ACL fibres in terms of this ligament's function.
Collapse
Affiliation(s)
- Pedro Baches Jorge
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Diego Escudeiro
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Nilson Roberto Severino
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | - Cláudio Santili
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | | | - Aires Duarte Junior
- Departamento de Ortopedia e Traumatologia da, Irmandade da Santa Casa de Misericórdia de, São Paulo, Brazil
| | | |
Collapse
|
13
|
Zhu M, Li S, Su Z, Zhou X, Peng P, Li J, Wang J, Lin L. Tibial tunnel placement in anatomic anterior cruciate ligament reconstruction: a comparison study of outcomes between patient-specific drill template versus conventional arthroscopic techniques. Arch Orthop Trauma Surg 2018; 138:515-525. [PMID: 29380050 DOI: 10.1007/s00402-018-2880-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Accurate anatomic graft tunnel positioning is essential for the successful application of anatomic anterior cruciate ligament (ACL) reconstruction. The accurate insertion of the tibial tunnel (TT) remains challenging. Here, we explored a novel strategy of patient-specific drill template (PDT) for the placement of TT in ACL reconstruction and assessed its efficacy and accuracy. MATERIALS AND METHODS TT placement was randomized and performed by use of the PDT technique in 40 patients (PDT group) and the conventional arthroscopic technique in 38 patients (Arthroscopic group). After surgery, the deviations at the center point of the ACL tibial attachment area and radiological TT positioning were assessed in both groups. The preoperative and follow-up examinations included pivot-shift testing, KT-1000 arthrometer testing, the Lysholm and International Knee Documentation Committee scales were used to compare the knee stability and the functional state. RESULTS The ideal center points achieved in the PDT group were more precise than that in the arthroscopic group (p < 0.001). Radiological TT positioning performed by use of the PDT technique was more accurate than that by the arthroscopic technique (p = 0.027). Statistical differences could not be found between the groups in terms of the pivot-shift test, KT-1000 arthrometer laxity measurements, the Lysholm or International Knee Documentation Committee scales. Both groups improved at follow-up compared with the preoperative assessment in terms of the pivot-shift test, the laxity tests, and scoring scales. CONCLUSIONS The novel PDT strategy could provide more accurate TT positioning than the traditional arthroscopic technique in ACL reconstruction. However, functional scales and stability tests gave similar results in the PDT and the standard techniques. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Meisong Zhu
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Zhong Road, Guangzhou, Guangdong, China
| | - Sijing Li
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Zhong Road, Guangzhou, Guangdong, China
| | - Zexin Su
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Zhong Road, Guangzhou, Guangdong, China
| | - Xiaoqi Zhou
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Zhong Road, Guangzhou, Guangdong, China
| | - Peng Peng
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, 1023 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Jianyi Li
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, 1023 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Jinping Wang
- Department of Orthopedics, Qingyuan People's Hospital, B24 Xinchengyinquan Road, Qingcheng District, Qingyuan, Guangdong, China.
| | - Lijun Lin
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Zhong Road, Guangzhou, Guangdong, China.
| |
Collapse
|
14
|
Stress distribution is deviated around the aperture of the femoral tunnel in the anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:1145-1151. [PMID: 28401277 DOI: 10.1007/s00167-017-4543-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/04/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Final tunnel location in the anterior cruciate ligament (ACL) reconstruction is unpredictable due to tunnel widening and/or transposition. The mechanical stress around the tunnel aperture seems to be a major factor but is not fully investigated. The purpose of this study was to measure the stress from the ACL graft around the tunnel aperture when the ACL graft tension reaches its peak. METHODS Six cadaveric knees were used. Single-bundle ACL reconstruction was performed using a hamstrings graft. Both femoral and tibial tunnels were created at the centre of the original ACL footprint. A 7-mm-internal-diameter aluminium cylinder with pressure sensors was placed in the femoral tunnel. Hamstrings graft with a microtension sensor was inserted. After fixation, passive extension-flexion was performed while monitoring the tunnel aperture pressure and the graft tension simultaneously. The pressure on the femoral tunnel aperture when the ACL graft tension reach its peak was compared between four directions. RESULTS The ACL graft tension peaked (67 ± 49 N) at full extension (-5.8 ± 4.1°). Pressure at the femoral tunnel aperture was different between different directions (p < 0.01). Distal part had significantly larger pressure (1.7 ± 1.3 MPa) than the other directions (p < 0.01). Second largest pressure was carried in the anterior part (0.6 ± 0.5 MPa), followed by proximal and posterior parts (0.4 ± 0.3, 0.2 ± 0.2 MPa respectively). CONCLUSION The stress distribution at the femoral tunnel aperture is not equal in different directions, while the distal part dominantly bears the stress from the ACL graft. Surgeons should pay close attention to the distal edge of the femoral tunnel which should be inside the anatomic ACL footprint eventually.
Collapse
|
15
|
Achtnich A, Ranuccio F, Willinger L, Pogorzelski J, Imhoff AB, Braun S, Herbst E. High incidence of partially anatomic tunnel placement in primary single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:462-467. [PMID: 28439635 DOI: 10.1007/s00167-017-4555-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/19/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate tunnel position and width in failed primary single-bundle (SB) anterior cruciate ligament (ACL) reconstructions. It was hypothesized that both femoral and tibial bone tunnels are frequently malplaced in terms of a partially anatomic position in the setting of failed SB ACL reconstruction. METHODS Patients with recurrent instability following isolated SB ACL reconstruction using hamstring tendon autografts, undergoing revision ACL surgery, were retrospectively included. Further inclusion criteria were age >18 years and availability of preoperative computed tomography (CT) scans and radiographs of the affected knee. Patients with multiligamentous instabilities as well as incomplete or poor radiographs were excluded. Tunnel position was evaluated according to the method described by Harner et al. and Stäubli and Rauschning. Tunnel width was determined on CT scans perpendicular to the bone tunnel axis at three different heights of each bone tunnel. RESULTS Eighty-two patients met the inclusion criteria and were considered for radiological analysis. Femoral tunnels were graded as anatomic in 60% (49 of 82) of all cases. In the remaining 40% (33/82), 27% of the tunnels were placed partially anatomic and 13% were graded as non-anatomic. Tibial tunnel placement was found to be anatomic in 54% (44/82) of all cases, partially anatomic in 45% and non-anatomic in 1% of the cases. No statistically significant difference between anatomic or partially anatomic tunnel position and tunnel diameter, neither for the femoral nor for the tibial side, was observed (n.s.). CONCLUSION The present study demonstrates that there is a high incidence of partially anatomic placed tunnels in failed SB ACL reconstruction. Tunnel width was not associated with tunnel position. Clinically, partially anatomic bone tunnels frequently require a staged procedure with bone grafting and subsequent ACL revision surgery. Thus, surgeons should carefully analyse tunnel position and width preoperatively to properly plan ACL revision surgery.
