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Yumashev AV, Baltina TV, Babaskin DV. Outcomes after arthroscopic revision surgery for anterior cruciate ligament injuries. Acta Orthop 2021; 92:443-447. [PMID: 33739222 PMCID: PMC8381895 DOI: 10.1080/17453674.2021.1897744] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The frequency of primary anterior cruciate ligament (ACL) reconstruction is increasing resulting in more ACL revision surgeries. Therefore, we assessed survival rates of 2 different grafts for ACL revision surgery at 1- and 5-year follow-ups, as well as physical activity levels of patients after revision surgery.Patients and methods - This is a retrospective cohort study involving 218 patients (176 males) who had revision surgery for anterior cruciate ligament injuries between 2008 and 2017 at the Clinic of Traumatology, Orthopedics and Joint Pathology Clinic (I.M. Sechenov First Moscow State Medical University). A comparison group involved 189 patients with only primary surgery. Surgical interventions were performed according to the standard procedure using bone-patellar tendon-bone (BTB) and semitendinosus/gracilis (ST/G) autografts. The results of revision surgery were assessed at 1- and 5-year follow-ups by using the Lysholm and International Knee Documentation Committee scores.Results - Malpositioned bone tunnels were found in 87/218 patients (40%). At 1 and 5 years postoperatively, the revision BTB group had significantly better results in terms of IKDC and Lysholm scores than the revision ST/G group (p = 0.03, Mann-Whitney U-test), and these results were comparable to those in the comparison group. Graft survival after revision was lower than after the primary operation. However, the survival rate of 80% is quite high and is consistent with previous findings. There were no statistically reliable differences in survival between ST/G and BTB autografts.Interpretation - The graft choice for revision ACL surgery should be decided upon before surgery based on, among other things, the state of bone tunnels, in particular their position and degree of bone resorption. Tunnel widening that exceeds 14 mm (osteolysis) would require 2-stage surgery using a BTB autograft with bone plugs because it is larger than the ST/G autograft.
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Affiliation(s)
- Alexei V Yumashev
- Department of Prosthetic Dentistry, Sechenov First Moscow State Medical University (Sechenov University), Moscow; ,Correspondence:
| | - Tatyana V Baltina
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan;
| | - Dmitrii V Babaskin
- Department of Pharmacy, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
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2
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Hodel S, Mania S, Vlachopoulos L, Fürnstahl P, Fucentese SF. Influence of femoral tunnel exit on the 3D graft bending angle in anterior cruciate ligament reconstruction. J Exp Orthop 2021; 8:44. [PMID: 34173071 PMCID: PMC8233443 DOI: 10.1186/s40634-021-00364-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To quantify the influence of the femoral tunnel exit (FTE) on the graft bending angle (GBA) and GBA-excursion throughout a full range of motion (ROM) in single-bundle anterior cruciate ligament (ACL) reconstruction. Methods Three-dimensional (3D) surface models of five healthy knees were generated from a weight-bearing CT obtained throughout a full ROM (0, 30, 60, 90, 120°) and femoral and tibial ACL insertions were computed. The FTE was simulated for 16 predefined positions, referenced to the Blumensaat's line, for each patient throughout a full ROM (0, 30, 60, 90, 120°) resulting in a total of 400 simulations. 3D GBA was calculated between the 3D directional vector of the ACL and the femoral tunnel, while the intra-articular ACL insertions remained unchanged. For each simulation the 3D GBA, GBA-excursion, tunnel length and posterior tunnel blow-out were analysed. Results Overall, mean GBA decreased with increasing knee flexion for each FTE (p < 0.001). A more distal location of the FTE along the Blumensaat's line resulted in an increase of GBA and GBA-excursion of 8.5 ± 0.6° and 17.6 ± 1.1° /cm respectively (p < 0.001), while a more anterior location resulted in a change of GBA and GBA-excursion of -2.3 ± 0.6° /cm (+ 0.6 ± 0.4°/ cm from 0–60° flexion) and 9.8 ± 1.1 /cm respectively (p < 0.001). Mean tunnel length was 38.5 ± 5.2 mm (range 29.6–50.5). Posterior tunnel blow-out did not occur for any FTE. Conclusion Aiming for a more proximal and posterior FTE, with respect to Blumensaat’s line, reliably reduces GBA and GBA-excursion, while preserving adequate tunnel length. This might aid to reduce excessive graft stress at the femoral tunnel aperture, decrease femoral tunnel widening and promote graft-healing. Level of Evidence IV
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Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Sylvano Mania
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
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黄 碧, 邓 文, 李 韬, 李 棋. [Progress of different methods for femoral tunnel positioning in anterior cruciate ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:118-123. [PMID: 33448209 PMCID: PMC8171607 DOI: 10.7507/1002-1892.202005003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/31/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To systematically review the progress of different methods for femoral tunnel positioning in anterior cruciate ligament (ACL) reconstruction and provide a clinical reference for treatment of ACL rupture. METHODS The literature about the femoral tunnel positioning in ACL reconstruction was widely reviewed. The advantages and disadvantages and the clinical results of each method were summarized. RESULTS Currently in ACL reconstruction, methods for femoral tunnel positioning include transtibial technique (TT), anteromedial technique (AM), outside-in (OI), modified TT (mTT), and computer assisted surgery. There is no significant difference in the postoperative effectiveness between TT technique and AM technique. Compared with the TT technique, the OI technique has higher rotational stability of knee, but there is no significant difference in clinical results. The femoral tunnel located by mTT technique is closer to the anatomical placement than that of TT technique, but mTT technique is not effective for systematically anatomic femoral tunnel positioning, and further research is needed to prove its advantages. CONCLUSION Different femoral tunnel positioning methods have their own advantages and disadvantages, and there is no definite evidence that one is superior than the rest.
