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Häner M, Stoffels T, Guenther D, Pfeiffer T, Imhoff A, Herbort M, Stein T, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Mehl J, Niederer D, Jung T, Kittl C, Eberle C, Vernacchia C, Ellermann A, Braun PJ, Krause M, Mengis N, Müller PE, Best R, Achtnich A, Petersen W. Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment. Knee Surg Sports Traumatol Arthrosc 2024; 32:223-234. [PMID: 38293720 DOI: 10.1002/ksa.12064] [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: 11/03/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Martin Häner
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
| | | | - Daniel Guenther
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Thomas Pfeiffer
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Andreas Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | | | - Thomas Stein
- SPORTHOLOGICUM® Frankfurt am Main, Frankfurt, Germany
- Department of Sports Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum, Duisburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | | | | | | | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel Niederer
- Department of Movement and Training Science, Faculty of Humanities and Social Sciences, Institute of Sport Science, University of Wuppertal, Wuppertal, Germany
- Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt, German
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | | | - Cara Vernacchia
- Department of Physical Medicine & Rehabilitation, Shirley Ryan Ability Lab, Chicago, Illinois, USA
- McGaw, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Philipp-Johannes Braun
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus, Berlin, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natalie Mengis
- ARCUS Sports Clinic, Pforzheim, Germany
- KSA Aarau/Spital Zofingen, Zofingen, Switzerland
| | - Peter E Müller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
- Department of Sports Medicine and Orthopaedics, University of Tuebingen, Tuebingen, Germany
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Wolf Petersen
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
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Hughes JD, Gabrielli AS, Dalton JF, Raines BT, Dewald D, Musahl V, Lesniak BP. More anterior placement of femoral tunnel position in ACL-R is associated with postoperative meniscus tears. J Exp Orthop 2023; 10:66. [PMID: 37389669 DOI: 10.1186/s40634-023-00630-y] [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: 03/01/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023] Open
Abstract
PURPOSE The purpose of this study was to investigate the relationship between tunnel position in ACL reconstruction (ACL-R) and postoperative meniscus tears. METHODS This was a single institution, case-control study of 170 patients status-post ACL-R (2010-2019) separated into two matched groups (sex, age, BMI, graft type). Group 1-symptomatic, operative meniscus tears (both de novo and recurrent) after ACL-R. Group 2-no postoperative meniscus tears. Femoral and tibial tunnel positions were measured by 2 authors via lateral knee radiographs that were used to measure two ratios (a/t and b/h). Ratio a/t was defined as distance from the tunnel center to dorsal most subchondral contour of the lateral femoral condyle (a) divided by total sagittal diameter of the lateral condyle along Blumensaat's line (t). The ratio b/h was defined as distance between the tunnel and Blumensaat's line (b) divided by maximum intercondylar notch height (h). Wilcoxon sign-ranks paired test was used to compare measurements between groups (alpha set at p < 0.05). RESULTS Group 1 had average follow up of 45 months and Group 2 had average follow up of 22 months. There were no significant demographic differences between Groups 1 and 2. Group 1-a/t was 32.0% (± 10.2), which was significantly more anterior than group 2, 29.3% (± 7.3; p < 0.05). There was no difference in average femoral tunnel ratio b/h or tibial tunnel placement between groups. CONCLUSIONS A relationship exists between more anterior/less anatomic femoral tunnel position and the presence of recurrent or de novo, operative meniscus tears after ACL-R. Surgeons performing ACL-R should strive for recreation of native anatomy via proper tunnel placement to maximize postoperative outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jonathan D Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Freddie Fu Sports Medicine Center, 3200 S. Water St, Pittsburgh, PA, 15203, USA.