Collapse
Affiliation(s)
- Andrea Achtnich
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Francesco Ranuccio
- Department of Orthopaedic and Trauma Surgery, Policlinico San Pietro, Ponte St. Pietro, Italy
| | - Lukas Willinger
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jonas Pogorzelski
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Sepp Braun
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Elmar Herbst
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
| |
Collapse
|
16
|
Kosy JD, Mandalia VI. Plain radiographs can be used for routine assessment of ACL reconstruction tunnel position with three-dimensional imaging reserved for research and revision surgery. Knee Surg Sports Traumatol Arthrosc 2018; 26:534-549. [PMID: 28224200 DOI: 10.1007/s00167-017-4462-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 01/30/2017] [Indexed: 01/14/2023]
Abstract
PURPOSE The position of the osseous tunnels and graft during anterior cruciate ligament (ACL) reconstruction has been the subject of multiple studies aiming for either anatomical placement or an alternative. The assessment of these positions, using post-operative imaging, is therefore of interest to the surgeon in both the evaluation of surgical performance and surveillance of potential complications. The purpose of this review is to identify the optimal use of imaging in both the surveillance of clinical practice and in planning revision surgery. METHODS A comprehensive systematic review was performed using Medline and Pubmed searches to identify radiological methods used to assess ACL reconstruction tunnel position. Commonly used methods were identified with correlation to either native anatomy or clinical results. RESULTS The findings suggest that plain radiographs can be used to assess tunnel position and identify grafts that are positioned non-anatomically and may be at increased risk of complications. Computer tomography (CT) offers additional information about the tunnel aperture shape and size that is of importance for revision surgery and research projects whilst magnetic resonance imaging (MRI) provides further assessment of both graft integrity and associated soft tissue damage. CONCLUSION In the surveillance of routine clinical practice, plain radiographs are sufficient to define tunnel position. The additional information provided by three-dimensional imaging is only required in revision surgery or research studies. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Jonathan David Kosy
- ST8 Registrar in Trauma and Orthopaedics, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.
| | - Vipul I Mandalia
- Consultant Orthopaedic Surgeon with Specialist Interest in Knee Surgery, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, EX2 5DW, UK
| |
Collapse
|
17
|
Biazzo A, Manzotti A, Motavalli K, Confalonieri N. Femoral press-fit fixation versus interference screw fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: 20-year follow-up. J Clin Orthop Trauma 2018; 9:116-120. [PMID: 29896012 PMCID: PMC5995157 DOI: 10.1016/j.jcot.2018.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/21/2017] [Accepted: 02/22/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this paper is to present our experience with femoral press-fit fixation in anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft. METHODS The patient population was randomly placed in two groups: group A (58 patients), who underwent femoral screw fixation; group B (62 patients), who underwent femoral press-fit fixation. RESULTS At last follow-up 9.2% of patients were lost; 28% of patients in group A and 64% of patients in group B had excellent International Knee Documentation Committee score (grade A); 66% of patients in group A and 32% of patients in group B had good International Knee Documentation Committee scores (grade B). The difference was statistically significant (p < 0.05). CONCLUSIONS Femoral press-fit fixation of bone- patellar tendon- bone autograft provides stable fixation at low cost, it ensures unlimited bone-to-bone healing and high primary stability, avoiding the disadvantages of hardware and the need for removal in case of revision.
Collapse
Affiliation(s)
- A. Biazzo
- Orthopaedic Department, ASST Gaetano Pini-CTO, via Bignami 1, 20126 Milano, Italy
- Corresponding author.
| | - A. Manzotti
- Orthopaedic Department, Ospedale Luigi Sacco, Via Giovanni Battista Grassi, 74, 20157 Milano, Italy
| | - K. Motavalli
- Orthopaedic Department, ASST Gaetano Pini-CTO, via Bignami 1, 20126 Milano, Italy
| | - N. Confalonieri
- Orthopaedic Department, ASST Gaetano Pini-CTO, via Bignami 1, 20126 Milano, Italy
| |
Collapse
|
18
|
Luites JWH, Verdonschot N. Radiographic positions of femoral ACL, AM and PL centres: accuracy of guidelines based on the lateral quadrant method. Knee Surg Sports Traumatol Arthrosc 2017; 25:2321-2329. [PMID: 26142164 DOI: 10.1007/s00167-015-3681-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 06/18/2015] [Indexed: 01/01/2023]
Abstract
PURPOSE Femoral tunnel positioning is an important factor in anatomical ACL reconstructions. To improve accuracy, lateral radiographic support can be used to determine the correct tunnel location, applying the quadrant method. Piefer et al. (Arthroscopy 28:872-881, 2012) combined various outcomes of eight studies applying this method to one guideline. The studies included in that guideline used various insertion margins, imaging techniques and measurement methods to determine the position of the ACL centres. The question we addressed is whether condensing data from various methods into one guideline, results in a more accurate guideline than the results of one study. METHODS The accuracy of the Piefer's guideline was determined and compared to a guideline developed by Luites et al. (2000). For both guidelines, we quantified the mean absolute differences in positions of the actual anatomical centres of the ACL, AM and PL measured on the lateral radiographs of twelve femora with the quadrant method and the positions according to the guidelines. RESULTS The accuracy of Piefer's guidelines was 2.4 mm (ACL), 2.7 mm (AM) and 4.6 mm (PL), resulting in positions significantly different from the actual anatomical centres. Applying Luites' guidelines for ACL and PL resulted in positions not significantly different from the actual centres. The accuracies were 1.6 mm (ACL) and 2.2 mm (PL and AM), which were significantly different from Piefer for the PL centres, and therefore more accurate. CONCLUSIONS Condensing the outcomes of multiple studies using various insertion margins, imaging techniques and measurement methods, results in inaccurate guidelines for femoral ACL tunnel positioning at the lateral view. CLINICAL RELEVANCE An accurate femoral tunnel positioning for anatomical ACL reconstruction is a key issue. The results of this study demonstrate that averaging of various radiographic guidelines for anatomical femoral ACL tunnel placement in daily practice, can result in inaccurate tunnel positions. LEVEL OF EVIDENCE Diagnostic study, Level 1.
Collapse
Affiliation(s)
- Joan W H Luites
- Sint Maartenskliniek Research, P.O. Box 9011, 6500 GM, Nijmegen, The Netherlands.
| | - Nico Verdonschot
- Orthopaedic Research Lab, Radboud University Medical Center, Nijmegen, The Netherlands
- Laboratory for Biomechanical Engineering, University of Twente, Enschede, The Netherlands
| |
Collapse
|
19
|
Irarrázaval S, Albers M, Chao T, Fu FH. Gross, Arthroscopic, and Radiographic Anatomies of the Anterior Cruciate Ligament. Clin Sports Med 2017; 36:9-23. [DOI: 10.1016/j.csm.2016.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
20
|
Functional outcome after transphyseal anterior cruciate ligament reconstruction in young patients with open growth plates. Knee 2016; 23:1121-1132. [PMID: 27717626 DOI: 10.1016/j.knee.2016.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 08/23/2016] [Accepted: 09/01/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study evaluates sports ability, rotational laxity and potential growth changes in children after transphyseal ACL reconstruction with metaphyseal fixation technique, considering physis biology by placing drill holes vertically in the femoral anatomic origin in order to reduce volumetric injury to the physis. METHODS In this retrospective trial of 42 patients data were collected. Thirty-seven were reviewed measuring rotational laxity and anteroposterior tibial translation using the Laxitester (ORTEMA Sport Protection, Markgroeningen, Germany) and the KT1000. Clinical examination was evaluated with the IKDC 2000 knee examination form. Leg axis was determined with digital photography and leg length was assessed clinically. Sports ability was assessed with questionnaires including subjective IKDC, Tegner Activity Scale, Activity Rating Scale and a questionnaire on sports and level of sports. RESULTS Mean follow-up was 24.9months. Mean age at surgery was 13.2years in boys and 13.1years in girls. IKDC 2000 grading was A or B in 28 patients and C in nine patients. Significant increased anterior tibial translation was observed in neutral position and in external tibia rotation. No growth abnormalities were seen. Fifty-seven percent of the patients were able to participate in competitive sports at follow-up. CONCLUSION Transphyseal ACL reconstruction with metaphyseal fixation in children with open growth plates can be done with low risk of growth changes. Return to competitive sports is possible although low rotational laxity still exists. LEVEL OF EVIDENCE IV.