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Affiliation(s)
- 碧滢 黄
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 文宇 邓
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 韬 李
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 棋 李
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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4
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Yanagisawa S, Kimura M, Hagiwara K, Ogoshi A, Yoneyama T, Omae H, Miyamoto R, Chikuda H. A steep coronal graft bending angle is associated with bone tunnel enlargement of the posterolateral bundle after anterior cruciate ligament reconstruction. J Orthop Surg (Hong Kong) 2020; 28:2309499019888811. [PMID: 31829103 DOI: 10.1177/2309499019888811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The correlation between the graft bending angle (GBA) of the anteromedial bundle and posterolateral bundle after anterior cruciate ligament reconstruction (ACLR) and postoperative tunnel enlargement was evaluated. METHODS Two hundred fifty-eight patients (137 males, 121 females; mean age 27.3 years) who had undergone double-bundle ACLR were included. Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months postoperatively. The area of the tunnel aperture for femoral anteromedial tunnel (FAMT) and femoral posterolateral tunnel (FPLT) was measured; the area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The femoral tunnel angles were obtained with Cobb angle measurements. The femoral tunnel angle in the coronal plane was measured relative to the tibial plateau (coronal GBA). On the median value, the patients were divided into two groups in each of FAMT and FPLT; those with a coronal GBA of FAMT of ≥27° were classified as group A, while those with a coronal GBA of <27° were classified as group B, those with a coronal GBA of FPLT of ≥23° were classified as group C, while those with a coronal GBA of<23° were classified as group D. RESULTS Group A included 129 knees, while group B included 129 knees. Groups A and B did not significantly differ regarding FAMT enlargement. Group C included 133 knees, while group D included 125 knees. The percentage of FPLT enlargement in group C was significantly smaller than that in group D (p = 0.001). CONCLUSIONS A steep coronal GBA of the FPLT after ACLR results in greater FPLT enlargement. The present findings suggest that surgeons should avoid creating a steep GBA of the FPLT in the outside-in technique.
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Affiliation(s)
- Shinya Yanagisawa
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Masashi Kimura
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Keiichi Hagiwara
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Atsuko Ogoshi
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Tomotaka Yoneyama
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Hiroaki Omae
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Ryosuke Miyamoto
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
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Trofa DP, Saltzman BM, Corpus KT, Connor PM, Fleischli JE, Piasecki DP. A Hybrid Transtibial Technique Combines the Advantages of Anteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial. Am J Sports Med 2020; 48:3200-3207. [PMID: 33017169 DOI: 10.1177/0363546520956645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The anteromedial (AM) portal and transtibial (TT) approaches are 2 common anterior cruciate ligament (ACL) femoral tunnel drilling techniques, each with unique benefits and disadvantages. A hybrid TT (HTT) technique using medial portal guidance of a flexible TT guide wire has recently been described that may combine the strengths of both the AM portal and the TT approaches. HYPOTHESIS The HTT technique will achieve anatomic femoral tunnel apertures similar to the AM portal technique, with improved femoral tunnel length and orientation. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS A total of 30 consecutive patients with primary ACL tears were randomized to undergo the TT, AM portal, or HTT technique for femoral tunnel positioning at the time of reconstruction. All patients underwent 3-dimensional computed tomography of the operative knee at 6 weeks postoperatively. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as graft bending angles in the sagittal and coronal planes, were measured. RESULTS Tibial tunnel lengths and aperture positions were identical between the 3 groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regard to both height (P = .629) and depth (P = .582). By contrast, compared with the AM portal and HTT techniques, femoral apertures created with the TT technique were significantly higher (P < .001 and P < .001, respectively) and shallower (P = .014 and P = .022, respectively) in the notch. The mean femoral tunnel length varied significantly between the groups, measuring 35.2, 41.6, and 54.1 mm for the AM portal, HTT, and TT groups, respectively (P < .001). Last, there was no difference between the mean coronal (P = .190) and sagittal (P = .358) graft bending angles between the TT and HTT groups. By contrast, compared with the TT and HTT techniques, femoral tunnels created with the AM portal technique were significantly more angulated in the coronal plane (17.7° [P < .001] and 12.5° [P = .006], respectively) and sagittal plane (13.5° [P < .001] and 10.5° [P = .013], respectively). CONCLUSION This prospective randomized controlled trial found that the HTT technique achieved femoral aperture positions equally as anatomic as the AM portal technique but produced longer, less angulated femoral tunnels, which may help reduce graft strain and mismatch. As such, this hybrid approach may represent a beneficial combination of both the TT and the AM portal techniques. REGISTRATION NCT02795247 (ClinicalTrials.gov identifier).
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Affiliation(s)
- David P Trofa
- Department of Orthopedics, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Bryan M Saltzman
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Keith T Corpus
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Patrick M Connor
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - James E Fleischli
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Dana P Piasecki
- Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
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Graft Inclination Angles in Anterior Cruciate Ligament Reconstruction Vary Depending on Femoral Tunnel Reaming Method: Comparison Among Transtibial, Anteromedial Portal, and Outside-In Retrograde Drilling Techniques. Arthroscopy 2020; 36:1095-1102. [PMID: 31791892 DOI: 10.1016/j.arthro.2019.09.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/25/2019] [Accepted: 09/29/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare graft coronal and sagittal inclination angles in anterior cruciate ligament (ACL) reconstruction performed by different femoral tunnel drilling techniques with respect to intact native ACL. METHODS In total, 72 patients were prospectively enrolled in the study. The inclusion criteria were complete ACL rupture and patient age between 18 and 55 years. Reconstructions were performed using 4 different femoral tunnel drilling technique: transtibial (TT), anteromedial portal with rigid (AMP-RR) or flexible (AMP-FR) reamer, and outside-in retrograde drilling (OI) techniques. Eighteen patients with intact native ACL were included as controls. Sagittal and coronal graft inclination angles were measured by magnetic resonance imaging 6 months after the procedure by 1 radiologist blinded in regards to the used technique. RESULTS OI and AMP-FR techniques allowed for the maintenance of native-like ACL inclination in both the sagittal and coronal planes, whereas TT and AMP-RR increased the sagittal angle by a mean of 9.5° (P < .001) and 6.7° (P = .003), respectively, compared with native ACLs. AMP-RR and TT also showed increased sagittal graft inclination compared with AMP-FR (+6.1°, P = .009 and +9.0°, P < .001, respectively) and OI-drilling techniques (+5.5°, P = .024 and +8.4°, P < .001, respectively). No differences were observed among study groups in terms of coronal graft inclination. CONCLUSIONS The study hypothesis was partially confirmed, since OI and AMP-FR techniques, but not AMP-RR, using an independent portal for femoral drilling produce a more anatomic graft inclination on the sagittal plane with respect to TT. LEVEL OF EVIDENCE II, prospective comparative study.