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Alexandra S Gabrielli
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Freddie Fu Sports Medicine Center, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Jonathan F Dalton
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Freddie Fu Sports Medicine Center, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Benjamin T Raines
- The Hughston Clinic, Fort Walton Beach, FL, USA
- The Hughston Foundation, Inc, Columbus, GA, USA
| | | | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Freddie Fu Sports Medicine Center, 3200 S. Water St, Pittsburgh, PA, 15203, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Freddie Fu Sports Medicine Center, 3200 S. Water St, Pittsburgh, PA, 15203, USA
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Borque KA, Laughlin MS, Pinheiro VH, Jones M, Williams A. Rebranding the 'anatomic' ACL reconstruction: Current concepts. J ISAKOS 2023; 8:23-28. [PMID: 36435433 DOI: 10.1016/j.jisako.2022.11.001] [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] [Received: 06/27/2022] [Revised: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022]
Abstract
The anterior cruciate ligament (ACL) is a complex ribbon-like structure, which is approximately 3.5 times larger at the tibial and femoral insertions than at the midpoint. Accordingly, it is impossible to recreate with a single cylindrical graft. However, this has not stopped surgeons from using the term "anatomic" to describe multiple ACL reconstruction techniques inserting at a number of different locations within the original ACL footprint, causing confusion. The term "anatomic" should be discarded and replaced by an anatomic description of the tunnel placements on the tibia and femur. Current ACL reconstruction techniques cite anatomical studies that identified "direct and indirect fibres" of the ACL. The "direct fibres" bear 85-95% of the load and provide the main resistance to both anterior tibial translation and internal rotation/pivot shift. On the femur, these fibres insert in a line just posterior to the intercondylar ridge and comprise the portion of the ACL that surgeons should strive to restore. Placement of the graft just posterior to the intercondylar ridge creates a line of placement options from the anteromedial bundle to the "central" position and finally to the posterolateral bundle position. The authors prefer placing the femoral tunnel in the isometric anteromedial position and addressing a high-grade pivot shift at the IT-band with a lateral extra-articular tenodesis. As with the femoral tunnel, the native ACL footprint on the tibia is much larger than the ACL graft and thus can be placed in multiple "anatomic" locations. The authors prefer placement of the tibial tunnel in the anterior most position of the native footprint that does not cause impingement in the femoral notch. Additional research is needed to determine the ideal tunnel positions on the femur and tibia and validating the technique with patient outcomes. However, this cannot be accomplished without describing tunnel placement with specific anatomical locations so other surgeons can replicate the technique.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Hospital, Houston, TX, 77479, USA.
| | | | | | - Mary Jones
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
| | - Andy Williams
- Fortius Clinic, FIFA Medical Centre of Excellence, London, W1H 6EQ, UK
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Chiba D, Yamamoto Y, Kimura Y, Sasaki E, Sasaki S, Tsuda E, Ishibashi Y. Association Between Early Postoperative Graft Signal Intensity and Residual Knee Laxity After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2022; 10:23259671221109608. [PMID: 35898202 PMCID: PMC9310230 DOI: 10.1177/23259671221109608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 03/31/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) graft signal intensity is associated with graft damage after anterior cruciate ligament reconstruction (ACLR). However, little is known about the relationship between graft signal intensity and residual laxity of the reconstructed knee based on patient age. Purpose/Hypothesis: To evaluate the relationship between graft signal intensity and residual laxity in younger and older patients who underwent ACLR. We hypothesized that higher graft signal intensity would be associated with reduced postoperative knee stability. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 192 patients who underwent double-bundle ACLR were recruited. Proton density–weighted and T2-weighted MRI was performed at 3, 6, and 12 months after surgery, and the signal intensity ratio (SIR) of the anteromedial and posterolateral bundles was measured as the graft signal intensity reference values. At 12 months after surgery, if the KT-1000 arthrometer measurement exhibited a side-to-side difference of ≥2 mm, the patient was determined as having anterior knee laxity. Rotatory knee laxity was defined as a positive pivot shift with International Knee Documentation Committee grade ≥1. The Mann-Whitney U test was used to compare the SIR in patients with and without residual laxity. The Spearman correlation coefficient was used to evaluate the relationship between demographic parameters and the SIR. Based on receiver operating characteristic curves, the optimal SIR cutoff values to predict residual laxity were calculated, and logistic regression analysis was conducted. Results: Of 192 patients, 26 (13.5%) had anterior knee laxity, and 20 (10.4%) had rotatory knee laxity. The SIR was negatively correlated with age. In younger patients (<30 years; n = 135), those with residual laxity had a significantly higher SIR than those without laxity; this relationship was not significant in older patients (≥30 years; n = 57). Based on receiver operating characteristic curves and logistic regression analysis, the cutoff values that were determined for the SIR were significantly associated with a higher odds ratio of residual laxity. Conclusion: Graft signal intensity decreased with patient age. Patients with higher graft signal intensity in the early postoperative phase after ACLR exhibited a higher prevalence of residual laxity, particularly in younger patients.
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Affiliation(s)
- Daisuke Chiba
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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