Collapse
|
21
|
Radiographic assessment of the postoperative knee. Clin Imaging 2016; 42:68-82. [PMID: 27889679 DOI: 10.1016/j.clinimag.2016.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/04/2016] [Accepted: 11/16/2016] [Indexed: 11/21/2022]
Abstract
Radiologists often encounter postoperative knee radiographs lacking any adjunct clinical data which might hinder accurate image interpretation. Surgical techniques are constantly evolving with new devices being used which make it sometimes challenging for the radiologist to deduce the performed procedure and to look for associated complications. This article reviews commonly performed surgical procedures of the knee, highlights their expected postoperative radiographic appearance and describes the appearance of certain postoperative complications.
Collapse
|
22
|
Salzler MJ, Harner CD. Tunnel Placement for the ACL During Reconstructive Surgery of the Knee: A Critical Analysis Review. JBJS Rev 2016; 2:01874474-201404000-00003. [PMID: 27490873 DOI: 10.2106/jbjs.rvw.m.00054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Matthew J Salzler
- UPMC Center for Sports Medicine, 3200 South Water Street, Pittsburgh, PA 15203
| | | |
Collapse
|
23
|
Kim DH, Lim WB, Cho SW, Lim CW, Jo S. Reliability of 3-Dimensional Computed Tomography for Application of the Bernard Quadrant Method in Femoral Tunnel Position Evaluation After Anatomic Anterior Cruciate Ligament Reconstruction. Arthroscopy 2016; 32:1660-6. [PMID: 27090722 DOI: 10.1016/j.arthro.2016.01.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/22/2015] [Accepted: 01/21/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To validate whether the Bernard quadrant method, which was developed for application on simple lateral radiography, can be used with 3-dimensional computed tomography (3D CT) to localize the femoral insertion of the reconstructed anterior cruciate ligament (ACL). METHODS We analyzed 32 knees with ACL tears that were reconstructed using a metal interference screw for fixation at the femoral tunnel between March 2012 and May 2013. Postoperative lateral radiographs and 3D CT images were obtained 7 days after the operation. By use of the Bernard quadrant method, the location of the femoral tunnel was measured by 2 orthopaedic surgeons by locating the position of the metal interference screw using 3D CT imaging and simple lateral knee radiography. The correlation between the femoral tunnels on the 2 radiographic images was compared using the MedCalc statistical analysis program. RESULTS On the 3D CT image, the position of the femoral insertion of the ACL as measured by the position of the metal screw head was 36.3% ± 6.0% in the x-coordinate and 39.6% ± 9.1% in the y-coordinate compared with 37.6% ± 5.8% and 41.0% ± 11.6%, respectively, on the simple radiograph. The Pearson correlation coefficients between 3D CT and simple radiography were 0.840 for the x-coordinate and 0.858 for the y-coordinate. Intraobserver reliability and interobserver reliability for both coordinates were greater than 0.9 on 3D CT. CONCLUSIONS Application of the Bernard quadrant method on 3D CT showed high correlation to the originally described method using lateral radiographs and can be used reliably for localizing the reconstructed ACL. LEVEL OF EVIDENCE Level III, diagnostic study.
Collapse
Affiliation(s)
- Dong Hwi Kim
- Department of Orthopaedic Surgery, School of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Won-Bong Lim
- Department of Orthopaedic Surgery, School of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Sung-Won Cho
- Department of Orthopaedic Surgery, School of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Chae-Won Lim
- Department of Orthopaedic Surgery, School of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Suenghwan Jo
- Department of Orthopaedic Surgery, School of Medicine, Chosun University, Gwangju, Republic of Korea.
| |
Collapse
|
24
|
Yanasse RH, Lima AA, Antoniassi RS, Ezzedin DA, Laraya MHF, Mizobuchi RR. Transtibial technique versus two incisions in anterior cruciate ligament reconstruction: tunnel positioning, isometricity and functional evaluation. Rev Bras Ortop 2016; 51:274-81. [PMID: 27274480 PMCID: PMC4887439 DOI: 10.1016/j.rboe.2016.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 04/24/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To compare the transtibial and two-incision techniques for anterior cruciate ligament (ACL) reconstruction using a single band. METHODS A prospective and randomized study was conducted in blocks. Patients underwent ACL reconstruction by means of two techniques: transtibial (group 1: 20 patients) or two incisions (group 2: 20 patients). The radiographic positioning of the tunnel, inclination of the graft, graft isometricity and functional results (IKDC and Lysholm) were evaluated. RESULTS The positioning of the femoral tunnel on the anteroposterior radiograph, expressed as a mean percentage relative to the medial border of the tibial plateau, was 54.6% in group 1 and 60.8% in group 2 (p < 0.05). The positioning of the femoral tunnel on the lateral radiograph, expressed as a mean percentage relative to the anterior border of Blumensaat's line, was 68.4% in group 1 and 58% in group 2 (p < 0.05). The mean inclination of the graft was 19° in group 1 and 27.2° in group 2 (p < 0.05). The mean graft isometricity was 0.96 mm in group 1 and 1.33 mm in group 2 (p > 0.05). Group 2 had better results from the pivot-shift maneuver (p < 0.05). CONCLUSION The technique of two incisions allowed positioning of the femoral tunnel that was more lateralized and anteriorized, such that the graft was more inclined and there was a clinically better result from the pivot-shift maneuver. There was no difference in isometricity and no final functional result over the short follow-up time evaluated.
Collapse
|
25
|
Técnica transtibial versus duas incisões na reconstrução do ligamento cruzado anterior: posicionamento dos túneis, isometricidade e avaliação funcional. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
26
|
Galdi B, Reyes A, Brabston EW, Levine WN. Autologous Hamstring Anterior Cruciate Ligament Graft Failure Using the Anteromedial Portal Technique With Suspensory Femoral Fixation: A Case Series of 7 Patients. Orthop J Sports Med 2015; 3:2325967114566599. [PMID: 26535370 PMCID: PMC4555582 DOI: 10.1177/2325967114566599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint. Furthermore, suspensory fixation of soft tissue grafts has become popularized because of complications associated with cross-pin fixation. Concerns regarding the use of both have recently arisen. PURPOSE To raise awareness of the increased risk of graft failure when using the anteromedial portal technique with suspensory femoral fixation during ACL reconstruction. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS From November 1998 to August 2012, a total of 465 primary ACL reconstructions were performed using quadrupled hamstring autograft tendons, with drilling of the femoral tunnel performed via the transtibial portal. Graft fixation on the femur was achieved with cross-pin fixation, while interference screw fixation was used on the tibia. From September 2012 to October 2013, there were 69 reconstructions performed through an anteromedial portal. While there was no change in graft choice, a change was made to using suspensory femoral fixation. No other surgical or postoperative rehabilitation changes were made. RESULTS During the 14-year period in which ACL reconstructions were performed via the transtibial portal and with cross-pin fixation, 2 graft failures (0.4% failure rate) were reported. After switching to the anteromedial portal with suspensory fixation, 7 graft failures (10.1% failure rate) were reported over a 13-month period. These were 5 male and 2 female patients, with a mean age of 18.8 years-all elite athletes. The same surgical technique was used in all patients, and all patients had at least an 8 mm-diameter graft. Patients were cleared to return to sport at an average of 8.4 months postoperatively, after completing functional performance tests. Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition. The final patient sustained a rerupture 10 months after being cleared to play. CONCLUSION Compared with the transtibial technique with cross-pin graft fixation, there is an increased risk of graft failure when performing autologous hamstring ACL reconstructions using the anteromedial portal technique with cortical suspensory fixation.