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7
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Lee SS, Seo IW, Cho MS, Shin YS. Comparison of femoral tunnel length and obliquity of anatomic versus nonanatomic anterior cruciate ligament reconstruction: A meta-analysis. PLoS One 2020; 15:e0230497. [PMID: 32203530 PMCID: PMC7089554 DOI: 10.1371/journal.pone.0230497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 03/03/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose Theoretical considerations suggest that femoral tunnel length might cause graft mismatch, and femoral tunnel obliquity could be related to the longevity of graft in anterior cruciate ligament (ACL) reconstruction. However, controversy still exists regarding these issues in the context of the comparison of anatomic and nonanatomic ACL reconstructions. The purpose of this meta-analysis was to compare the length and obliquity of the femoral tunnel created by drilling through either anatomic or nonanatomic ACL reconstructions. Materials and method In this meta-analysis, we reviewed studies that compared femoral tunnel length and femoral tunnel obliquity in the coronal plane with the use of anatomic or nonanatomic ACL reconstruction. The major databases were reviewed for appropriate studies from the earliest available date of indexing through December 31, 2018. No restrictions were placed on the language of publication. Results Twenty-seven studies met the criteria for inclusion in this meta-analysis. The femur tunnel length of anatomic ACL reconstruction was significantly shorter compared with that of nonanatomic ACL reconstruction by 8.66 mm (95% CI: 7.10–10.22 mm; P<0.001), while the femur tunnel obliquity in the coronal plane of anatomic ACL reconstruction was significantly more oblique versus that of nonanatomic ACL reconstruction by 15.29° (95% CI: 8.07°–22.52°; P<0.001). Similar results in terms of femoral tunnel length were found for the subgroup with cadaveric (7.15 mm; 95% CI: 2.69–11.61 mm; P = 0.002) and noncadaveric (8.96 mm; 95% CI: 7.24–10.69 mm; P<0.001) studies, whereas different results in terms of femoral tunnel obliquity were noted for the subgroup with cadaveric (10.62°; 95% CI: −6.12° to 27.37°; P = 0.21) and noncadaveric (15.86°; 95% CI: 8.11°–23.60°; P<0.001) studies. Conclusion Anatomic ACL reconstruction resulted in the femoral tunnel length and femoral tunnel obliquity in the coronal plane being shorter and more oblique, respectively, as compared with nonanatomic ACL reconstruction. Level of evidence Therapeutic study, Level III.
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Affiliation(s)
- Sang-Soo Lee
- Institute for Skeletal Aging & Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University School of Medicine, Chuncheon, Republic of Korea
| | - In-Wook Seo
- Department of Orthopedic Surgery, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Min-Soo Cho
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University School of Medicine, Chuncheon, Republic of Korea
| | - Young-Soo Shin
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University School of Medicine, Chuncheon, Republic of Korea
- * E-mail:
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Saito M, Nakajima A, Sonobe M, Takahashi H, Akatsu Y, Inaoka T, Iwasaki J, Morikawa T, Watanabe A, Aoki Y, Sasho T, Nakagawa K. Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique. Knee Surg Sports Traumatol Arthrosc 2019; 27:2468-2477. [PMID: 30374576 DOI: 10.1007/s00167-018-5240-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel. METHODS Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups. RESULTS There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004). CONCLUSION There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.
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Affiliation(s)
- Masahiko Saito
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan.
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Tsutomu Inaoka
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
| | - Junichi Iwasaki
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Tsuguo Morikawa
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba, 260-8670, Japan
| | - Koichi Nakagawa
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
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Mehta A, Lin CC, Campbell RA, Chin G, McGarry MH, Lee TQ, Adamson GJ. Effects of Anteromedial Portal versus Transtibial ACL Tunnel Preparation on Contact Characteristics of the Graft and the Tibial Tunnel Aperture. Clin Orthop Surg 2019; 11:52-59. [PMID: 30838108 PMCID: PMC6389531 DOI: 10.4055/cios.2019.11.1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/27/2018] [Indexed: 12/24/2022] Open
Abstract
Background The purpose of this study was to compare the tibial tunnel aperture contact characteristics simulating an anteromedial and transtibial anterior cruciate ligament (ACL) tunnel preparation. Methods Seven matched pairs of cadaveric knees were tested. From each knee, a 10-mm quadriceps ACL graft was prepared. The native ACL was arthroscopically removed and tibial tunnels were drilled. In one knee, a transtibial technique was performed with femoral tunnel drilling approached through the tibial tunnel. For the anteromedial technique on the contralateral knee, the posterior tibial tunnel was chamfered with a rasp. The knees were then disarticulated and tibial tunnel aperture geometry was measured. A pressure sensor was placed between the graft and the posterior aspect of the tibial tunnel and the graft was secured with an interference screw. Contact force, contact area, contact pressure, peak contact pressure, hysteresis and stiffness were measured at cyclic loads of 50 N, 100 N, 150 N, and 200 N. Results Tibial tunnel aperture area, diameter and deviation from a circle were significantly larger with the transtibial technique (p < 0.05). There was no significant difference in hysteresis, stiffness, contact area, contact force and mean contact pressure. The peak contact pressure between the ACL graft and the tibial tunnel was significantly higher with the anteromedial technique for 100 N (p = 0.04), 150 N (p = 0.01), and 200 N (p = 0.002) cyclic loading. Conclusions Increased peak contact pressure on the graft at the tibial aperture with the anteromedial technique may increase the stress on the graft and possibly lead to failure following ACL reconstruction.
