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Nestorovoski DL, Haratian R, Guzman A, Bolia IK, Chen JL, Liu JN, Petrigliano FA, Weber AE, Rick Hatch GF. All-Inside PCL Reconstruction, Double Bundle, With Internal Brace Augmentation. Arthrosc Tech 2023; 12:e1211-e1218. [PMID: 37533902 PMCID: PMC10391337 DOI: 10.1016/j.eats.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/17/2023] [Indexed: 08/04/2023] Open
Abstract
PCL reconstructive techniques are constantly evolving, and further clinical studies are needed to definitively understand the potential benefits of internal brace augmentation and anatomic double-bundle PCL reconstruction. This Technical Note reports an arthroscopic all-inside anatomic double-bundle PCL reconstruction with internal brace augmentation that is effective and reproducible.
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Affiliation(s)
- Douglas L. Nestorovoski
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California, U.S.A
| | - Ryan Haratian
- Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation, Wright State University Boonshoft School of Medicine, Dayton, Ohio, U.S.A
| | - Alvarho Guzman
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Ioanna K. Bolia
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California, U.S.A
| | - James L. Chen
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Joseph N. Liu
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California, U.S.A
| | - Frank A. Petrigliano
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California, U.S.A
| | - Alexander E. Weber
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California, U.S.A
| | - George. F. Rick Hatch
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California, U.S.A
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Guo J, Qi C, Zhang D, Yang G, Wang C, Yang P, Wang B. Safe femoral tunnel drilling angles avoid injury to the medial and posteromedial femoral anatomic structures during single-bundle posterior cruciate ligament reconstruction with the inside-out technique. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07412-0. [PMID: 37039872 DOI: 10.1007/s00167-023-07412-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/03/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To investigate the relationship between the medial and posteromedial femoral anatomic structures and the femoral tunnel exit produced by different tunnel orientations when creating the femoral tunnel for posterior cruciate ligament reconstruction (PCLR) using the inside-out (IO) technique and to estimate safe tunnel orientations to minimize the risk of iatrogenic injury to these structures. METHODS Eleven cadaveric knees were used. The medial and posteromedial aspects of each knee joint were dissected to reveal the "safe zone," which is a bony area that avoids the distribution or attachment of at-risk structures (MCL, PMC structures, and articular cartilage), while remaining 10 mm away from the articular cartilage. The hypothesis of this study was that by creating the femoral tunnel at specific angles using the IO technique, the tunnel outlet would be as close to the safe zone as possible, protecting the at-risk structures from damage. Femoral tunnels were drilled at 20 different angle combinations on each specimen: 0°, 15°, 30°, 45°, and 60° relative to a line parallel to the transepicondylar axis in the axial plane, as well as 15°, 30°, 45°, and 60° relative to a line parallel to the femoral axis in the coronal plane. The positional relationship between each tunnel exit and the safe zone was recorded, and the shortest distance between the exit center and the safe zone boundary was measured. RESULTS The risk of iatrogenic injury differed depending on the drilling orientation (χ2 = 168.880, P < 0.001). Femoral drilling angle combinations of 45/45°, 45/60°, 60/30°, 60/45°, and 60/60° (axial/coronal) were considered relatively safer than other orientations (P < 0.05). The shortest distance between the tunnel exit and the safe zone boundary was negatively correlated with the angle in the axial plane (P < 0.001, r = - 0.810). CONCLUSIONS When creating the IO femoral tunnel for single-bundle PCL reconstruction, angle combinations of 45/45°, 45/60°, 60/30°, 60/45°, and 60/60° (axial/oblique coronal) could be utilized to prevent at-risk structures from being damaged. The drilling angles and the safe zone can be employed to optimize the femoral tunnel in PCLR.
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Affiliation(s)
- Jia Guo
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Chao Qi
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
| | - Dongfang Zhang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Guodong Yang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Chen Wang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Pu Yang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Bin Wang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
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Lin Y, Huang Z, Zhang K, Pan X, Huang X, Li J, Li Q. Lower Tibial Tunnel Placement in Isolated Posterior Cruciate Ligament Reconstruction: Clinical Outcomes and Quantitative Radiological Analysis of the Killer Turn. Orthop J Sports Med 2020; 8:2325967120923950. [PMID: 32874997 PMCID: PMC7436807 DOI: 10.1177/2325967120923950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 02/05/2023] Open
Abstract
Background The "killer turn" effect after posterior cruciate ligament (PCL) reconstruction is a problem that can lead to graft laxity or failure. Solutions for this situation are currently lacking. Purpose To evaluate the clinical outcomes of a modified procedure for PCL reconstruction and quantify the killer turn using 3-dimensional (3D) computed tomography (CT). Study design Case series; Level of evidence, 4. Methods A total of 15 patients underwent modified PCL reconstruction with the tibial aperture below the center of the PCL footprint. Next, 2 virtual tibial tunnels with anatomic and proximal tibial apertures were created on 3D CT. All patients were assessed according to the Lysholm score, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Tegner score, side-to-side difference (SSD) in tibial posterior translation using stress radiography, and 3D gait analysis. Results The modified tibial tunnel showed 2 significantly gentler turns (superior, 109.87° ± 10.12°; inferior, 151.25° ± 9.07°) compared with those reconstructed with anatomic (91.33° ± 7.28°; P < .001 for both comparisons) and proximal (99° ± 7.92°; P = .023 and P < .001, respectively) tibial apertures. The distance from the footprint to the tibial aperture was 16.49 ± 3.73 mm. All patient-reported outcome scores (mean ± SD) improved from pre- to postoperatively: Lysholm score, from 46.4 ± 18.87 to 83.47 ± 10.54 (P < .001); Tegner score, from 2.47 ± 1.85 to 6.07 ± 1.58 (P < .001); IKDC sports activities score, from 19 ± 9.90 to 33.07 ± 5.35 (P < .001); and IKDC knee symptoms score, from 17.87 ± 6.31 to 25.67 ± 3.66 (P < .001). The mean SSD improved from 9.15 ± 2.27 mm preoperatively to 4.20 ± 2.31 mm postoperatively (P < .001). The reconstructed knee showed significantly more adduction (by 1.642°), less flexion (by 1.285°), and more lateral translation (by 0.279 mm) than that of the intact knee (P < .001 for all). Conclusion Lowering the tibial aperture during PCL reconstruction reduced the killer turn, and the clinical outcomes remained satisfactory. However, SSD and clinical outcomes were similar to those of previously described techniques using an anatomic tibial tunnel.