Collapse
Affiliation(s)
- Balazs Galdi
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Allan Reyes
- New York Presbyterian/Columbia University Medical Center, New York, New York, USA
| | | | - William N Levine
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
27
|
Wei J, Yang HB, Qin JB, Yang TB. A meta-analysis of anterior cruciate ligament reconstruction with autograft compared with nonirradiated allograft. Knee 2015; 22:372-9. [PMID: 25991542 DOI: 10.1016/j.knee.2014.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 05/10/2014] [Accepted: 06/06/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND To compare autograft with non-irradiated allograft for reconstruction of anterior cruciate ligament. METHODS MEDLINE, EMBASE, and Cochrane Library databases, as well as unpublished and ongoing studies were searched through up to 20 July 2013 to identify studies meeting the pre-stated inclusion criteria. RESULTS A total of 12 studies (n=1167, including 597 patients in the autograft group and 570 patients in the allograft group) were included. The methodological scores for randomized controlled trials ranged from two to four (total score: seven), and for non-randomized prospective studies and cohort studies ranged from four to seven (total score: 12). Except for the Lysholm score (WMD, -1.46; P<0.05) showing a statistically significant difference but a small and clinically irrelevant difference, there was no significant difference between autograft and non-irradiated allograft with respect to the overall IKDC (International Knee Documentation Committee) level, subjective IKDC score, Tegner score, complication, ROM (range of motion), Pivot-shift test, Anterior drawer test, Lachman test, Daniel's one-leg hop test, Harner's vertical jump test, and Instrumented knee laxity test. The results were consistent across a series of sensitivity analyses and subgroup analyses. CONCLUSIONS Patients with autograft exhibited little clinical advantage over non-irradiated allograft with respect to knee stability, function and side effects. The robustness of the findings might need to be further validated due to the relatively small number of randomized controlled trials. LEVEL OF EVIDENCE Level II, meta-analysis of prospective studies.
Collapse
Affiliation(s)
- Jie Wei
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan Province 410008, China
| | - Hao-bin Yang
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan Province 410008, China
| | - Jia-bi Qin
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan Province 410008, China
| | - Tu-bao Yang
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan Province 410008, China.
| |
Collapse
|
28
|
Sven S, Maurice B, Hoeher J, Marc B. Variability of tunnel positioning in fluoroscopic-assisted ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:2269-2277. [PMID: 24817162 DOI: 10.1007/s00167-014-3029-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/19/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE Intraoperative fluoroscopy has been proposed as a feasible method to improve the accuracy of anatomical tunnel positioning. However, it has so far not been determined, whether this technique reduces the variability of tunnel positioning in a clinical set-up. Therefore, the purpose of this study was to determine the variability of tunnel positions applying intraoperative fluoroscopy. METHODS Femoral and tibial tunnel positions of 112 fluoroscopic ACL reconstruction cases were determined according to validated radiological measurement methods. Mean positions, standard deviations and ranges were calculated to determine the variability of the tunnel positions. Subgroup variability analysis was performed to analyse cases in which tunnel positions were corrected. RESULTS Applying intraoperative fluoroscopy, the variability of tunnel positions was found to be 3 % at the femur (range 15.4 %) and 2.3 % at the tibia (9.7 %). In 34 cases (30.0 %), non-satisfactory tunnel positions were identified and could be corrected achieving more accurate positions regarding to radiological parameters (14× femur, 16× tibia, 4× femur and tibia). CONCLUSIONS The results of the presented study indicate that intraoperative fluoroscopy allows to identify non-accurate tunnel positions regarding to radiological criteria. The determined low variability indicates that fluoroscopic-based ACL reconstruction can be recommended as a feasible, easy and effective adjunct that enables surgeons to create more consistent and reliable tunnel positions in ACL reconstruction. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Shafizadeh Sven
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany.
| | - Balke Maurice
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Juergen Hoeher
- Orthopaedics and Sports Traumatology, Cologne Merheim Medical Centre, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Banerjee Marc
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| |
Collapse
|
29
|
Palmieri-Smith RM, Lepley LK. Quadriceps Strength Asymmetry After Anterior Cruciate Ligament Reconstruction Alters Knee Joint Biomechanics and Functional Performance at Time of Return to Activity. Am J Sports Med 2015; 43:1662-9. [PMID: 25883169 PMCID: PMC4758854 DOI: 10.1177/0363546515578252] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quadriceps strength deficits are observed clinically after anterior cruciate ligament (ACL) injury and reconstruction and are often not overcome despite rehabilitation. Given that quadriceps strength may be important for achieving symmetrical joint biomechanics and promoting long-term joint health, determining the magnitude of strength deficits that lead to altered mechanics is critical. PURPOSE To determine if the magnitude of quadriceps strength asymmetry alters knee and hip biomechanical symmetry as well as functional performance and self-reported function. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 73 patients were tested at the time they were cleared for return to activity after ACL reconstruction. Quadriceps strength and activation, scores on the International Knee Documentation Committee form, the hop for distance test, and sagittal plane lower extremity biomechanics were recorded while patients completed a single-legged hop. RESULTS Patients with high and moderate quadriceps strength symmetry had larger central activation ratios as well as greater limb symmetry indices on the hop for distance compared with patients with low quadriceps strength symmetry (P < .05). Similarly, knee flexion angle and external moment symmetry were higher in the patients with high and moderate quadriceps symmetry compared with those with low symmetry (P < .05). Quadriceps strength was found to be associated with sagittal plane knee angle and moment symmetry (P < .05). CONCLUSION Patients with low quadriceps strength displayed greater movement asymmetries at the knee in the sagittal plane. Quadriceps strength was related to movement asymmetries and functional performance. Rehabilitation after ACL reconstruction needs to focus on maximizing quadriceps strength, which likely will lead to more symmetrical knee biomechanics.
Collapse
Affiliation(s)
- RM Palmieri-Smith
- School of Kinesiology, University of Michigan, 401 Washtenaw Avenue, Ann Arbor, MI 48109-2214,Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48109
| | - LK Lepley
- School of Kinesiology, University of Michigan, 401 Washtenaw Avenue, Ann Arbor, MI 48109-2214,Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY 40536
| |
Collapse
|
30
|
Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc 2015; 23:640-8. [PMID: 25086574 DOI: 10.1007/s00167-014-3209-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 07/22/2014] [Indexed: 02/07/2023]
Abstract
Injury to the anterior cruciate ligament (ACL) of the knee is potentially devastating for the patient and can result in both acute and long-term clinical problems. Consequently, the ACL has always been and continues to be of great interest to orthopaedic scientists and clinicians worldwide. Major advancements in ACL surgery have been made in the past few years. ACL reconstruction has shifted from an open to arthroscopic procedure, in which a two- and later one-incision technique was applied. Studies have found that traditional, transtibial arthroscopic single-bundle reconstruction does not fully restore rotational stability of the knee joint, and as such, a more anatomic approach to ACL reconstruction has emerged. The goal of anatomic ACL reconstruction is to replicate the knee's normal anatomy and restore its normal kinematics, all while protecting long-term knee health. This manuscript describes the research that has changed the paradigm of ACL reconstruction from traditional techniques to present day anatomic and individualized concepts.