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Affiliation(s)
- Akshay Mehta
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Charles C Lin
- Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Ronald A Campbell
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Garwin Chin
- Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA.,Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA.,Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA.,Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA.,Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Gregory J Adamson
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
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Ra HJ, Celik H, Kim HJ, Lee DH. Femoral tunnel widening is similar between anteromedial portal and transtibial techniques following single-bundle anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2019; 27:626-635. [PMID: 30306239 DOI: 10.1007/s00167-018-5204-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE In anterior cruciate ligament (ACL) reconstruction, there is concern regarding the potential risk of femoral tunnel widening in the anteromedial portal (AMP) technique due to the acute graft-bending angle at the aperture and the more elliptical aperture shape of the femoral tunnel compared to the transtibial (TT) techniques. Therefore, the aim of the current systematic review and meta-analysis was to compare the femoral tunnel widening between the AMP and TT techniques in patients who underwent ACL reconstruction. METHODS It should be included the studies that reported on femoral tunnel widening in patients who underwent single-bundle ACL reconstruction, using soft-tissue tendon graft, with AMP and/or TT techniques. Two reviewers independently recorded data from each study, including the sample size and magnitude of tunnel widening after ACL reconstruction. RESULTS Twenty-one studies were finally included in this meta-analysis. The pooled changes of absolute millimeters of tunnel widening from the immediate postoperative status to the last follow-up did not differ significantly between the AMP and TT techniques at both the aperture [3.31 mm, 95% confidence interval (CI) 1.7-5.0. mm versus 2.9 mm, 95% CI 2.4-3.4 mm, P = n.s.] and the midportion (3.5 mm, 95% CI 0.8-6.3 mm versus 3.0 mm, 95% CI 2.2-3.9 mm, P = n.s.) of the femoral tunnel. No significant difference was observed between the two techniques in the relative percentage of femoral tunnel widening (AMP; 28.8%, 95% CI 14.8-42.9% vs. TT; 29.7%, 95% CI 15.6-43.7%, P = n.s.). CONCLUSION No significant difference in femoral tunnel widening was observed between the AMP and TT techniques, both in absolute millimeter and relative percentage, in patients who underwent single-bundle ACL reconstruction. This finding could alleviate the potential concerns associated with femoral tunnels being wider for the AMP than for the TT technique. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ho Jong Ra
- Department of Orthopaedic Surgery, College of Medicine, Gangneung Asan Hospital, Ulsan University, Gangneung, Republic of Korea
| | - Haluk Celik
- Department of Orthopaedic Surgery, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Hyun-Jun Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu, 06351, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu, 06351, Seoul, South Korea.
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11
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Geng Y, Gai P. Comparison of 2 femoral tunnel drilling techniques in anterior cruciate ligament reconstruction. A prospective randomized comparative study. BMC Musculoskelet Disord 2018; 19:454. [PMID: 30579352 PMCID: PMC6303949 DOI: 10.1186/s12891-018-2376-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 12/10/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To evaluate the length and position of femoral tunnel,and exam whether knee stability and clinical functional outcomes are superior in AMP method. METHODS From August 2014 to February 2015, we prospectively recruited 104 patients undergoing anterior cruciate ligament reconstruction. They were randomized to anteromedial portal or transtibial method. All patients underwent Lysholm score, International Knee Documentation Committee score,Tegner score at pre-operative and last follow-up point as subjective assessment of clinical function. The Lachman test, the Pivot-shift test and KT-1000 were performed at the last follow-up as a evaluation of knee joint stability. We measured the length of femoral tunnel intraoperatively and at 1 week post-operatively, CT-based three-dimensional reconstruction was used to assess femoral tunnel location. RESULTS The average follow-up time of anteromedial portal group was 25.7 ± 6.8 months (range:12-36.5 months), and the average follow-up time of the transtibial group was 24.9 ± 6.0 months (range:12-37 months). There was no significant difference between the groups pre-operative Lysholm score, IKDC score and Tegner scores. Both groups showed significantly improvement in these clinical function scores at follow up for their ACL reconstruction. However, there was no significant difference in the function scores between the two groups at last follow up. However, the mean femoral tunnel length in the anteromedial portal group was significantly shorter than that in the transtibial group. And tunnel location was significantly lower and deeper with the anteromedial portal technique than with the transtibial technique. CONCLUSION The use of anteromedial portal method resulted in a significantly lower and deeper placement of the femoral tunnel, and a shorter tunnel length compared to the transtibial method. However, there was no statistical difference in terms of clinical function and knee joint stability between the anteromedial portal method and the transtibial method. TRIAL REGISTRATION Name of the registry: Chinese Clinical Trial Registry. The registration number: ChiCTR1800014874 . The date of registration: 12 February, 2018. The study is retrospectively registered.
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Affiliation(s)
- Yunhang Geng
- Qingdao University Medical College, Qingdao, China.,Department of Orthopaedic Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, People's Republic of China
| | - Pengzhou Gai
- Department of Orthopaedic Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, People's Republic of China.
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12
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Kim JG, Kang SH, Kim JH, Lim CO, Wang JH. Comparison of Clinical Results, Second-Look Arthroscopic Findings, and MRI Findings Between the Transportal and Outside-In Techniques for Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Trial With a Minimum 2-Year Follow-up. Am J Sports Med 2018; 46:544-556. [PMID: 29293362 DOI: 10.1177/0363546517744535] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques. PURPOSE To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups. RESULTS No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05). CONCLUSION With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.
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Affiliation(s)
- Jae Gyoon Kim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Seung Hoon Kang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Chae Ouk Lim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
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13
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Choi CH, Kim SJ, Chun YM, Kim SH, Lee SK, Eom NK, Jung M. Influence of knee flexion angle and transverse drill angle on creation of femoral tunnels in double-bundle anterior cruciate ligament reconstruction using the transportal technique: Three-dimensional computed tomography simulation analysis. Knee 2018; 25:99-108. [PMID: 28978459 DOI: 10.1016/j.knee.2017.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/19/2017] [Accepted: 09/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to find appropriate flexion angle and transverse drill angle for optimal femoral tunnels of anteromedial (AM) bundle and posterolateral (PL) bundle in double-bundle ACL reconstruction using transportal technique. METHODS Thirty three-dimensional knee models were reconstructed. Knee flexion angles were altered from 100° to 130° at intervals of 10°. Maximum transverse drill angle (MTA), MTA minus 10° and 20° were set up. Twelve different tunnels were determined by four flexion angles and three transverse drill angles for each bundle. Tunnel length, wall breakage, inter-tunnel communication and graft-bending angle were assessed. RESULTS Mean tunnel length of AM bundle was >30mm at 120° and 130° of flexion in all transverse drill angles. Mean tunnel length of PL bundle was >30mm during every condition. There were ≥1 cases of wall breakage except at 120° and 130° of flexion with MTA for AM bundle. There was no case of wall breakage for PL bundle. Considering inter-tunnel gap of >2mm without communication and obtuse graft-bending angle, 120° of flexion and MTA could be recommended as optimal condition for femoral tunnels of AM and PL bundles. CONCLUSION Flexion angle and transverse drill angle had combined effect on femoral tunnel in double-bundle ACL reconstruction using transportal technique. Achieving flexion angle of 120° and transverse drill angle close to the medial femoral condyle could be recommended as optimal condition for femoral tunnels of AM and PL bundles to avoid insufficient tunnel length, wall breakage, inter-tunnel communication and acute graft-bending angle.
