Evaluation and Comparison of Femoral Tunnel Placement During Anterior Cruciate Ligament Reconstruction Using 3-Dimensional Computed Tomography: Effect of Notchplasty on Transtibial and Medial Portal Drilling (original) (raw)
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Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2019
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 ¼ .003), respectively, compared with native ACLs. AMP-RR and TT also showed increased sagittal graft inclination compared with AMP-FR (þ6.1 , P ¼ .009 and þ9.0 , P < .001, respectively) and OI-drilling techniques (þ5.5 , P ¼ .024 and þ8.4 , 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.
Joints, 2017
Purpose The purpose of this study was to investigate, through three-dimensional computed tomography (3D-CT), the accuracy of femoral tunnel positioning in patients undergoing anterior cruciate ligament (ACL) reconstruction, comparing transtibial (TT) and anteromedial (AM) techniques. Methods We evaluated postoperative 3D-CT scans of 26 patients treated with ACL reconstruction with hamstrings autograft using a low accessory AM portal technique and 26 treated with the TT technique. The position of the femoral tunnel center was measured with the quadrant method. Results Using quadrant method on CT scans, femoral tunnels were measured at a mean of 32.2 and 28.1% from the proximal condylar surface (parallel to Blumensaat line) and at a mean of 31.2 and 15.1% from the notch roof (perpendicular to Blumensaat line) for the AM and TT techniques, respectively. Conclusion The AM portal technique provides more anatomical graft placement than TT techniques. Level of Evidence Level I, randomized ...
Ain Shams medical journal, 2021
Background: Although numerous clinical and cadaveric studies have compared transtibial (TT) versus tibial independent (TI) either anteromedial (AM) portal or Outside-in (OI) drilling techniques regarding anatomic femoral tunnel aperture placement in single bundle anterior cruciate ligament reconstruction (ACLR), there is no consensus on which technique offers the best anatomic position according to footprint position. Aim of the Work: The aim of this study is to conduct a systematic review and meta-analysis for studies comparing the anatomical position of femoral tunnel aperture in single bundle ACLR using TI and TT techniques. Methods: (PubMed, Cochrane library and Google Scholar) were searched for relative studies that evaluated femoral tunnel aperture position in patients and cadavers underwent arthroscopic single bundle ACLR. Meta-analyses were performed to pool 28 studies included in 15 outcomes measuring femoral tunnel aperture position by estimating the mean differences and their 95% confidence intervals from mean and standard deviation for each study. Results: 48 clinical and cadaveric studies compared femoral tunnel aperture position between TT and TI (AM and OI) techniques were obtained for final research. In these studies, 2384 clinical and cadaveric knees underwent arthroscopic single bundle ACLR, we qualitatively assessed the femoral aperture position in all 48 studies showing that the difference between TI and TT was non significant except in the direction perpendicular to Blumensaat's line (BL), but with low mean difference and anteroposterior (AP) anatomical axis. Conclusions: There was non-significant difference between TI and TT technique regarding placing femoral aperture position closer to footprint position. There was non-significant difference in femoral aperture sagittal plane position along BL or along (proximal-distal) PD axis. Regarding femoral aperture coronal plane placement in the axis perpendicular to BL; modified TT technique improved the femoral aperture position in this axis. While regarding femoral aperture placement in the anteroposterior (AP) anatomical axis; TI technique placed femoral aperture significantly more posterior than TT technique, this was proper position regarding anatomic ACLR, while according to the recent concept of ACL femoral footprint, this might be improper position." INTRODUCTION: Improper femoral aperture placement is the most common cause of anterior cruciate ligament reconstruction (ACLR) failure or unsatisfactory outcomes (long term joint degeneration and re-rupture, technical errors
Journal of Orthopaedic Surgery and Research, 2022