Collapse
|
31
|
The Impact of the Multicenter Orthopaedic Outcomes Network (MOON) Research on Anterior Cruciate Ligament Reconstruction and Orthopaedic Practice. J Am Acad Orthop Surg 2015; 23:154-63. [PMID: 25667401 PMCID: PMC4344406 DOI: 10.5435/jaaos-d-14-00005] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction.
Collapse
|
32
|
Shafizadeh S, Balke M, Kelz S, Hoeher J, Banerjee M. Low inter- and intraobserver variability allows for reliable tunnel measurement in ACL reconstruction using the quadrant method. Arch Orthop Trauma Surg 2014; 134:529-36. [PMID: 24477290 DOI: 10.1007/s00402-014-1931-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Correct anatomic tunnel positions are essential in anterior cruciate ligament (ACL) reconstruction. To establish recommendations for tunnel positioning based on anatomical findings and to compare tunnel positions with clinical results, different radiological measurement methods as the quadrant method exist. Comparing the data of different observers requires the validation of the reliability of measurement methods. The purpose of this study therefore was to determine the reliability of the quadrant method to measure tunnel positions in ACL reconstruction. The hypothesis was, that the quadrant method shows a low inter- and intraobserver variability. MATERIALS AND METHODS In a test/retest scenario 20 knee surgeons were asked to determine defined tunnel positions in five lateral radiographs applying the quadrant method. Rotation, angle deviation, height and depth of the quadrant as well as absolute and relative tunnel positions of each observation were measured along referenced scales. Mean sizes and angle deviations of the quadrants, tunnel positions and deviations between the test/retest positions were calculated as well as standard deviations and range. RESULTS Interobserver variability analyses, to plan as well as to determine tunnel positions in ACL reconstruction, showed a mean variability (SD) of <1 mm, with ranges of 2.5 mm for planning and 3.7 mm for determination of tunnel positions using the quadrant method. Intraobserver analysis showed mean variability with deviations of <1 mm and maximum standard deviations of 0.7 mm and ranges of up to 2.3 mm. CONCLUSIONS We confirmed the hypothesis that the quadrant method has a low inter- and intraobserver variability. Based on the presented validation data, the quadrant method can be recommended as reliable method to radiographically describe insertion areas of the ACL as well as to determine tunnel positions in ACL reconstruction intra and postoperatively.
Collapse
Affiliation(s)
- Sven Shafizadeh
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany,
| | | | | | | | | |
Collapse
|
33
|
Vieira RB, De Pinho Tavares LA, Pace Lasmar RC, Da Cunha FA, De Melo Lisboa LA. Análise radiológica do posicionamento do túnel femoral com as técnicas de reconstrução isométrica ou de reconstrução anatômica do LCA. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
34
|
Vieira RB, de Pinho Tavares LA, Pace Lasmar RC, da Cunha FA, de Melo Lisboa LA. Radiological analysis on femoral tunnel positioning between isometric and anatomical reconstructions of the anterior cruciate ligament. Rev Bras Ortop 2014; 49:160-6. [PMID: 26229793 PMCID: PMC4511654 DOI: 10.1016/j.rboe.2014.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 02/08/2013] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE the aim of this study was to radiologically evaluate the femoral tunnel position in anterior cruciate ligament (ACL) reconstructions using the isometric and anatomical techniques. METHODS a prospective analytical study was conducted on patients undergoing ACL reconstruction by means of the isometric and anatomical techniques, using grafts from the knee flexor tendons or patellar tendon. Twenty-eight patients were recruited during the immediate postoperative period, at the knee surgery outpatient clinic of FCMMG-HUSJ. Radiographs of the operated knee were produced in anteroposterior (AP) view with the patient standing on both feet and in lateral view with 30° of flexion. The lines were traced out and the distances and angles were measured on the lateral radiograph to evaluate the sagittal plane. The distance from the center of the screw to the posterior cortical bone of the lateral condyle was measured and divided by the Blumensaat line. In relation to the height of the screw, the distance from the center of the screw to the joint surface of the lateral condyle of the knee was measured. On the AP radiograph, evaluating the coronal plane, the angle between the anatomical axis of the femur and a line traced at the center of the screw was measured. RESULTS with regard to the p measurement (posteriorization of the interference screw), the tests showed that the p-value (0.4213) was greater than the significance level used (0.05); the null hypothesis was not rejected and it could be stated that there was no statistically significant difference between the anatomical and isometric techniques. With regard to the H measurement (height of the screw in relation to the lower cortical bone of the knee), the p-value observed (0.0006) was less than the significance level used (0.05); the null hypothesis was rejected and it could be stated that there was a statistically significant difference between the anatomical and isometric techniques. It can be concluded that the latter difference occurred because the isometric technique generated greater values for the H measurement than the anatomical technique. With regard to the MED variable (position of the screw on the AP radiograph), the observed p-value (0.000) was less than the significance level (5%); the null hypothesis was rejected and it could be stated with 95% confidence that there was a significant difference between the anatomical and isometric techniques. CONCLUSIONS there were statistically significant differences in the radiological evaluations of the femoral tunnel, both in the sagittal and in the coronal plane, between the ACL reconstruction techniques.
Collapse
Affiliation(s)
- Rodrigo Barreiros Vieira
- Orthopedics and Traumatology Service, Faculdade de Ciências Médicas de Minas Gerais, Hospital Universitário São José, Belo Horizonte, MG, Brazil
| | | | | | | | | |
Collapse
|
35
|
Yang JH, Chang M, Kwak DS, Jang KM, Wang JH. In vivo three-dimensional imaging analysis of femoral and tibial tunnel locations in single and double bundle anterior cruciate ligament reconstructions. Clin Orthop Surg 2014; 6:32-42. [PMID: 24605187 PMCID: PMC3942600 DOI: 10.4055/cios.2014.6.1.32] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 04/08/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Anatomic footprint restoration of anterior cruciate ligament (ACL) is recommended during reconstruction surgery. The purpose of this study was to compare and analyze the femoral and tibial tunnel positions of transtibial single bundle (SB) and transportal double bundle (DB) ACL reconstruction using three-dimensional computed tomography (3D-CT). METHODS In this study, 26 patients who underwent transtibial SB ACL reconstruction and 27 patients with transportal DB ACL reconstruction using hamstring autograft. 3D-CTs were taken within 1 week after the operation. The obtained digital images were then imported into the commercial package Geomagic Studio v10.0. The femoral tunnel positions were evaluated using the quadrant method. The mean, standard deviation, standard error, minimum, maximum, and 95% confidence interval values were determined for each measurement. RESULTS The femoral tunnel for the SB technique was located 35.07% ± 5.33% in depth and 16.62% ± 4.99% in height. The anteromedial (AM) and posterolateral (PL) tunnel of DB technique was located 30.48% ± 5.02% in depth, 17.12% ± 5.84% in height and 34.76% ± 5.87% in depth, 45.55% ± 6.88% in height, respectively. The tibial tunnel with the SB technique was located 45.43% ± 4.81% from the anterior margin and 47.62% ± 2.51% from the medial tibial articular margin. The AM and PL tunnel of the DB technique was located 33.76% ± 7.83% from the anterior margin, 45.56% ± 2.71% from the medial tibial articular margin and 53.19% ± 3.74% from the anterior margin, 46.00% ± 2.48% from the medial tibial articular margin, respectively. The tibial tunnel position with the transtibial SB technique was located between the AM and PL tunnel positions formed with the transportal DB technique. CONCLUSIONS Using the 3D-CT measuring method, the location of the tibia tunnel was between the AM and PL footprints, but the center of the femoral tunnel was at more shallow position from the AM bundle footprint when ACL reconstruction was performed by the transtibial SB technique.