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Affiliation(s)
- Chong Hyuk Choi
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Jae Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su-Keon Lee
- Department of Orthopaedic Surgery, Gwangmyung Sungae Hospital, Gyeonggi, Republic of Korea
| | - Nam-Kyu Eom
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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14
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Chen H, Tie K, Qi Y, Li B, Chen B, Chen L. Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials. J Orthop Surg Res 2017; 12:167. [PMID: 29115973 PMCID: PMC5678560 DOI: 10.1186/s13018-017-0671-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 10/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study was to compare the clinical outcome and postoperative complication between single-bundle anterior cruciate ligament (ACL) reconstruction with an anteromedial (AM) technique and a transtibial (TT) technique. Methods The study includes clinical randomized controlled trials comparing the clinical outcomes of ACL reconstruction using the autologous hamstring tendon with an AM method and a TT method published up to September 2017 were retrieved from PubMed, Cochrane Library, and Embase databases. Relevant data were extracted and the Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality. Stata/SE 12.0 was used to perform a meta-analysis of the clinical outcome. Results Five RCTs were included, with a total of 479 patients: 239 patients and 240 patients in the AM group and the TT group, respectively. Assessing postoperative stability, better results were found in the AM group for the negative rate of the Lachman test (P < 0.05), the negative rate of the pivot-shift test (P < 0.05) and the side-to-side difference (P < 0.05). Assessing postoperative functional outcome, the AM group yielded superior results in proportion with International Knee Documentation Committee (IKDC) grade A (P < 0.05) and the Lysholm scores (P < 0.05) but had a comparable IKDC score (P > 0.05). In terms of postoperative complication, no significant difference was found between the AM group and the TT group (P > 0.05). Conclusions The outcome of single-bundle ACL reconstruction with the AM technique is better than that with the TT technique in terms of postoperative stability and functional recovery of the knee.
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Affiliation(s)
- Haitao Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Kai Tie
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yongjian Qi
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Bin Li
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Biao Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Liaobin Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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Tashiro Y, Gale T, Sundaram V, Nagai K, Irrgang JJ, Anderst W, Nakashima Y, Tashman S, Fu FH. The Graft Bending Angle Can Affect Early Graft Healing After Anterior Cruciate Ligament Reconstruction: In Vivo Analysis With 2 Years' Follow-up. Am J Sports Med 2017; 45:1829-1836. [PMID: 28402758 DOI: 10.1177/0363546517698676] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A high graft bending angle (GBA) after anterior cruciate ligament (ACL) reconstruction has been suggested to cause stress on the graft. Nevertheless, evidence about its effect on graft healing in vivo is limited. HYPOTHESIS The signal intensity on magnetic resonance imaging (MRI) would be higher in the proximal region of the ACL graft, and higher signals would be correlated to a higher GBA. STUDY DESIGN Descriptive laboratory study. METHODS Anatomic single-bundle ACL reconstruction was performed on 24 patients (mean age, 20 ± 4 years) using the transportal technique. A quadriceps tendon autograft with a bone plug was harvested. To evaluate graft healing, the signal/noise quotient (SNQ) was measured in 3 regions of interest (ROIs) of the proximal, midsubstance, and distal ACL graft using high-resolution MRI (0.45 × 0.45 × 0.70 mm), with decreased signals suggesting improved healing. Dynamic knee motion was examined during treadmill walking and running to assess the in vivo GBA. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors at each motion frame, based on tibiofemoral kinematics determined from dynamic stereo X-ray analysis. Graft healing and GBAs were assessed at 6 and 24 months postoperatively. Repeated-measures analysis of variance was used to compare the SNQ in the 3 ROIs at 2 time points. Pearson correlations were used to analyze the relationship between the SNQ and mean GBA during 0% to 15% of the gait cycle. RESULTS The SNQ of the ACL graft in the proximal region was significantly higher than in the midsubstance ( P = .022) and distal regions ( P < .001) at 6 months. The SNQ in the proximal region was highly correlated with the GBA during standing ( R = 0.64, P < .001), walking ( R = 0.65, P = .002), and running ( R = 0.54, P = .015) but not in the other regions. At 24 months, signals in the proximal and midsubstance regions decreased significantly compared with 6 months ( P < .001 and P = .008, respectively), with no difference across the graft area. CONCLUSION The signal intensity was highest in the proximal region and lowest in the distal region of the reconstructed graft at 6 months postoperatively. A steep GBA was significantly correlated with high signal intensities of the proximal graft in this early period. A steep GBA may negatively affect proximal graft healing after ACL reconstruction.
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Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vani Sundaram
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kanto Nagai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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16
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Tashiro Y, Sundaram V, Thorhauer E, Gale T, Anderst W, Irrgang JJ, Fu FH, Tashman S. In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament-Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique. Arthroscopy 2017; 33:1393-1402. [PMID: 28343809 PMCID: PMC5495610 DOI: 10.1016/j.arthro.2017.01.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the in vivo dynamic graft bending angle (GBA) in anterior cruciate ligament (ACL)-reconstructed knees, correlate the angle to tunnel positions and tunnel widening, and evaluate the effects of 2 femoral tunnel drilling techniques on GBA. METHODS Patients with an isolated ACL injury undergoing reconstruction from 2011 to 2012 were included. Transportal techniques were used to create femoral tunnels. Tunnel locations were determined by 3-dimensional computed tomography. Tibiofemoral kinematics during treadmill walking and running were assessed by dynamic stereo x-ray analysis 6 months and 2 years postoperatively. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors on each motion frame. The cross-sectional areas of femoral tunnels were measured at 6 months and compared with the initial size to assess tunnel widening. RESULTS A total of 54 patients were included. Use of flexible drills resulted in significantly higher GBAs during walking (80.6° ± 7.8°, P < .001) and running (80.5° ± 9.0°, P = .025) than rigid drills (walking, 67.5° ± 9.3°; running, 74.1° ± 9.6°). Their use led to greater tunnel widening of 113.9% ± 17.6%, as compared with 97.7% ± 17.5% for rigid drills (P = .003). The femoral and tibial apertures were located in similar anatomic positions in both groups, but the femoral tunnel exits were located more anteriorly (P < .001) in the flexible drill group. A higher GBA was highly correlated with anterior location of femoral exits (r = 0.63, P < .001) and moderately correlated with greater tunnel widening (r = 0.48, P < .001). CONCLUSIONS High GBAs were identified during dynamic activities after anatomic ACL reconstruction with a transportal femoral tunnel drilling technique. The GBA was greater when flexible drills were used. The high bending angle resulted from the more anterior location of the femoral tunnel exits, and it correlated with early bone tunnel widening at 6 months. These results suggest that a high GBA may increase stress at the bone-graft interface and contribute to greater tunnel widening after anatomic ACL reconstruction, although the clinical impact should be further investigated. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ysutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Vani Sundaram
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Eric Thorhauer
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - James J. Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Freddie H. Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
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Kang K, Bae TS. Effect of femoral tunnel positions on graft stress in outside-in ACL reconstruction surgery during continuous knee motion: A simulation study. Int J Med Robot 2017; 13. [PMID: 28370840 DOI: 10.1002/rcs.1817] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/07/2017] [Accepted: 02/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Previous studies regarding the optimal femoral tunnel location for an anterior cruciate ligament (ACL) reconstruction were based on static experiments at specific angles, and did not consider continuous motion of the knee. METHODS Twenty-four surgical sites were set and continuous kinematic data, obtained from motion analysis, was used to describe knee movement. The bending angle and stress of the ACL graft as well as the length of the femoral tunnel was calculated through multi-flexible body dynamics analysis. RESULTS The lowest stress was found at both 5 mm and 10 mm radius at a proximal posterior of 45°, and the highest stress was also found at a distal 15 mm radius. Relatively high stresses were also identified between the distal and anterior regions as well as the distal and posterior regions at 15 mm radius. CONCLUSION Considering the availability of surgery, it was identified that the optimum femoral tunnel location is at 10 mm radius locations at a proximal posterior of 45°.