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Affiliation(s)
- Yipeng Lin
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zeyuan Huang
- College of Software Engineering, Sichuan University, Chengdu, China
| | - Kaibo Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xuelin Pan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xihao Huang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qi Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Graft bending angle of the reconstructed posterior cruciate ligament gradually decreases as knee flexion increases. Knee Surg Sports Traumatol Arthrosc 2020; 28:2626-2633. [PMID: 32062684 DOI: 10.1007/s00167-020-05899-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 02/03/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of the study was to determine the change in the graft bending angles at the femoral and tibial tunnel aperture in single-bundle posterior cruciate ligament (PCL) reconstruction. It was hypothesized that different knee flexion and different tunnel directions may affect changes of the femoral and tibial graft bending angle. METHODS The right knees of 12 male subjects were scanned with a high-resolution computed tomography scanner at 4 different knee flexion angles (0°, 45°, 90° and 135°). To begin with, the 3D knee models were created and manipulated with the use of several modeling programs. Single-bundle PCL reconstruction was then virtually conducted in a 90° flexion model: The femoral and tibial graft bending angle, according to the various knee flexion angles, was calculated using a special software program. RESULTS The femoral graft bending angle significantly decreased as the knee flexion increased between 0° and 135° (all p < 0.001). The femoral graft bending angle of the AL graft showed the most obtuse angles among the three types of the graft beyond 45° of knee flexion. For the tibial graft bending angle, the anteromedial tunnel group showed significantly more acute tibial graft bending angle than the anterolateral tunnel group in all three types of the graft at all flexion angles (all p < 0.001). CONCLUSION Changes in the femoral graft bending angle were generally affected by different knee flexion angles. The effect of tibial tunnel direction on the tibial graft bending angle was found to be significant. The clinical relevance is that a mostly obtuse femoral graft bending angle was shown by the AL graft among three types of the graft.
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林 奕, 蔡 武, 黄 锡, 李 箭, 李 棋. [The killer turn in the posterior cruciate ligament reconstruction: mechanism and improvement]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:787-792. [PMID: 32538573 PMCID: PMC8171534 DOI: 10.7507/1002-1892.201907066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/20/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To summarize the research progress of killer turn in posterior cruciate ligament (PCL) reconstruction. METHODS The literature related to the killer turn in PCL reconstruction in recent years was searched and summarized. RESULTS The recent studies show that the killer turn is considered to be the most critical cause of graft relaxation after PCL reconstruction. In clinic, this effect can be reduced by changing the fixation mode of bone tunnel, changing the orientation of bone tunnel, squeezing screw fixation, retaining the remnant, and grinding the bone at the exit of bone tunnel. But there is still a lack of long-term follow-up. CONCLUSION There are still a lot of controversies on the improved strategies of the killer turn. More detailed basic researches focusing on biomechanics to further explore the mechanism of the reconstructed graft abrasion are needed.
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Affiliation(s)
- 奕鹏 林
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 武峰 蔡
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 锡豪 黄
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 箭 李
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 棋 李
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Kim MU, Kim JW, Kim MS, Kim SJ, Yoo OS, In Y. Variation in Graft Bending Angle During Range of Motion in Single-Bundle Posterior Cruciate Ligament Reconstruction: A 3-Dimensional Computed Tomography Analysis of 2 Techniques. Arthroscopy 2019; 35:1183-1194. [PMID: 30871901 DOI: 10.1016/j.arthro.2018.10.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 10/06/2018] [Accepted: 10/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare variations in femoral graft bending angle during range of motion (ROM) of the knee between inside-out (IO) and retro-socket outside-in (OI) techniques in posterior cruciate ligament (PCL) reconstruction using in vivo 3-dimensional (3D) computed tomography analysis. METHODS Ten patients underwent PCL reconstruction by the IO technique (5 patients) or the retro-socket OI technique (5 patients) for suspensory femoral fixation. After PCL reconstruction, 3D computed tomography was performed in 0° extension and 90° flexion to reconstruct 3D femur and tibia bone models using Mimics software. Positions of femur and tibia at 30°, 45°, and 60° flexion were reproduced by determining the kinematic factors of anteroposterior translation, mediolateral translation, and internal-external rotation angle of each patient based on previously measured kinematic data. Variation in graft bending angle according to the flexion range of the knee was calculated by the difference in graft angulation measured at each flexion angle. The results were compared between the 2 techniques. RESULTS There was significant difference in variation of femoral graft bending angle between IO and retro-socket OI techniques from 0° to 90° flexion of the knee (P = .008). Significant difference was also noticed at 30° to 45° (P = .008), 45° to 60° (P = .008), and 60° to 90° (P = .016) ROM of the knee between the 2 groups. CONCLUSIONS The retro-socket OI technique resulted in less variation in femoral graft bending angle compared with the IO technique during knee ROM. We recommend the retro-socket OI technique for femoral tunnel placement to reduce the graft motion at the intra-articular femoral tunnel aperture. CLINICAL RELEVANCE The retro-socket OI technique produces significantly less variation in femoral graft bending angle when compared with the IO technique. Such reduction in variation of femoral graft bending angle might be related to lower stress at the femoral tunnel aperture.