Collapse
Affiliation(s)
- Jae-Hyuk Yang
- Department of Orthopedic Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Minho Chang
- Department of Mechanical Engineering, Korea University, Seoul, Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ki-Mo Jang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
36
|
The influence of femoral tunnel position in single-bundle ACL reconstruction on functional outcomes and return to sports. Knee Surg Sports Traumatol Arthrosc 2014; 22:97-103. [PMID: 23132410 DOI: 10.1007/s00167-012-2288-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 10/26/2012] [Indexed: 12/28/2022]
Abstract
PURPOSE The purpose of this study was to radiographically investigate the influence of femoral tunnel placement in ACL reconstruction on early outcomes and return to sports due to anatomic and nonanatomic positioning. METHODS A prospective study was conducted from 2008 to 2010, with 86 athletes who underwent ACL reconstruction between anteromedial (AM) footprint and high AM position. Knee functional outcomes (IKDC objective and subjective, Tegner score, and Lysholm scale) return to sports and complications were analyzed at 6- and 12-month follow-up. RESULTS At follow-up, it was observed that tunnel projection along Blumensaat's line was correlated with functional outcomes on Tegner scale (at 6 and 12 months) and IKDC subjective (at 12 months). There was a significant difference in mean tunnel projection along Blumensaat's line when analyzing return to sports (73 ± 1.4 and 79 ± 1.7 %, respectively, for projections on return vs. no return to sports, p = 0.02) and complications (73 ± 1.3 vs. 78 ± 1.6 %, respectively, for projections on no complications vs. complications, p = 0.03). No differences were stated on coronal view. These correlations between tunnel positioning on functional outcomes could not be explained by demographic or baseline characteristics. CONCLUSION The clinical relevance of this study is that tunnel positioning along AM footprint and high AM position represented by tunnel projection along Blumensaat's line is associated with early return to sports on previous Tegner level and better functional outcome in athletes.
Collapse
|
37
|
Radiological evaluation for conflict of the femoral tunnel entrance area prior to anterior cruciate ligament revision surgery. INTERNATIONAL ORTHOPAEDICS 2013; 38:607-15. [PMID: 24158238 DOI: 10.1007/s00264-013-2126-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/14/2013] [Indexed: 01/23/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) revision surgery is a demanding procedure and requires meticulous pre-operative clinical and radiological assessment. In clinical practice the position of the femoral tunnel is identified mainly using plain radiographs (XR). Two-dimensional computed tomography (2D-CT) and magnetic resonance imaging (MRI) are not yet routine imaging methods and are only performed in specific clinical indications or in the scientific setting. Several measurement methods describe the femoral tunnel after ACL reconstruction and indicate 'ideal or wrong' placement to the surgeon. The aim of this study is to provide a reliable measurement method to predict potential conflict between the pre-existing and the planned femoral tunnel entrance area (FTEA). METHODS Ten patients with primary ACL reconstruction served as a reference group to describe our desired FTEA. Their femoral tunnel positioning was measured on XR and 2D-CT according to published measurement methods. These results were compared to the FTEA measured with a new technique on 3-dimensionally reconstructed CT-images (3D-CT) based on intra-operative landmarks. Twenty patients requiring ACL revision surgery underwent identical radiological examination. The mean values of the reference group were compared to each measurement of the patients requiring revision surgery. RESULTS 3D-CT measurements found potential conflicts in nine out of 20 patients, which all proved to be true during arthroscopic revision surgery. Only one of these patients was identified in all XR and 2D-CT measurements. In 12 out of all 30 patients some measurements on XR or 2D-CT could not be recorded. CONCLUSION 3D-CT reconstruction shows the most accuracy in depicting conflict of the pre-existing and desired femoral tunnel prior to ACL revision surgery. The desired FTEA must be defined for each surgeon and his individual technique. In contrast, precision of conventional measurement techniques on XR and 2D-CT is low and does not qualify for this purpose.
Collapse
|
38
|
Ferraz V, Westerberg P, Brand JC. Anterior cruciate ligament femoral socket drilling with a retrograde reamer: lessons from the learning curve. Arthrosc Tech 2013; 2:e389-93. [PMID: 24400187 PMCID: PMC3882701 DOI: 10.1016/j.eats.2013.06.007] [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: 03/16/2013] [Accepted: 06/11/2013] [Indexed: 02/03/2023] Open
Abstract
Whereas "anatomic" anterior cruciate ligament reconstruction may improve clinical results, the technique has introduced new technical challenges. The purpose of this technical note and video is to explore tips and tricks that improve femoral socket drilling with a retrograde reamer, bone-patellar tendon-bone graft passage, and interference screw fixation. The techniques for retrograde femoral socket drilling in an inside-out direction, bone-patellar tendon-bone graft passage, and interference screw fixation are described and demonstrated. Pitfalls, troubleshooting tips, and possible solutions are discussed. With the retrograde reamer, the femoral socket can be placed in the footprint of the anterior cruciate ligament with a longer and more vertical tunnel. By modifying the size of the patellar bone plug, graft passage is improved. With care and technique, interference screw fixation in the femoral socket over a guidewire is possible.
Collapse
Affiliation(s)
- Victor Ferraz
- Metropolitan University of Santos, Santos, Brazil, U.S.A
| | - Paul Westerberg
- Heartland Orthopedic Specialists, Alexandria, Minnesota, U.S.A
| | - Jefferson C. Brand
- Heartland Orthopedic Specialists, Alexandria, Minnesota, U.S.A.,Address correspondence to Jefferson C. Brand, M.D., Heartland Orthopedic Specialists, 111 17th Ave E, Ste 101, Alexandria, MN 56308, U.S.A.
| |
Collapse
|
39
|
Tunnel widening after anatomic double-bundle and mid-position single-bundle anterior cruciate ligament reconstruction. Arthroscopy 2013; 29:1514-24. [PMID: 23992989 DOI: 10.1016/j.arthro.2013.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the amount of postoperative bone tunnel enlargement after anatomic double-bundle (DB) and single-bundle (SB) anterior cruciate ligament (ACL) reconstruction 6 to 8 months after surgery. METHODS Twenty-one consecutive patients undergoing anatomic 4-tunnel DB ACL reconstruction and 24 patients undergoing anatomic 2-tunnel SB ACL reconstruction were included in this study. In both groups a hybrid fixation technique with interference screw and extracortical fixation at the tibia and an extracortical fixation technique at the femur were used. Magnetic resonance imaging was performed on the second postoperative day and at a mean of 8 months' follow-up (range, 6.8 to 8.3 months) to assess intraoperative and postoperative bone tunnel enlargement. Tunnel widening was determined in different planes by digitally measuring the diameters of the bone tunnels. Tunnel position was measured and classified according to Harner et al. (femoral) and Stäubli et al. and Petersen et al. (tibial). RESULTS Magnetic resonance imaging showed that all bone tunnels were anatomically placed within the area of the original ACL insertion zone. Compared with the intraoperative drill diameter, we observed only a slight increase in tunnel diameter in both groups on the second postoperative day. At 8 months postoperatively, significant bone tunnel widening occurred in all bone tunnels (P < .001). However, no significant differences were found between tunnel enlargement in the DB group and tunnel enlargement in the SB group (P > .05), either on the tibial side or on the femoral side. In 2 cases tibial tunnel communication was noted at follow-up. CONCLUSIONS With the use of anatomic SB and DB ACL reconstruction techniques, the results of bone tunnel enlargement were comparable; no significant difference was observed between the tibial and femoral tunnels. LEVEL OF EVIDENCE Level III, prospective comparative study.