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Affiliation(s)
- Kyungmin Kang
- Dept. of Biomedical Engineering, Jungwon University, 85, Munmu-ro, Goesan-eup, Goesan-gun, Chungcheongbuk-do, 367-805, Korea
| | - Tae Soo Bae
- Dept. of Biomedical Engineering, Jungwon University, 85, Munmu-ro, Goesan-eup, Goesan-gun, Chungcheongbuk-do, 367-805, Korea
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18
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Tashiro Y, Irarrázaval S, Osaki K, Iwamoto Y, Fu FH. Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:129-137. [PMID: 27277192 DOI: 10.1007/s00167-016-4191-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/31/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine graft bending angle (GBA) during knee motion after anatomic anterior cruciate ligament (ACL) reconstruction and to clarify whether surgical techniques affect GBA. Our hypotheses were that the graft bending angle would be highest at knee extension and the difference of surgical techniques would affect the bending steepness. METHODS Eight healthy volunteers with a mean age of 29.3 ± 3.0 years were recruited and 3D MRI knee models were created at three flexion angles (0°, 90° and 130°). Surgical simulation of the tunnel drilling was performed with anatomic tunnel position using each outside-in (OI), trans-portal (TP) and trans-tibial (TT) techniques on the identical cases. The models were matched to other knee positions and the GBA in 3D was measured using computational software. Double-bundle ACL reconstruction was analysed first, and single-bundle reconstruction was also analysed to evaluate its effect to reduce GBA. A repeated-measures ANOVA was used to compare GBA difference at three flexion angles, by three techniques or of three bundles. RESULTS GBA changed substantially with knee motion, and it was highest at full extension (p < 0.001) in each surgical technique. OI technique exhibited highest GBA for anteromedial bundle (94.3° ± 5.2°) at extension, followed by TP (83.1° ± 6.5°) and TT (70.0° ± 5.2°) techniques (p < 0.01). GBA for posterolateral bundle at extension were also high in OI (84.6° ± 7.4°), TP (83.0° ± 6.3°) and TT (77.2° ± 7.0°) techniques (n.s.). Single-bundle grafts did not decrease GBA compared with double-bundle grafts. In OI technique, a more proximal location of the femoral exit reduced GBA of each bundle at extension and 90° flexion. CONCLUSION A significant GBA change with knee motion and considerably steep bending at full extension, especially with OI and TP techniques, were simulated. Although single-bundle technique did not reduce GBA as seen in double-bundle technique, proximal location of femoral exits by OI technique, with tunnels kept in anatomic position, was effective in decreasing GBA at knee extension and flexion. For clinical relevance, high stress on graft and bone interface has been suggested by steep GBA at full extension after anatomic ACL reconstruction. LEVEL OF EVIDENCE Therapeutic study (prospective comparative study), Level II.
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Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA. .,Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Sebastián Irarrázaval
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
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19
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Figueroa D, Calvo R, Figueroa F, Paccot D, Izquierdo G, Morales N. Clinical and arthrometric outcomes of an anatomic outside-in single-bundle anterior cruciate ligament reconstruction using a retrodrill. Knee 2016; 23:1098-1105. [PMID: 27816290 DOI: 10.1016/j.knee.2016.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 05/28/2016] [Accepted: 07/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The main option to perform an anatomic anterior cruciate ligament (ACL) reconstruction is the anteromedial portal (AMP) technique. It has several reported complications (iatrogenic chondral injury, posterior-wall blowout, short sockets, increased risk of injury to common peroneal nerve). In an attempt to avoid these complications the outside-in (OI) technique was revived with the addition of a retrodrill. The aim of this study is to evaluate the clinical and arthrometric outcomes of a series of anatomical OI single bundle ACL reconstruction using a retrodrill. METHODS Prospective case series. KT-1000 and Pivot Shift Test were done at 24 months follow-up. International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores preoperatively and at final follow-up. Complications were reported. Statistical analysis was done with t-test. RESULTS 275 knees of 200 (73%) males and 75 (27%) females were enrolled in the study. Mean age 29.1 years (15-54). Mean follow-up 34.5 months (24-49). Mean preoperatively Lysholm Score 62 (25-95) versus 95 (76-100) at final follow-up (p<0.001) Mean preoperatively IKDC score 60 (26.4-90.8) versus 92 (59.8-100) at final follow-up (p<0.001) Mean Tegner activity Score pre injury 5 versus 5 at final follow-up. (p=0.59) Mean KT-1000 side-to-side difference 2mm (1-6). Pivot Shift test negative in 243 patients (90%); positive in 32 (10%) patients. 13 (5%) ACL re-ruptures. 2 (0.7%) infections. No other complications were reported. CONCLUSION OI single bundle anatomic ACL reconstruction using a retrodrill is a valid and safe option that avoids the complications reported with the AMP technique.