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Affiliation(s)
- Min Up Kim
- Department of Orthopedic Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Won Kim
- Central R&D Center, Corentec, Cheonan, Republic of Korea
| | - Man Soo Kim
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Ju Kim
- Central R&D Center, Corentec, Cheonan, Republic of Korea
| | - Oui Sik Yoo
- Central R&D Center, Corentec, Cheonan, Republic of Korea
| | - Yong In
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Weiss WM. Editorial Commentary: Posterior Cruciate Ligament Femoral Techniques: The "Critical Corner" Is Just Not as Exciting as the "Killer Turn". Arthroscopy 2019; 35:1195-1196. [PMID: 30954111 DOI: 10.1016/j.arthro.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/04/2018] [Indexed: 02/02/2023]
Abstract
The "killer turn" between the graft and tibial tunnel in posterior cruciate ligament reconstruction has always been of technical and clinical importance. The "critical corner" of the graft and femoral tunnel has garnered less interest. Technical advances in arthroscopic instrumentation have allowed a move from inside-out to outside-in techniques, which can assist with tunnel placement and drilling. While these techniques do not impact the "killer turn," they have been demonstrated to decrease the acuity of the "critical corner," but there remains no evidence of impact on graft rupture or clinical outcomes.
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Location of the femoral tunnel aperture during single-bundle posterior cruciate ligament reconstruction: outside-in versus inside-out techniques. INTERNATIONAL ORTHOPAEDICS 2018; 42:2097-2103. [PMID: 29700585 DOI: 10.1007/s00264-018-3954-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Placement of the femoral tunnel is critical to graft function after posterior cruciate ligament (PCL) reconstruction. To date, however, the location of the femoral tunnel aperture has not been compared by in vivo 3-dimensional computed tomography (3D-CT) during PCL reconstruction with the outside-in (OI) and inside-out (IO) techniques. This study used 3D-CT analysis to compare the location of the femoral tunnel aperture in patients who underwent PCL reconstruction with the OI and IO techniques. METHODS A total of 77 patients underwent single-bundle PCL reconstruction using the OI (n = 46) or IO (n = 31) technique. The location of the femoral tunnel aperture was assessed by 3D-CT and measured by the anatomic coordinate axis method to construct 3D surface models. RESULTS The mean location of the femoral tunnel aperture in the low-to-high direction did not differ significantly in the OI and IO groups (75.0 vs. 75.2%, P = 0.869). However, in the deep-to-shallow direction, the femoral tunnel aperture was positioned more shallowly in the IO than in the OI group (75.7 vs. 81.1%, P < 0.001). CONCLUSION The IO technique of single-bundle PCL reconstruction yielded a shallower femoral tunnel in the deep-to-shallow direction than did the OI technique. However, femoral tunnel location in the low-to-high direction was similar using the two techniques.
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Van Der Bracht H, Tampere T, Beekman P, Schepens A, Devriendt W, Cromheecke M, Verdonk P, Victor J. Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis. Knee Surg Sports Traumatol Arthrosc 2018; 26:508-517. [PMID: 29124289 DOI: 10.1007/s00167-017-4739-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 10/02/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft. METHODS Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12®. 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations. RESULTS In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture. CONCLUSION In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture. CLINICAL RELEVANCE the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Hans Van Der Bracht
- Department of Orthopaedic Surgery and Traumatology, AZ Sint-Lucas Gent, Groenebriel 1, 9000, Ghent, Belgium
| | - Thomas Tampere
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
| | - Pieter Beekman
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium.
| | - Alexander Schepens
- Department of Orthopaedic Surgery and Traumatology, AZ Sint-Lucas Gent, Groenebriel 1, 9000, Ghent, Belgium
| | - Wouter Devriendt
- Department of Biofluid, Tissue and Solid Mechanics for Medical Applications, bioMMeda, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Michiel Cromheecke
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
| | - Peter Verdonk
- Department of Orthopaedics and Traumatology, AZ Monica, Harmoniestraat 68, 2018, Antwerp, Belgium
| | - Jan Victor
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
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Narvy SJ, Hatch GF, Ihn HE, Heckmann ND, McGarry MH, Tibone JE, Lee TQ. Evaluating the Femoral-Side Critical Corner in Posterior Cruciate Ligament Reconstruction: The Effect of Outside-In Versus Inside-Out Creation of Femoral Tunnels on Graft Contact Pressure in a Synthetic Knee Model. Arthroscopy 2017; 33:1370-1374. [PMID: 28392051 DOI: 10.1016/j.arthro.2017.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 01/10/2017] [Accepted: 01/13/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To characterize and compare the graft contact characteristics of outside-in (OI) and inside-out (IO) femoral tunnels during single-bundle reconstruction of the anterolateral bundle of the posterior cruciate ligament in a synthetic knee model. METHODS Femoral tunnels were separately made in 16 synthetic femora (8 OI and 8 IO). Achilles tendon allografts were fixed using suspensory fixation with a pressure sensor between the allograft and femoral tunnel. Grafts were cyclically loaded; force, contact area, contact pressure, and peak pressure at the aperture were measured. This process was repeated using the same allograft to assess the other tunnel angle in a separate specimen. RESULTS IO specimens showed higher mean contact pressure at all loading cycles, with significance shown at 50 N (P = .02). Peak pressure was also greater in IO specimens at all loading cycles and reached statistical significance at 100 N (P = .04). IO specimens had a lower contact area at 150 N (P = .04). No statistically significant differences in force were observed between the 2 groups. CONCLUSIONS OI creation of the femoral tunnel for anterolateral bundle reconstruction of the posterior cruciate ligament resulted in decreased mean and peak contact pressures at the femoral aperture compared with IO tunnel creation at the specific trajectories and loading parameters tested in this synthetic femoral model. These biomechanical data suggest that OI creation of the femoral tunnel may help reduce in vivo graft contact pressure at the femoral aperture. CLINICAL RELEVANCE These data suggest that a tunnel drilled from OI may result in less graft pressure at the femoral aperture, which may prevent graft elongation and optimize graft survival.