Collapse
|
40
|
Abstract
The Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) group was developed to investigate revision ACL reconstruction outcomes. An important part of this is obtaining and reviewing radiographic studies. The goal for this radiographic analysis is to establish radiographic findings for a large revision ACL cohort to allow comparison with future studies. The study was designed as a cohort study. Various established radiographic parameters were measured by three readers. These included sagittal and coronal femoral and tibial tunnel position, joint space narrowing, and leg alignment. Inter- and intraobserver comparisons were performed. Femoral sagittal position demonstrated 42% were more than 40% anterior to the posterior cortex. On the sagittal tibia tunnel position, 49% demonstrated some impingement on full-extension lateral radiographs. Limb alignment averaged 43% medial to the medial edge of the tibial plateau. On the Rosenberg view (45-degree flexion view), the minimum joint space in the medial compartment averaged 106% of the opposite knee, but it ranged down to a minimum of 4.6%. Lateral compartment narrowing at its minimum on the Rosenberg view averaged 91.2% of the opposite knee, but it ranged down to a minimum of 0.0%. On the coronal view, verticality as measured by the angle from the center of the tibial tunnel aperture to the center of the femoral tunnel aperture measured 15.8 degree ± 6.9% from vertical. This study represents the radiographic findings in the largest revision ACL reconstruction series ever assembled. Findings were generally consistent with those previously demonstrated in the literature.
Collapse
|
41
|
|
42
|
Nandra R, Matharu GS, Porter K, Ashraf T, Greaves I. A review of anterior cruciate ligament injuries and reconstructive techniques. Part 2: Treatment. TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613479289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aims of treatment of anterior cruciate ligament rupture are to eliminate pain, restore stability and allow early return to activity while preventing early degeneration. Ruptures can be treated conservatively, which requires careful patient selection and avoidance of high-risk activity. Each patient must be treated on an individual basis with consideration given to the level of activity, desire to return to sport, donor site morbidity and compliance with post-operative regimes. Through the evolution of single incision, arthroscopic anatomic reconstruction, our knowledge of the native anterior cruciate ligament anatomy and knee kinematics has progressed. The current gold standard uses four-stranded hamstring autograft with endobutton and interference screw fixation. Double-bundle reconstruction is technically challenging with greater risk and best reserved for larger knees with larger native ligaments. Although treatment has advanced considerably over the years, there are still a number of contentious issues which are considered in this review. Part two of this review discusses the short- and long-term objectives of surgery, the indications and timing of surgery, different graft materials, tunnel positions and rehabilitation programmes. We also evaluate the role of anatomical reconstruction and single- versus double-bundle anterior cruciate ligament reconstructions.
Collapse
Affiliation(s)
- R Nandra
- Trauma & Orthopaedics – University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - GS Matharu
- Trauma & Orthopaedics – University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - K Porter
- Trauma & Orthopaedics – University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - T Ashraf
- Trauma & Orthopaedics – University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - I Greaves
- Trauma & Orthopaedics – University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| |
Collapse
|
43
|
Lynch JL, Anderson K. Anterior Cruciate Ligament Reconstruction: All-Inside Reconstruction. OPER TECHN SPORT MED 2013. [DOI: 10.1053/j.otsm.2012.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
44
|
Lubowitz JH, Akhavan S, Waterman BR, Aalami-Harandi A, Konicek J. Technique for creating the anterior cruciate ligament femoral socket: optimizing femoral footprint anatomic restoration using outside-in drilling. Arthroscopy 2013; 29:522-8. [PMID: 23332371 DOI: 10.1016/j.arthro.2012.10.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 09/02/2012] [Accepted: 10/07/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate and optimize anterior cruciate ligament (ACL) femoral outside-in drilling technique with a goal of anatomic restoration of the footprint morphologic length, width, area, and angular orientation. METHODS Ex vivo, computer navigation was used to create virtual 3-dimensional maps of femoral bone tunnels for ACL drill guide pin insertion paths on small, medium, and large models of averaged femora considering various pin insertion angles to the femur. We then determined which pin insertion angle resulted in an ACL femoral footprint optimally matching normal human anatomic length, width, area, and angular orientation of the footprint long axis. RESULTS During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of 60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin entrance angle of 20° to the transepicondylar axis, results in the closest approximation of the gold standard of normal anatomic morphology of the human knee ACL femoral footprint length, width, area, and angular orientation. CONCLUSIONS During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of 60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin entrance angle of 20° to the transepicondylar axis, results in optimal reconstruction of the normal human anatomic ACL femoral footprint length, width, area, and angular orientation. CLINICAL RELEVANCE We describe arthroscopic landmarks for anatomic ACL femoral socket creation that may be considered by practicing arthroscopic surgeons in the operating room, without open dissection or fluoroscopy and unaffected by type of drill guide or variations in the thickness of the femoral soft-tissue envelope.
Collapse
Affiliation(s)
- James H Lubowitz
- Taos Orthopaedic Institute Research Foundation, Taos, New Mexico, USA.
| | | | | | | | | |
Collapse
|
45
|
Samuelsson K, Andersson D, Ahldén M, Fu FH, Musahl V, Karlsson J. Trends in Surgeon Preferences on Anterior Cruciate Ligament Reconstructive Techniques. Clin Sports Med 2013. [DOI: 10.1016/j.csm.2012.08.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
46
|
Holm I, Oiestad BE, Risberg MA, Gunderson R, Aune AK. No differences in prevalence of osteoarthritis or function after open versus endoscopic technique for anterior cruciate ligament reconstruction: 12-year follow-up report of a randomized controlled trial. Am J Sports Med 2012; 40:2492-8. [PMID: 22984128 DOI: 10.1177/0363546512458766] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although arthroscopic techniques are the most common procedures today when reconstructing the anterior cruciate ligament (ACL), many surgeons still prefer the open and/or 2-incision techniques. HYPOTHESIS There are no differences in knee function or prevalence of knee osteoarthritis (OA) in patients who have undergone the open versus endoscopic technique for ACL reconstruction using the patellar tendon autograft. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS Sixty-seven patients with subacute or chronic rupture of the ACL were randomly assigned to open (OPEN) (n = 33) or endoscopic (ENDO) (n = 34) reconstruction. Function was evaluated by the Cincinnati knee score, single-legged hop tests, and isokinetic muscle strength tests. The radiographs were classified according to the Kellgren and Lawrence (KL) classification system, defining grade 2 or more as the cutoff point for knee OA. The Insall-Salvati ratio and the Blackburne-Peel ratio were used to calculate the patellar position and height. RESULTS Mean age at inclusion and at the 12-year follow-up evaluation was 27.9 ± 8.6 and 39.8 ± 8.6 years, respectively. At 12-year follow-up, 53 patients (79%) were eligible for evaluation. There were no significant differences between the 2 surgical procedures with respect to the pain, function, muscle strength, hop tests, patellar height, or the prevalence of OA. The prevalence of OA was high in the tibiofemoral joint on the operated side, 79% and 80% in the OPEN and ENDO groups, respectively. For the uninvolved knee, the corresponding numbers were 36% and 21%. CONCLUSION This study suggests that the open procedure does not produce more functional problems or osteoarthritis compared with the endoscopic technique up to 12 years postoperatively.