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Affiliation(s)
- David Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile.
| | - Rafael Calvo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Francisco Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Daniel Paccot
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Guillermo Izquierdo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Nelson Morales
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
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Kumar BS, Andrade R, Leal A, Sarmento A, Pereira H, Sevivas N, Espregueira-Mendes J. Surgical Adjustment of the Guide Pin to Perform a Correct Tibial Tunnel in Anatomical Anterior Cruciate Ligament Single-Bundle Reconstruction. Arthrosc Tech 2016; 5:e757-e762. [PMID: 27709033 PMCID: PMC5040105 DOI: 10.1016/j.eats.2016.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 03/02/2016] [Indexed: 02/03/2023] Open
Abstract
Anatomical positioning of the graft in anterior cruciate ligament reconstruction is important to restore normal knee kinematics and prevent early joint degeneration. Inadequate position of a first attempt to place the guide pin within the center of the tibial footprint may occur. Therefore, its adjustment is important to achieve the anatomical positioning of the graft within the tibial footprint. When the guide pin exits eccentrically in an inadequate position, it is possible to correct it to the center of the footprint. A small tunnel with a 4.5-mm reamer is made and the guide pin is shifted to the center of the footprint. The center of the tunnel can be corrected until 50% and in all direction in relation to the initial drilled tunnel, without additional associated morbidity. Once the correct position of the center is achieved, the guide pin is fixed in the femoral notch roof to guarantee the accurate correction of the axis, without toggling of the guide pin inside the tunnel and metal dusting. The final tunnel is then drilled with the same size of the graft. With this technique it is possible to adjust an eccentrically misplaced guide pin to the center of the footprint without additional morbidity.
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Affiliation(s)
| | - Renato Andrade
- Faculty of Sports, University of Porto, Porto, Portugal
- Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
| | - Ana Leal
- Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- CMEMS Center for MicroElectroMechanical Systems, Mechanical Engineering Department, University of Minho, Guimarães, Portugal
| | - André Sarmento
- Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, Porto, Portugal
- Orthopaedic Department, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | - Hélder Pereira
- Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal
- 3B's Research Group—Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Barco, Portugal
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Nuno Sevivas
- Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- 3B's Research Group—Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Barco, Portugal
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Orthopaedics Department, Hospital de Braga, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | - João Espregueira-Mendes
- Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- 3B's Research Group—Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Barco, Portugal
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Orthopaedics Department of Minho University, Minho, Portugal
- Address correspondence to João Espregueira-Mendes, M.D., Ph.D., Via Futebol Clube do Porto—F. C. Porto Stadium, Porto, Portugal.Via Futebol Clube do Porto—F. C. Porto StadiumPortoPortugal
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21
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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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22
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Lee DH, Kim HJ, Ahn HS, Bin SI. Comparison of Femoral Tunnel Length and Obliquity Between Transtibial, Anteromedial Portal, and Outside-In Surgical Techniques in Single-Bundle Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Arthroscopy 2016; 32:142-50. [PMID: 26422705 DOI: 10.1016/j.arthro.2015.07.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 06/27/2015] [Accepted: 07/27/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE It is unclear whether femoral tunnel length and obliquity differ after transtibial and independent femoral drilling techniques of anterior cruciate ligament (ACL) reconstruction. This meta-analysis therefore compared femoral tunnel length and obliquity in patients who underwent ACL reconstruction by the transtibial, anteromedial (AM) portal, and outside-in (OI) techniques. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, all studies comparing femoral tunnel length and obliquity with various measurement tools-from direct measurement to imaging methods such as plain radiography, computed tomography, or magnetic resonance imaging-in patients who underwent reconstruction by the transtibial or independent femoral drilling (AM portal or OI) techniques were included. RESULTS Fourteen studies were included in the meta-analysis. The femoral tunnel length was 7.8 to 11.0 mm longer (P < .05) and coronal obliquity was 7.5° to 29.1° more vertical (P < .05) with the transtibial technique than with the AM portal or OI technique. Femoral tunnel and graft obliquity in the sagittal plane, however, did not differ significantly (P > .05). CONCLUSIONS ACL reconstruction using the AM portal and OI femoral drilling techniques resulted in a shorter length and greater coronal obliquity of the femoral tunnel than did the transtibial technique. However, these 3 femoral drilling techniques resulted in similar obliquities of the femoral tunnel and graft in the sagittal plane. LEVEL OF EVIDENCE Level III, meta-analysis.
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Affiliation(s)
- Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyeong-Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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23
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Osti M, Krawinkel A, Ostermann M, Hoffelner T, Benedetto KP. Femoral and tibial graft tunnel parameters after transtibial, anteromedial portal, and outside-in single-bundle anterior cruciate ligament reconstruction. Am J Sports Med 2015; 43:2250-8. [PMID: 26138734 DOI: 10.1177/0363546515590221] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic graft tunnel placement is recommended in anterior cruciate ligament (ACL) reconstruction to restore knee joint stability and function. Transtibial (TT), anteromedial portal (AMP), and outside-in (OI) retrograde drilling surgical techniques have been described for tibial and femoral bone tunnel preparation. PURPOSE/HYPOTHESIS The purpose of this study was to evaluate the bone tunnel parameters and compare the ability of 3 different surgical techniques to achieve placement of the ACL femoral and tibial bone tunnels at the center of the native ACL femoral and tibial attachment sites. The hypothesis was that tunnel placement using an AMP or OI technique would result in optimized tunnel parameters and more closely reconstruct the center of the native ACL femoral attachment site. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study population consisted of 100 patients undergoing anatomic single-bundle ACL reconstruction using multiple-stranded hamstring tendon grafts. In group 1 (n = 36), the femoral tunnel was drilled using a TT surgical technique; in group 2 (n = 32), the femoral tunnel was drilled through an AMP; and in group 3 (n = 32), the femoral tunnel was created by use of an OI technique with retrograde drilling. Computed tomography (CT) scans were obtained postoperatively, and characteristics of femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. The position of the resulting tibial and femoral bone tunnels for each group was compared with the center of the native ACL attachment sites. RESULTS There were statistically significant differences (P < .05) for the ACL femoral tunnel between the 3 groups with respect to intercondylar height, total tunnel length, graft fixation length, tunnel axis, and tunnel entry angle. Statistically significant differences (P < .05) were found for the ACL tibial tunnel with respect to anteroposterior tunnel position and sagittal tunnel axis between the TT and both the OI and AMP techniques. The OI surgical technique produced more oblique and anatomically correct femoral tunnel apertures and longer femoral tunnel lengths compared with the AMP technique. Both AMP and OI techniques resulted in a more precise replication of intercondylar tunnel depth and height. There was no statistically significant difference for graft fixation length between the AMP and OI techniques. CONCLUSION The AMP and OI surgical techniques were superior in positioning the ACL femoral tunnel at the center of the native ACL attachment site compared with the TT technique. An acceptable graft fixation length was obtained for all 3 surgical techniques.