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Affiliation(s)
- Steven J Narvy
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - George F Hatch
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A..
| | - Hansel E Ihn
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A.; University of California, Irvine, Irvine, California, U.S.A
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A.; University of California, Irvine, Irvine, California, U.S.A
| | - James E Tibone
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, U.S.A.; University of California, Irvine, Irvine, California, U.S.A
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An anatomic and histologic study of the origin and terminal points in the anterior and posterior cruciate ligaments in rats. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Camarda L, Grassedonio E, Lauria M, Midiri M, D'Arienzo M. How to avoid collision between PCL and MCL femoral tunnels during a simultaneous reconstruction. Knee Surg Sports Traumatol Arthrosc 2016; 24:2767-2772. [PMID: 25429764 DOI: 10.1007/s00167-014-3446-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/14/2014] [Indexed: 01/30/2023]
Abstract
PURPOSE The purpose of the present study was to assess the risk of femoral tunnel collisions between the medial collateral ligament (MCL) and the posterior cruciate ligament (PCL) tunnels during a simultaneous PCL and MCL reconstruction. METHODS Fourth generation medium and large synthetic femur bones were used. On each femur, a MCL tunnel and a PCL tunnel were reamed. The MCL tunnel was drilled at 0°, 20° and 40° of axial and coronal angulations. The PCL femoral tunnel was reamed to simulate two different tunnel directions that could be obtained through an inside-out and outside-in technique. Tunnels were filled with epoxy resin augmented with BaSO4, and a multidetector CT examination of each specimen was performed. RESULTS High rate of tunnel collision (62.5 %) was found when the MCL femoral tunnel was reamed with a coronal angulation of 0° and 20°. The rate of tunnel collision significantly decreased (0 %) when the MCL tunnel was reamed proximally with a coronal angulation of 40°. No differences were found between the two PCL tunnel directions in terms of tunnel collision. CONCLUSION The results of this study can help surgeons to better direct the femoral MCL tunnel in order to avoid a collision between femoral tunnels during a combined MCL and PCL reconstruction. In order to minimize such potential complications, the MCL tunnel should be created limiting the axial angulation and it should be drilled with a proximal angulation from 20° to 40°, depending on the medial condyle width.
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Affiliation(s)
- Lawrence Camarda
- Department of Orthopaedic Surgery, DICHIRONS, University of Palermo, Via del Vespro, 90100, Palermo, Italy.
| | - Emanuele Grassedonio
- Department of Radiology, DIBIMEF, University of Palermo, Via del Vespro, 90100, Palermo, Italy
| | - Michele Lauria
- Department of Orthopaedic Surgery, DICHIRONS, University of Palermo, Via del Vespro, 90100, Palermo, Italy
| | - Massimo Midiri
- Department of Radiology, DIBIMEF, University of Palermo, Via del Vespro, 90100, Palermo, Italy
| | - Michele D'Arienzo
- Department of Orthopaedic Surgery, DICHIRONS, University of Palermo, Via del Vespro, 90100, Palermo, Italy
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Jang KM, Park SC, Lee DH. Graft Bending Angle at the Intra-articular Femoral Tunnel Aperture After Single-Bundle Posterior Cruciate Ligament Reconstruction: Inside-Out Versus Outside-In Techniques. Am J Sports Med 2016; 44:1269-75. [PMID: 26847488 DOI: 10.1177/0363546515625046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND To date, no in vivo 3-dimensional computed tomography (3D-CT) studies have compared graft bending angles at the femoral tunnel aperture and femoral tunnel length in patients who underwent posterior cruciate ligament (PCL) reconstruction with outside-in (OI) and inside-out (IO) techniques. PURPOSE/HYPOTHESIS This study used in vivo 3D-CT analysis to compare graft bending angles at the femoral tunnel aperture and femoral tunnel lengths after OI and IO femoral drilling techniques in single-bundle PCL reconstruction. It was hypothesized that the graft bending angle at the femoral tunnel aperture would be less acute with the OI compared with the IO technique, with no difference in femoral tunnel lengths. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Immediate postoperative in vivo 3D-CT and curved planar reformation were used to assess the graft bending angles and femoral tunnel lengths in the sagittal, axial, and coronal planes in 67 patients who underwent single-bundle PCL reconstruction with the OI (n = 37) and IO (n = 30) techniques. RESULTS The mean graft bending angles on the sagittal and axial planes were 8.2° more acute (23.5° vs 15.3°, P = .011) and 5.3° more acute (49.0° vs 43.7°, P = .013), respectively, with the IO compared with the OI technique, but the difference in the coronal plane was not statistically significant (25.3° vs 24.8°, P = .623). Femoral tunnel length was similar in the 2 groups. CONCLUSION The graft bending angles in single-bundle PCL reconstruction were more acute in the sagittal and axial planes with the IO compared with the OI technique, but there was no difference in the coronal plane. In addition, femoral tunnel lengths did not differ significantly in patients who underwent OI and IO single-bundle PCL reconstructions. Although further biomechanical studies are needed to evaluate the effect on graft failure of a <10° difference in graft bending angle, the small magnitude of this difference would likely have little adverse effect on graft survival.