Background: Femoral tunnel can be drilled through tibial tunnel (TT), or independent of it (TI) by out-in (OI) technique or by anteromedial (AM) technique. No consensus has been reached on which technique achieves more proper femoral aperture position because there have been evolving concepts in the ideal place for femoral aperture placement. This meta-analysis was performed to analyze the current literature comparing femoral aperture placement by TI versus TT techniques in ACL reconstruction. Methods: We performed a comprehensive systematic review and meta-analysis of English-language literature in PubMed, Cochrane, and Web of Science databases for articles comparing femoral aperture placement by TI versus TT techniques with aperture position assessed by direct measurement or by postoperative imaging, PXR and/or CT and/ or MRI. Results: We included 55 articles with study population of 2401 knees of whom 1252 underwent TI and 1149 underwent TT techniques. The relevant baseline characteristics, whenever compared, were comparable between both groups. There was nonsignificant difference between TI and TT techniques in the distance from aperture center to footprint center and both techniques were unable to accurately recreate the anatomic footprint position. TI technique significantly placed aperture at more posterior position than TT technique. TI technique significantly lowered position of placed aperture perpendicular to Blumensaat's line (BL) than TT technique, and modifications to TT technique had significant effect on this intervention effect. Regarding sagittal plane aperture placement along both AP anatomical axis and BL, there was nonsignificant difference between both techniques. Conclusion: Modifications to TT technique could overcome limitations in aperture placement perpendicular to BL. The more anterior placement of femoral aperture by TT technique might be considered, to some extent, a proper position according to recent concept of functional anatomical ACL reconstruction.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2011
Purpose: This cadaveric study was undertaken to characterize the femoral tunnel geometry resulting from commonly used drilling techniques in anterior cruciate ligament reconstruction. Methods: We randomized 10 matched-pair cadaveric knees (20 knees) into 2 groups with right and left matched pairs from each cadaver. Of the knees, 10 underwent transtibial femoral tunnel drilling from a far-medial starting point on the tibia (group 1) and 10 had the femoral tunnel drilled from a medial arthroscopic portal (group 2). The dimensions and size of the apertures, the volume and length of the tunnels, and the distance of the tunnels from the posterior wall and articular surface were measured by computed tomography. Results: The mean femoral tunnel length was 29.7 mm in group 1 and 15.7 mm in group 2. The mean volume for each tunnel was 2,401 mm 3 in group 1 and 2,071 mm 3 in group 2. The intra-articular aperture area was 94.6 mm 2 in group 1 and 98.6 mm 2 in group 2. In group 2 the intra-articular shape was more elliptical than in group 1, with the long axis averaging 13.5 Ϯ 1.3 mm (P ϭ .004) and short axis averaging 9.7 Ϯ 1.0 mm (P ϭ .002); in group 2 the long axis averaged 12.5 Ϯ 1.7 and short axis averaged 10.3 Ϯ 0.7 (P ϭ .002). Group 2 was closer to the posterior wall and articular surface (6.9 Ϯ 0.6 mm and 9.4 Ϯ 0.6 mm, respectively) than group 1 (10.8 Ϯ 1.0 mm and 11.8 Ϯ 1.9 mm, respectively). Conclusions: We determined the length and volume of the femoral tunnel to be shorter and smaller, respectively, with a medial arthroscopic portal. In addition, the aperture shape was more of an ellipse with a medial arthroscopic portal. The medial arthroscopic portal also created a femoral tunnel that was closer to the posterior wall and articular surface of the femur. Clinical Relevance: Improved characterization of osseous tunnels with 3-dimensional figures will allow for improved matching of graft and incorporation.
The Journal of Bone and Joint Surgery-American Volume, 2010
Background: Transtibial drilling techniques are widely used for arthroscopic reconstruction of the anterior cruciate ligament, most likely because they simplify femoral tunnel placement and reduce surgical time. Recently, however, there has been concern that this technique results in nonanatomically positioned bone tunnels, which may cause abnormal knee function. The purpose of this study was to use three-dimensional computed tomography models to visualize and quantify the positions of femoral and tibial tunnels in patients who underwent traditional transtibial single-bundle reconstruction of the anterior cruciate ligament and to compare these positions with reference data on anatomical tunnel positions. Methods: Computed tomography scans were performed on thirty-two knees that had undergone transtibial singlebundle reconstruction of the anterior cruciate ligament. Three-dimensional computed tomography models were aligned into an anatomical coordinate system. Tibial tunnel aperture centers were measured in the anterior-to-posterior and medial-to-lateral directions on the tibial plateau. Femoral tunnel aperture centers were measured in anatomic posteriorto-anterior and proximal-to-distal directions and with the quadrant method. These measurements were compared with reference data on anatomical tunnel positions. Results: Tibial tunnels were located at a mean (and standard deviation) of 48.0% ± 5.5% of the anterior-to-posterior plateau depth and a mean of 47.8% ± 2.4% of the medial-to-lateral plateau width. Femoral tunnels