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Affiliation(s)
- Michael Osti
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Alessa Krawinkel
- Department for Diagnostic and Interventional Radiology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Michael Ostermann
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Thomas Hoffelner
- Department for Trauma Surgery and Sports Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Karl Peter Benedetto
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
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24
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Relationship between femoral tunnel location and graft bending angle in outside-in and transportal technique for ACL double bundle reconstruction in 3D-CT study. Arch Orthop Trauma Surg 2015; 135:839-46. [PMID: 25940125 DOI: 10.1007/s00402-015-2226-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Indexed: 01/10/2023]
Abstract
INTRODUCTION In anterior cruciate ligament (ACL) reconstruction, sharp angulation of the graft at tunnel aperture increases local strain to the graft. The purpose of this study is to investigate the relationship between femoral tunnel location and femoral graft bending angle after ACL double bundle reconstruction (ACL-DBR) with two different drilling techniques. MATERIALS AND METHODS In ACL-DBR, femoral tunnel was created by two techniques; outside-in technique (26 patients, group A) and transportal technique (25 patients, group B). CT scan was taken at 1 week postoperatively. The position of femoral tunnel exit on the lateral femoral cortex, and intra-articular femoral and tibial tunnel aperture of the anteromedial bundle (AMB) and postero-lateral bundle (PLB) was measured using a rectangular frame on three-dimensional CT images. Femoral graft bending angle was measured using two-dimensional CT images. RESULTS Femoral tunnel exits of AMB and PLB in group A were significantly anterior and proximal than those in group B (p < 0.05), while there was no significant difference in intra-articular femoral and tibial tunnel apertures between group A and B. A mean femoral graft bending angle of AMB was 80.3° in group A and 69.2 degrees in group B, respectively (p < 0.05). A mean femoral graft bending angle of PLB was 66.3° in group A and 64.6° in group B, respectively. In both groups, a significant (p < 0.05) correlation (r < -0.4) was observed between the position of the femoral tunnel exit (anterior-posterior ratio from femoral anterior border line) and the femoral graft bending angle in AMB. CONCLUSIONS Since the femoral tunnel exit in outside-in technique was located more anterior and proximal, femoral graft bending angle of AMB in outside-in technique was greater than that in transportal technique. Anterior position of the femoral tunnel exit in AMB increased femoral graft bending angle in outside-in and transportal techniques.
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25
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Farmedial versus anteromedial portal drilling of the femoral tunnel in ACL reconstruction: a computed tomography analysis. Arch Orthop Trauma Surg 2015; 135:539-47. [PMID: 25697814 DOI: 10.1007/s00402-015-2176-z] [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: 09/10/2014] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The success of ACL reconstruction is predicated on a variety of factors. Tunnel placement plays one of the most significant roles in achieving knee kinematics and function. The purposes of this study were to compare femoral tunnel position, angle, length and posterior wall blow-out after ACL reconstruction with hamstring tendons autograft through either a farmedial portal or an anteromedial portal technique. MATERIALS AND METHODS We evaluated 36 patients who underwent ACL reconstruction between January 2014 and July 2014 in our institute, in a prospective, randomised cohort study. All the surgical procedures were performed by a sports fellowship-trained orthopaedic surgeon with experience in both portal reaming. The operated knees were evaluated with 0.5 mm fine CT scans of 3-D CT between days 3 and 5 postoperatively. RESULTS According to the 3-D CT measurements, the mean femoral tunnel length was significantly longer (p < 0.05) in the FAM group compared with the AM group. The femoral bone tunnel length averaged 34.2 ± 3.6 mm versus 36.6 ± 3.0 mm (p = 0.042) in AM and the FAM groups, respectively. The femoral tunnel position, as evaluated with use of the quadrant method, was more anterior in the FAM transportal technique group, and the difference between the two groups was significant (p < 0.05). CONCLUSION FAM tranportal drilling of the femoral tunnel creates longer and anterior femoral tunnels with regard to the AM portal drilling techniques. Additional studies with clinical outcomes are required for the clinical relevance of these techniques and to show which one is superior. LEVEL OF EVIDENCE Level I, prospective randomised comparative cohort study.
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26
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Boddu CK, Arif SK, Hussain MM, Sankaranarayanan S, Hameed S, Sujir PR. Prevention of graft-tunnel mismatch during anatomical anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft. Bone Joint J 2015; 97-B:324-8. [DOI: 10.1302/0301-620x.97b3.34653] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Graft-tunnel mismatch of the bone-patellar tendon-bone (BPTB) graft is a major concern during anatomical anterior cruciate ligament (ACL) reconstruction if the femoral tunnel is positioned using a far medial portal technique, as the femoral tunnel tends to be shorter compared with that positioned using a transtibial portal technique. This study describes an accurate method of calculating the ideal length of bone plugs of a BPTB graft required to avoid graft–tunnel mismatch during anatomical ACL reconstruction using a far medial portal technique of femoral tunnel positioning. Based on data obtained intra-operatively from 60 anatomical ACL reconstruction procedures, we calculated the length of bone plugs required in the BPTB graft to avoid graft–tunnel mismatch. When this was prevented in all the 60 cases, we found that the mean length of femoral bone plug that remained in contact with the interference screw within the femoral tunnel was 14 mm (12 to 22) and the mean length of tibial bone plug that remained in contact with the interference screw within the tibial tunnel was 23 mm (18 to 28). These results were used to validate theoretical formulae developed to predict the required length of bone plugs in BPTB graft during anatomical ACL reconstruction using a far medial portal technique. Cite this article: Bone Joint J 2015;97-B:324–8.
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Affiliation(s)
- C. K. Boddu
- Lenox Hill Hospital, 210
East 64th Street, 4th Floor, New
York, New York 10065, USA
| | - S. K. Arif
- Yenepoya Medical College, Mangalore, Karnataka, India
| | - M. M. Hussain
- Yenepoya Medical College, Mangalore, Karnataka, India
| | | | - S. Hameed
- Hamad Medical Corporation, Doha, Qatar
| | - P. R. Sujir
- Kasturba Medical College, Mangalore, Karnataka, India
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