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Affiliation(s)
- Ki-Mo Jang
- Department of Orthopedic Surgery, Korea University, College of Medicine, Anam Hospital, Seoul, Korea
| | - Sung-Chul Park
- Department of Orthopedic Surgery, Korea University, College of Medicine, Anam Hospital, Seoul, Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Yi A, Kleiner MT, Lorenzana D, Koniceck J, Charlton T, Rick Hatch GF. Optimal femoral tunnel positioning in posterior cruciate ligament reconstruction using outside-in drilling. Arthroscopy 2015; 31:850-8. [PMID: 25660009 DOI: 10.1016/j.arthro.2014.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 11/20/2014] [Accepted: 12/03/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The goal of our study was to determine the precise femoral drill guide placement during reconstruction of the anterolateral bundle (ALB) of the posterior cruciate ligament (PCL) femoral footprint that would produce a minimum tunnel length of 25 mm, a maximum graft/femoral tunnel angle of 50°, and a minimum distance of 10 mm between the femoral socket and the subchondral bone of the weight-bearing surface of the medial femoral condyle. METHODS Using computer navigation, we used synthetic replicas of human femora to create a series of virtual femoral sockets. We then measured the bone tunnel length, angle of the femoral socket relative to the PCL footprint, and distance from the subchondral bone of the weight-bearing surface of the medial femoral condyle to the femoral socket at a series of guide pin sleeve positions. We positioned the guide pin using the following angle combinations: -20°, -10°, 0°, 10°, 20°, 30°, 40°, 50°, and 60° to a line perpendicular to the femoral axis in the coronal plane and -15°, 0°, 15°, 30°, 45°, and 60° to a line parallel to the transepicondylar axis in the axial plane. Using linear regression models, we determined the precise drill guide placement angles that would produce the optimal tunnel length, graft/femoral tunnel angle, and distance to the subchondral bone margin. RESULTS The results were consistent between small, medium, and large femora. We found that the optimal drilling angles for anatomic reconstruction of the femoral footprint of the ALB of the PCL were 0° to a line perpendicular to the femoral axis in the coronal plane and 15° to a line parallel to the transepicondylar axis in the horizontal or axial plane. CONCLUSIONS During outside-in drilling for PCL reconstruction, holding the guide pin sleeve at a position 0° to a line perpendicular to the femoral axis in the coronal plane and 15° to a line parallel to the transepicondylar axis in the horizontal or axial plane results in optimal bone tunnel length, graft/tunnel angle, and distance between the femoral socket and the subchondral bone of the weight-bearing surface of the medial femoral condyle. CLINICAL RELEVANCE We describe a precise femoral tunnel drill guide placement during outside-in PCL reconstruction that ensures an optimal femoral socket with a minimum bone tunnel length of 25 mm, maximum graft/femoral tunnel angle of 50°, and minimum distance of 10 mm between the subchondral bone of the weight-bearing surface of the medial femoral condyle and the femoral socket.
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Affiliation(s)
- Anthony Yi
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, U.S.A..
| | - Matthew T Kleiner
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, U.S.A
| | - Dan Lorenzana
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, U.S.A
| | - John Koniceck
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, U.S.A
| | - Timothy Charlton
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, U.S.A
| | - George F Rick Hatch
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, U.S.A
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Lee DY, Kim DH, Park JS, Nam DC, Cho SH, Jeong JH, Hwang SC. Systematic review of cadaveric studies on anatomic posterior cruciate ligament reconstruction: the landmarks in anatomic posterior cruciate ligament reconstruction. Knee Surg Relat Res 2014; 26:191-8. [PMID: 25505700 PMCID: PMC4258485 DOI: 10.5792/ksrr.2014.26.4.191] [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] [Received: 03/11/2014] [Revised: 06/09/2014] [Accepted: 06/25/2014] [Indexed: 11/29/2022] Open
Abstract
Recently, several new techniques for anatomic posterior cruciate ligament reconstruction (PCLR) have emerged and are believed to restore the normal anatomy of the posterior cruciate ligament more accurately. Despite the latest trend, the optimal methods for anatomic PCLR remain controversial. The purpose of this research is to review surgical techniques for PCLR in cadaver studies and suggest consistent and reproducible technical criteria. For the review of the literature, MEDLINE and EMBASE were screened for articles on anatomic PCLR. Only basic science studies on PCLR performed on human cadavers and written in English were included. Seventeen studies were included in this systematic review. Only the tunnel positions, graft types, and surgical techniques were reported in the majority of the studies. There were many variations of the reported tunnel positions, graft types, and surgical techniques among the studies. In most studies, surgical techniques for consistent and reproducible anatomic PCLR were not explained clearly. Therefore, high level medical research should be encouraged in order to establish standard surgical techniques for anatomic PCLR.
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Affiliation(s)
- Dong Yeong Lee
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Dong Hee Kim
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jin Sung Park
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Dae Cheol Nam
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Seong Hee Cho
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jin Hoon Jeong
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sun Chul Hwang
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
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Osti M, Krawinkel A, Gohm A, Muxel B, Benedetto KP. The effectiveness of skeletal imaging for quality assessment in posterior cruciate ligament reconstruction: reliability and validity of radiographs and computed tomography. Arch Orthop Trauma Surg 2014; 134:1731-7. [PMID: 25186075 DOI: 10.1007/s00402-014-2084-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE For intra- and postoperative evaluation of precise and anatomic graft tunnel position, radiographs (XR) and computed tomography (CT) scans have been suggested. The purpose of this study was to evaluate the reliability and validity of XR and CT for quality assessment following PCL reconstruction. METHODS Postoperative radiographs and CT scans were obtained in 45 consecutive patients following a standard single-bundle PCL reconstruction. Femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. To assess the reliability and validity of XR and CT scans three independent observers evaluated radiographic and CT images for the position of femoral and tibial tunnel apertures. RESULTS Almost perfect inter- and intra observer agreement (0.79-0.99) was found for all CT measurements except for the distance of the tunnel position to the previous physis line. Almost perfect and strong inter- and intraobserver agreement (0.70-0.98) was found for all tibial measurements on XR which tended to increase with repeated interpretation and to decrease with low levels of observer qualification. Femoral measurements yielded only poor-to-moderate reliability (0.02-0.5) between raters on XR but strong intraagreement within experienced observers (0.45-0.86). Specificity for XR was calculated with 75.7 % for P2 and P3 and with 71 % for femoral tunnel depth and height. CONCLUSION XR and CT represent complementary imaging modalities and both offer considerable accuracy and precision for the determination of femoral and tibial tunnel apertures following PCL reconstruction and can be recommended for intra- and postoperative quality assessment.