were measured at a mean of 54.3% ± 8.3% in the anatomic posterior-to-anterior direction and at a mean of 41.1% ± 10.3% in the proximal-todistal direction. With the quadrant method, femoral tunnels were measured at a mean of 37.2% ± 5.5% from the proximal condylar surface (parallel to the Blumensaat line) and at a mean of 11.3% ± 6.6% from the notch roof (perpendicular to the Blumensaat line). Tibial tunnels were positioned medial to the anatomic posterolateral position (p < 0.001). Femoral tunnels were positioned anterior to both anteromedial and posterolateral anatomic tunnel locations (p < 0.001 for both). Conclusions and Clinical Relevance: Transtibial anterior cruciate ligament reconstruction failed to accurately place femoral and tibial tunnels within the native anterior cruciate ligament insertion site. If anatomical graft placement is desired, transtibial techniques should be performed only after careful identification of the native insertions. If anatomical positioning of the femoral tunnel cannot be achieved, then an alternative approach may be indicated.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2013
Purpose: This study aimed to undertake a retrospective analysis of prospectively collected data comparing, at a minimum follow-up of 5 years (78.1 AE 5.3 months v 75.6 AE 4.8 months), the clinical, functional, and radiographic outcomes of 2 homogeneous groups of athletes who had undergone arthroscopic single-bundle autologous hamstring reconstruction of the anterior cruciate ligament (ACL) using a transtibial (TT) or an anteromedial portal (AMP) approach to drill the femoral tunnel. Methods: Ninety-four patients were operated on in 2005 and 2006, and 88 (93.6%) (73 men, 15 women) were evaluated subjectively and objectively, using the Lysholm and International Knee Documentation Committee (IKDC) scores, manual maximum displacement test with a KT-1000 arthrometer (MEDmetric, San Diego, CA) and the Lachman test, and rotational instability with the pivot shift test. Degenerative changes were assessed on radiographs according to the Fairbank classification. Results: The median age at operation was 29 years (20 to 43 years; SD, 5.4) in the TT group 1 and 28 years (19 to 45 years; SD, 6.1) in the AMP group 2. At the last appointment, the 2 groups had similar results for the Lysholm and IKDC scores (primary outcome). Patients who underwent the AMP approach had less glide pivot shift (P ¼ .42) and Lachman (P ¼ .47) phenomena, with no statistically significant intergroup difference. Radiography showed fewer, but not significantly different, degenerative changes in the AMP ACL reconstruction group at final follow-up (P ¼ .47). Conclusions: In our series, ACL reconstruction using a femoral tunnel drilled through an AMP provided better rotational stability and anterior translation than drilling the femoral tunnel using the TT technique. This difference likely is not relevant from a clinical and functional viewpoint. The 2 groups of patients were not significantly different in terms of development of degenerative changes seen radiographically at a minimum follow-up of 5 years. Level of Evidence: Level III, retrospective comparative study.
European Journal of Orthopaedic Surgery & Traumatology, 2019
The aim of this study was to compare the outcomes between anteromedial (AM) and transtibial (TT) femoral tunnel positioning techniques for the reconstruction of chronic anterior cruciate ligament (ACL) rupture. Materials and methods It is a randomized prospective study of 106 patients who underwent ACL reconstruction because of a chronic ACL rupture (55 AMT, 51 TT). Minimum follow-up was 2 years. Demographic, clinical and radiological data, including MRI grafts' anatomy and biomechanics intraoperative navigation system evaluation, were analyzed. Also, International Knee Documentation Committee score, Tegner Knee score, Lysholm Knee Score, Short-Form Health Survey and 4-point Likert Scale were evaluated. Results The AM technique achieves a more anatomic graft than TT technique in both sagittal and coronal plane (6° approximately). Immediate postoperative biomechanical evaluation of the graft showed both techniques significantly improved translational and rotational laxity (p = 0.000). AMT showed superiority only in controlling internal rotation (p = 0.016). Both techniques reported significant improvement in all evaluated score scales, without differences between techniques. Independently of the femoral tunnel positioning technique, patients with cartilage lesion had worse clinical outcomes. Conclusions Our findings suggest that AMT achieves a more anatomical and biomechanically accurate graft allowing better control over internal rotation laxity; however, this does not lead to better clinical outcomes if we compare with TT in the reconstruction of chronic ACL rupture. Patients with chronic ACL rupture and cartilage lesion had worse clinical outcomes, independently the femoral tunnel positioning technique.