Collapse
Affiliation(s)
- Inger Holm
- Division of Surgery and Clinical Neuroscience, Section of Research, Oslo University Hospital, Norway.
| | | | | | | | | |
Collapse
|
47
|
Femoral graft bending angle and femoral tunnel geometry of transportal and outside-in techniques in anterior cruciate ligament reconstruction: an in vivo 3-dimensional computed tomography analysis. Arthroscopy 2012; 28:1682-94. [PMID: 23107250 DOI: 10.1016/j.arthro.2012.05.884] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 05/12/2012] [Accepted: 05/17/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare femoral graft bending angles and femoral tunnel geometries between the transportal (TP) and outside-in (OI) techniques after anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. METHODS Thirty-nine patients underwent DB ACL reconstruction with the TP and OI techniques. They were randomized on the day of surgery to either the TP group (group I, 21 cases) or the OI group (group II, 18 cases). Femoral graft bending angle, femoral tunnel geometry, posterior wall breakage, and tunnel communication were assessed by computed tomography imaging with OsiriX imaging software (Pixmeo, Geneva, Switzerland). RESULTS The mean anteromedial (AM) and posterolateral (PL) femoral graft bending angles of group II (97.3° ± 8.3° and 97.4° ± 8.6°, respectively) were significantly more acute than those of group I (108.2° ± 8.4° and 109.9° ± 8.8°, respectively) (P < .001). The mean AM femoral tunnel length of group II (34.3 ± 3.9 mm) was significantly longer than that of group I (31.9 ± 2.7 mm) (P = .02). However, the mean PL femoral tunnel lengths did not differ between groups. In 7 cases-4 cases (19.0%) in group I and 3 cases (16.6%) in group II-the femoral tunnel communication was found around the intra-articular aperture. Posterior wall breakage was observed in 5 cases (23.8%), which were all in AM femoral tunnels of group I. CONCLUSIONS The OI technique resulted in more acute femoral graft bending angles (difference of 10.9° and 12.5° for AM and PL, respectively) and longer mean AM femoral tunnel lengths (difference of 2.4 mm) than the TP technique after anatomic DB ACL reconstruction, even though these small differences might be unlikely to be of clinical significance. Femoral tunnel communication was found in both groups, and posterior wall breakage was observed in AM femoral tunnels with the TP technique. LEVEL OF EVIDENCE Level I, prospective randomized trial.
Collapse
|
48
|
Sullivan JP, Matava MJ, Flanigan DC, Gao Y, Britton CL, Amendola A, Wolf BR. Reliability of tunnel measurements and the quadrant method using fluoroscopic radiographs after anterior cruciate ligament reconstruction. Am J Sports Med 2012; 40:2236-41. [PMID: 22962289 DOI: 10.1177/0363546512458086] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction tunnel placement is often evaluated by radiographs. This study examines the interobserver reliability of various radiographic measurements of ACL tunnels. HYPOTHESIS When ideal radiographic views are obtained, the interobserver reliability of the measurements among experienced surgeons would be good to excellent. STUDY DESIGN Descriptive laboratory study. METHODS Tunnels for single-bundle ACL reconstruction were drilled and filled with metal interference screws or a tibial reamer on 73 cadaveric knees. Ideal fluoroscopic radiographs were obtained. Three independent reviewers performed 18 measurements including a modification of the grid method. For the grid method analysis, reviewers fit a 16 × 12 grid to the lateral knee radiograph, and the center of the femoral tunnel was marked. Interobserver reliability of the measurements was performed using intraclass correlation coefficients (ICCs). A precision grouping analysis was performed for the grid measurements to calculate the mean radius and standard deviation grouping distances. RESULTS The ICCs were excellent (>.75) for the tibial tunnel angles and tunnel measurements, the clock face measurement, and the Aglietti et al and Jonsson et al measurements. The ICCs were good (.4-.75) for an estimation of graft impingement, Harner et al measurements, and notch height. The mean radius for grid measurements was 0.6 ± 0.4 units (range, 0-2.36 units), with each unit being 1 box in the 16 × 12 grid. When a circle was constructed with a 1.3-unit radius, 95% of the 3 surgeons' measurements would be included in the area of that circle. CONCLUSION Reliability of ACL tunnel measurements was good to excellent under ideal circumstances for the majority of measurements. The modified grid method demonstrated very acceptable reliability. CLINICAL RELEVANCE Measurements with good to excellent reliability can be used to evaluate ACL tunnel placement when ideal radiographic views are obtained.
Collapse
Affiliation(s)
- Jaron P Sullivan
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Della Villa S, Boldrini L, Ricci M, Danelon F, Snyder-Mackler L, Nanni G, Roi GS. Clinical Outcomes and Return-to-Sports Participation of 50 Soccer Players After Anterior Cruciate Ligament Reconstruction Through a Sport-Specific Rehabilitation Protocol. Sports Health 2012; 4:17-24. [PMID: 23016064 PMCID: PMC3435892 DOI: 10.1177/1941738111417564] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Rehabilitation of soccer players after anterior cruciate ligament reconstruction is usually performed without sport-specific guidelines, and the final phases are often left to the team coaches. The possibility of changing this approach has not yet been investigated. Study Design: Case series. Hypothesis: A specific rehabilitation protocol for soccer players, with direct control of the last on-field rehabilitation phases, may lead to complete functional recovery. Methods: Fifty competitive soccer players who followed a sport-specific rehabilitation protocol for soccer were evaluated during the recovery period until their return to competition. The assessment of the functional outcomes was performed using the Knee Outcome Survey–Sports Activity Scale and isokinetic and aerobic fitness tests. Results: The average start of on-field rehabilitation was 90 ± 26 days after surgery; the average time to return to the competitions was 185 ± 52 days. The improvement in the Knee Outcome Survey–Sports Activity Scale during on-field rehabilitation was significant (P < 0.01; from 79 ± 15% to 96 ± 7%). The isokinetic and aerobic fitness tests showed a significant improvement of muscle strength (knee extensors, +55%, P < 0.01; knee flexors, +86%, P < 0.01) and aerobic threshold (+23%, P < 0.01) from the beginning to the end of on-field rehabilitation. Conclusions: Adding on-field rehabilitation to the traditional protocols after anterior cruciate ligament reconstruction may safely lead to complete functional recovery in soccer players.
Collapse
|
50
|
Getgood A, Spalding T. The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop J 2012; 6:287-94. [PMID: 22905073 PMCID: PMC3415664 DOI: 10.2174/1874325001206010287] [Citation(s) in RCA: 27] [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: 02/14/2012] [Revised: 03/02/2012] [Accepted: 03/10/2012] [Indexed: 02/08/2023] Open
Abstract
Anterior cruciate ligament reconstruction has evolved significantly since the early 1900's, back when an emphasis was placed on repair and not reconstruction. Over the past century, the technique has evolved from intra-articular non anatomic reconstruction, to extra articular reconstruction, back to intra articular (performed arthroscopically), to now, the advent of anatomic insertion site restoration. This review will aim to illustrate the changes that have occurred, describing the rational for this process, based upon anatomical, radiological, biomechanical and clinical studies, all of which have aimed to improve patient function following ACL injury.
Collapse
Affiliation(s)
- Alan Getgood
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
| | | |
Collapse
|