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Affiliation(s)
- Michael Osti
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria,
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Osti M, Krawinkel A, Benedetto KP. In vivo evaluation of femoral and tibial graft tunnel placement following all-inside arthroscopic tibial inlay reconstruction of the posterior cruciate ligament. Knee 2014; 21:1198-202. [PMID: 25260864 DOI: 10.1016/j.knee.2014.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 05/13/2014] [Accepted: 07/05/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The arthroscopic all-inside tibial inlay technique represents a novel procedure for posterior cruciate ligament (PCL) reconstruction. However, in vivo investigations that evaluate the accuracy of this technique regarding anatomic graft tunnel placement are few. The objective of this study was to analyse the femoral and tibial tunnel apertures using computed tomography (CT) and compare these findings to recommendations in the literature. METHODS CT scans were obtained in 45 patients following single-bundle PCL reconstruction. The centres of the tibial and femoral tunnel apertures were correlated to measurement grid systems used as a radiographic reference. RESULTS The centre of the femoral tunnel aperture was located at 42.9% ± 9.4% of the total intercondylar depth and at 12.9% ± 7.2% of the total intercondylar height. The angle α for the femoral tunnel position was measured at 64.2° ± 10.0°. The centre of the tibial tunnel aperture was found at 51.8% ± 4.1% of the total mediolateral diameter of the tibial plateau. The superoinferior distance of the tibial tunnel aperture to the joint line was 9.6 mm ± 4.4 mm on frontal and 9.3 mm ± 3.4 mm on sagittal 3D-CT scans. The distance of the tibial tunnel aperture to the former physis line averaged to 0.8 mm ± 3.4 mm. Comparison to the corresponding reference values revealed no statistically significant difference. CONCLUSION Arthroscopic tibial inlay reconstruction is an efficient procedure for precise replication of the anatomical footprint of the PCL. LEVEL OF EVIDENCE IV, prospective case series.
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Affiliation(s)
- Michael Osti
- Academic Hospital Feldkirch, Department for Trauma Surgery and Sports Traumatology, Carinagasse 47, 6800 Feldkirch, Austria.
| | - Alessa Krawinkel
- Academic Hospital Feldkirch, Department for Radiology, Carinagasse 47, 6800 Feldkirch, Austria
| | - Karl Peter Benedetto
- Academic Hospital Feldkirch, Department for Trauma Surgery and Sports Traumatology, Carinagasse 47, 6800 Feldkirch, Austria
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18
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Skeletal imaging following reconstruction of the posterior cruciate ligament: in vivo comparison of fluoroscopy, radiography, and computed tomography. Skeletal Radiol 2014; 43:1687-95. [PMID: 25142908 DOI: 10.1007/s00256-014-1970-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 07/09/2014] [Accepted: 07/25/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Intra- and postoperative validation of anatomic footprint replication in posterior cruciate ligament (PCL) reconstruction can be conducted using fluoroscopy, radiography, or computed tomography (CT) scans. However, effectiveness and exposure to radiation of these imaging modalities are unknown. The objective of this study was to evaluate the comparative effectiveness of fluoroscopy, radiography, and CT in detecting femoral and tibial tunnel positions following an all-inside reconstruction of the PCL ligament in vivo. The study design was a retrospective case series. MATERIALS AND METHODS Intraoperative fluoroscopic images, postoperative radiographs, and CT scans were obtained in 50 consecutive patients following single-bundle PCL reconstruction. The centers of the tibial and femoral tunnel apertures were identified and correlated to measurement grid systems. The results of fluoroscopic, radiographic, and CT measurements were compared to each other and accumulated radiation dosages were calculated. RESULTS Comparing the imaging groups, no statistically significant difference could be detected for the reference of the femoral tunnel to the intercondylar depth and height, for the reference of the tibial tunnel to the mediolateral diameter of the tibial plateau and for the superoinferior distance of the tibial tunnel entry to the tibial plateau and to the former physis line. Effective doses resulting from fluoroscopic, radiographic, and CT exposure averaged 2.9 mSv, standard deviation (±SD) 4.1 mSv, to 1.3 ± 0.8 mSv and to 3.6 ± 1.0 mSv, respectively. CONCLUSIONS Fluoroscopy, radiography, and CT yield approximately equal effectiveness in detecting parameters used for quality validation intra- and postoperatively. An accumulating exposure to radiation must be considered.
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Osti M, Hierzer D, Krawinkel A, Hoffelner T, Benedetto KP. The predictive effect of anatomic femoral and tibial graft tunnel placement in posterior cruciate ligament reconstruction on functional and radiological outcome. INTERNATIONAL ORTHOPAEDICS 2014; 39:1181-6. [PMID: 25324225 DOI: 10.1007/s00264-014-2565-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 10/01/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Biomechanical reports have advocated anatomic graft tunnel placement for reconstruction of the posterior cruciate ligament (PCL) to restore knee joint stability and facilitate optimal functional outcome. However, in vivo investigations that correlate tunnel position to functional results are lacking so far. This study evaluates the anatomic accuracy of femoral and tibial tunnel apertures on postoperative computed tomography (CT) scans and compares these findings to subjective and objective clinical outcome parameters. METHODS After single-bundle PCL reconstruction, 29 patients were stratified into several subgroups according to the anatomic accuracy of femoral and tibial tunnel apertures measured on postoperative CT scans. A threshold value for the centres of the tunnel apertures was determined using a measurement grid system as a radiographic reference. To evaluate the functional and radiological results, visual analogue scale, International Knee Documentation Committee (IKDC), Tegner, Lysholm, Knee Injury and Osteoarthritis Outcome Score and osteoarthritis scores were obtained. RESULTS Comparison between functional outcome and tunnel position yielded a statistically significant difference for subjective IKDC score and angle segment α and for objective stability and tunnel position P3 but no statistically significant difference with respect to intercondylar depth, intercondylar height and tibial tunnel position P2. No correlation was found between anatomic tunnel position and present or progressive osteoarthritis on follow-up. Of the patients, 72 % classified their result as excellent and good and 90 % would repeat surgical treatment. CONCLUSIONS Despite a small sample size and subject to the threshold values we used, our data indicate a potentially minor effect of anatomic tunnel placement on midterm functional outcome following PCL reconstruction.
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Affiliation(s)
- Michael Osti
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria,
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20
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Keller TC, Tompkins M, Economopoulos K, Milewski MD, Gaskin C, Brockmeier S, Hart J, Miller MD. Tibial tunnel placement accuracy during anterior cruciate ligament reconstruction: independent femoral versus transtibial femoral tunnel drilling techniques. Arthroscopy 2014; 30:1116-23. [PMID: 24907026 DOI: 10.1016/j.arthro.2014.04.004] [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: 07/25/2013] [Revised: 04/04/2014] [Accepted: 04/04/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to compare the accuracy of tibial tunnel placement using independent femoral (IF) versus transtibial (TT) techniques. METHODS Ten matched pairs of cadaveric knees were randomized so that one knee in the pair underwent arthroscopic TT drilling of the femoral tunnel and the other underwent IF drilling through an accessory medial portal. For both techniques, an attempt was made to place the femoral and tibial tunnels as close to the center of the respective anterior cruciate ligament (ACL) footprints as possible. Preoperative and postoperative computed tomography using a technique optimized for ligament evaluation allowed comparison of the anatomic ACL tibial footprint to the tibial tunnel aperture. The percentage of tunnel aperture contained within the native footprint, as well as the distance from the center of the tunnel aperture to the center of the footprint, was measured. Additionally, graft obliquity relative to the tibial plateau was evaluated in the sagittal plane. RESULTS The percentage of tibial tunnel aperture contained within the native footprint averaged 71.6% ± 17.2% versus 52.1% ± 23.4% (P = .04) in the IF and TT groups, respectively. The distance from the center of the footprint to the center of the tibial tunnel aperture was 3.50 ± 1.6 mm and 4.40 ± 1.7 mm (P = .27) in the IF and TT groups, respectively. TT drilling placed 6 of 10 tunnels posterior to the center of the footprint versus 3 of 10 tunnels in IF drilling. The graft obliquity angles were 54.8° in TT specimens and 47.5° in IF specimens (P = .09). CONCLUSIONS This study adds to the literature suggesting that TT drilling with an 8-mm reamer has deleterious effects on tibial tunnel aperture and position. IF drilling, which does not involve repeated reaming of the tibial tunnel, is associated with the placement of a higher percentage of the tunnel aperture within the native tibial footprint. There was not a significant difference between the IF and TT techniques in their ability to place the center of the tibial aperture near the center of the footprint or in graft obliquity. CLINICAL RELEVANCE ACL reconstruction has continued to evolve in an attempt to restore the functional anatomy and biomechanical behavior of the knee. Tibial tunnel characteristics-such as location, aperture topography, and tunnel obliquity-are important factors to consider in ACL reconstruction. This study compares tibial tunnels after IF and TT techniques.
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Affiliation(s)
- Thomas C Keller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Marc Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | | | | | - Cree Gaskin
- Department of Musculoskeletal Radiology, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Stephen Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Joseph Hart
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Benedetto KP, Hoffelner T, Osti M. The biomechanical characteristics of arthroscopic tibial inlay techniques for posterior cruciate ligament reconstruction: in vitro comparison of tibial graft tunnel placement. INTERNATIONAL ORTHOPAEDICS 2014; 38:2363-8. [PMID: 25042695 DOI: 10.1007/s00264-014-2458-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 06/29/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE The hypothesis of the present study was that the biomechanical properties of arthroscopic tibial inlay procedures depend on tibial graft bone block position. METHODS Five paired fresh-frozen human cadaveric knee specimens were randomized to a reconstruction with quadriceps tendon placing the replicated footprint either to the more proximal margin of the remnants of the anatomical PCL fibrous attachments (group A) or to the distal margin of the anatomical PCL fibrous attachments at the edge of the posterior tibial facet to the posterior tibial cortex in level with the previous physis line (group B). The relative graft-tibia motions, post cycling pull-out failure load and failure properties of the tibia-graft fixation were measured. Cyclic displacement at 5, 500 and 1,000 cycles, stiffness and yield strength were calculated. RESULTS The cyclic displacement at 5, 500 and 1,000 cycles measured consistently more in group A without statistically significant difference (4.11 ± 1.37, 7.73 ± 2.73 and 8.18 ± 2.75 mm versus 2.81 ± 1.33, 6.01 ± 2.37 and 6.46 ± 2.37 mm). Mean ultimate load to failure (564.6 ± 212.3) and yield strength (500.2 ± 185.9 N) were significantly higher in group B (p < 0.05). CONCLUSION Replicating the anatomical PCL footprint at the posterior edge of the posterior tibial facet yields higher pull-out strength and less cycling loading displacement compared to a tunnel position at the centre of the posterior tibial facet.
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Affiliation(s)
- Karl Peter Benedetto
- Department of Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
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Starman JS, Griffin JW, Kandil A, Ma R, Hogan MV, Miller MD. What's new in sports medicine. J Bone Joint Surg Am 2014; 96:695-702. [PMID: 24740667 DOI: 10.2106/jbjs.m.01569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- James S Starman
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Justin W Griffin
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Abdurrahman Kandil
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Richard Ma
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Macalus V Hogan
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
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Ihle C, Ateschrang A, Albrecht D, Mueller J, Stöckle U, Schröter S. Occupational consequences after isolated reconstruction of the insufficient posterior cruciate ligament. BMC Res Notes 2014; 7:201. [PMID: 24684773 PMCID: PMC3994232 DOI: 10.1186/1756-0500-7-201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/19/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND With incorrect or even without treatment, acute injuries of the posterior cruciate ligament (PCL) can lead to chronic instability of the knee joint. After delayed treatment, negative occupational changes and reduced quality of life can occur. These aspects have not yet been investigated. The purpose of this study was to evaluate occupational consequences after isolated reconstruction in cases of chronic PCL insufficiency. FINDINGS 12 patients treated with PCL reconstruction in a single bundle technique, using hamstring tendon grafts, were evaluated. All patients were operated upon at least 3 months after injury. Mean time of follow-up was 51 ± 18.2 months (14-75). Radiological assessment (Telos stress device) showed a side comparison of total translation of 4.5 ± 2.6 mm. Occupational consequences have been evaluated by the classification system "REFA". Median time incapacity for work was 8 weeks. Nearly all patients achieved the mental status of the normal population (SF-36), but physical status was still restricted. A pre- to postoperative improvement of the clinical scores could be seen: Lysholm-Score: 46.4 ± 17.3 to 84.7 ± 14.1, HSS-Score: 74.3 ± 10.5 to 88.3 ± 10.7. Postoperative evaluated scores were: Tegner score: 4.8 ± 1.2, IKDC score: 80.0 ± 16.2, VPS: 3.4 ± 2.7. Patients with low physical load in their workplace described significantly better clinical results in every clinical score (p < .05) and less pain than patients with high physical load prior to the accident (VPS: REFA < 2: 2.4 ± 2.6, REFA ≥ 2: 5.5 ± 1.7; p < 0.05). CONCLUSIONS Operative treated patients with a chronic PCL insufficiency achieve an improvement of the clinical result. Patients with low physical load at their workplace achieve less restrictions.
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Affiliation(s)
- Christoph Ihle
- Department of Traumatology and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, Schnarrrenbergstr. 95, 72076 Tübingen, Germany
| | - Atesch Ateschrang
- Department of Traumatology and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, Schnarrrenbergstr. 95, 72076 Tübingen, Germany
| | - Dirk Albrecht
- Group practice, Traumatology and Reconstructive Surgery, Listplatz 1, 72764 Reutlingen, Germany
| | - Johannes Mueller
- Department of Gastroenterology, Klinikum Ludwigsburg, Posilipostraße 4, 71640 Ludwigsburg, Germany
| | - Ulrich Stöckle
- Department of Traumatology and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, Schnarrrenbergstr. 95, 72076 Tübingen, Germany
| | - Steffen Schröter
- Department of Traumatology and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, Schnarrrenbergstr. 95, 72076 Tübingen, Germany
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Tompkins M, Keller TC, Milewski MD, Gaskin CM, Brockmeier SF, Hart JM, Miller MD. Transtibial Tunnel Placement in Posterior Cruciate Ligament Reconstruction: How It Relates to the Anatomic Footprint. Orthop J Sports Med 2014; 2:2325967114523384. [PMID: 26535303 PMCID: PMC4555621 DOI: 10.1177/2325967114523384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: It is common to place the posterior cruciate ligament (PCL) tibial tunnel with a transtibial technique using a guide that attempts to place the center of the tunnel 1 to 1.5 cm distal to the tibiofemoral joint. It is unknown how well this technique will re-create the native tibial footprint of the PCL. Purpose: To evaluate the accuracy of tibial tunnel placement using a transtibial technique. Study Design: Controlled laboratory study. Methods: Ten cadaveric knees from 10 donors underwent arthroscopic transtibial drilling of the tibial tunnel with use of a posteromedial portal for visualization. The transtibial guide was rested flush against the tibial spines to allow for the guide to be as distal as possible, which was between 1 and 1.5 cm distal to the tibiofemoral joint line. Using this technique, an attempt was made to place the tibial tunnels as close to the center of the PCL footprint as possible. All knees underwent computed tomography both pre- and postoperatively with a previously reported technique optimized for ligament evaluation. This allowed comparison of the anatomic PCL tibial footprint to the tibial tunnel aperture. The percentage of tunnel aperture contained within the native footprint as well as the distance from the center of the tunnel aperture to the center of the footprint was measured. Results: The percentage of tunnel aperture contained within the native footprint was 45.9% ± 23.1%. The distance from the center of the tibial tunnel aperture to the center of the tibial PCL footprint was 6.4 ± 2.3 mm. The tunnels were almost always (9/10) distal (or inferior) to the native footprint and either slightly lateral (5/10) or centered (5/10) in a medial to lateral direction. Conclusion: This study demonstrates that using the transtibial drilling technique in the tibia for PCL reconstruction places approximately half of the tibial tunnel aperture within the tibial footprint. Generally, the tunnel is distal to the footprint. Clinical Relevance: Consideration should be given to the fact that, using this transtibial technique, the tibial tunnel aperture is generally not placed in the center of the footprint. This may not be a negative issue, however, since there are other potential advantages from distal tunnel placement.
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Affiliation(s)
- Marc Tompkins
- Department of Orthopaedic Surgery/TRIA Orthopaedic Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Thomas C Keller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Matthew D Milewski
- Elite Sports Medicine/Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Cree M Gaskin
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA. ; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Joseph M Hart
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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