Anatomic Anatomic Anterior Cruciate Ligament Reconstruction Research Articles

Anterolateral stabilization using the modified Lemaire technique for ACL deficiency

Treatment of persistent anterolateral knee instability. Subjective/objective (rotational) instability of the knee after anatomic anterior cruciate ligament (ACL) reconstruction. ACL re-rupture including special demands (e.g., high-performance athletes, hyperlaxity) RELATIVE CONTRAINDICATIONS: Osteoarthritis, additional instability of the knee, which should be treated independently; non-anatomic ACL reconstruction with persisting instability should be treated first with anatomic ACL reconstruction. General contraindications for surgery (e. g. septic arthritis), acute irritation of the affected knee. Supine position. Incision along the proximal lateral femoral epicondyle. Marking of the needed width and length of the iliotibial band (ITB) graft. Passing the ITB graft underneath the lateral collateral ligament. Find and mark the isometric point for fixation next to the lateral femoral epicondyle. Fixation of the ITB graft. Layered wound closure. Knee brace for at least 6weeks. Range of motion (RoM): from postoperative day1: flexion-extension 90-0-0°; first 2weeks after surgery: partial weight bearing (20 kg). An anterolateral extra-articular reconstruction may reduce apersistent anterolateral rotatory instability as well as the re-rupture rate following ACL reconstruction with good patient-reported short-term outcomes. Based on current (biomechanical) data, anterolateral tenodesis seems to be superior to areconstruction of the anterolateral ligament. If atenodesis is performed, the graft should be fixed in an isometric position, with neutral rotation of the knee and low graft tension to avoid extraphysiologic load within the lateral compartment. Indications for such aprocedure may include ahigh-grade pivot shift or revision ACL reconstruction as well as apersistent anterolateral rotatory instability following anatomic ACL reconstruction.

Comparison of clinical results, second look arthroscopic findings, and magnetic resonance imaging findings, between the transportal and outside-in techniques after double bundle anatomic anterior cruciate ligament reconstruction: A prospective randomized controlled trial with a minimum 2-year follow-up

Introduction 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 two techniques. We aimed 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. Methods From November 2010 to March 2013, 128 cases were enrolled in this study and were randomly assigned to either the TP group (64 cases) or the OI group (64 cases), 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. Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by using second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). Results There were no significant differences between the two groups in terms of clinical evaluation, with the exception of postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the functional test of the objective IKDC score was significantly larger for the OI group than the TP group (P = 0.005). The second-look arthroscopic findings were not significantly different between the two groups in either bundle (P > 0.05). In addition, MRI findings did not differ significantly between the two groups (P > 0.05). Conclusion With the exception of the functional test of IKDC objective score, clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction.

Graft choice for anatomic anterior cruciate ligament reconstruction: The comparison between thin autograft and thick hybrid graft. An observational study.

Great controversy over the graft choice has been lasted now. This study compared the second-look evaluation and clinical outcomes of anatomic anterior cruciate ligament reconstruction (ACL-R) using a thin autograft versus a thick hybrid graft.Seventy-six patients with complete follow-up data were categorized into the autograft group (N = 34) and hybrid group (N = 42). The Lysholm score, Tegner activity level, International Knee Documentation Committee (IKDC) Knee Evaluation Form, and KT-1000 test were performed before and at follow-up. Results were compared, and further comparisons were made for grafts thicker than 8.5 mm.The hybrid graft was thicker than the autograft (9.10 ± 0.52 vs 8.57 ± 0.48 mm, P < .001). The KT-1000 test, subjective evaluation, and activity level scores increased significantly between pre- and postoperation for all patients (P < .001). No significant differences were, however, found between the 2 groups. Only grafts thicker than 8.5 mm were selected from the autograft (N = 14) and hybrid (N = 34) groups, the Lysholm, IKDC, and KT-1000 test scores were significantly superior for the autograft than the hybrid graft (P = .021, P = .005, and P = .024, respectively).For anatomic ACL-R, a pure autograft is superior to a hybrid graft of the same diameter. The purity of the autograft was more important than the size, and augmenting allografts may be unnecessary.

Anatomic anterior cruciate ligament reconstruction with 70° arthroscope for better placement of Femoral and Tibial Tunnels

The 70° arthroscope in knee surgery is frequently used in posterior cruciate ligament reconstruction. There are previous reports of its use in anterior cruciate ligament surgery, but it has not achieved routine use. With the move toward anatomic anterior cruciate ligament reconstruction (ACLR), it is recognized that accurate tunnel placement is vital for a good clinical outcome. The 70° arthroscope provides an excellent view of the femoral and tibial footprints and a view of the full length of the femoral and tibial tunnels through a single anterolateral viewing portal, which is very important for anatomic ACLR. This technique for creating femoral tunnel through AL portal is easy and avoids instrument overcrowding, particularly in patients with small knees in our country. To the best of our knowledge, we first started using 70° arthroscope regularly for ACLR in our country.

Risk factors for progression of articular cartilage damage after anatomical anterior cruciate ligament reconstruction: a second-look arthroscopic evaluation.

To investigate the risk factors for progression of articular cartilage damage after anatomical anterior cruciate ligament (ACL) reconstruction. A total of 174 patients who underwent second-look arthroscopic evaluation after anatomical ACL reconstruction were enrolled in this study. The graded condition of the articular cartilage at the time of ACL reconstruction was compared with that at second-look arthroscopy. Age, gender, body mass index (BMI), ACL reconstruction technique, meniscal conditions, and other variables were assessed by regression analysis as risk factors for progression of damage to the articular cartilage. In the medial compartment, multivariable logistic regression analysis indicated that partial medial meniscectomy (odds ratio (OR) 6.82, 95% confidence interval (CI) 2.11 to 22.04, p = 0.001), pivot-shift test grade at the final follow-up (OR 3.53, CI 1.39 to 8.96, p = 0.008), BMI (OR 1.15, CI 1.03 to 1.28, p = 0.015) and medial meniscal repair (OR 3.19, CI 1.24 to 8.21, p = 0.016) were significant risk factors for progression of cartilage damage. In the lateral compartment, partial lateral meniscectomy (OR 10.94, CI 4.14 to 28.92, p < 0.001) and side-to-side differences in anterior knee laxity at follow-up (OR 0.63, p = 0.001) were significant risk factors. Partial meniscectomy was found to be strongly associated with the progression of articular cartilage damage despite r anatomical ACL reconstruction. Cite this article: Bone Joint J 2018;100-B:285-93.

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

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.

Chronicity of Anterior Cruciate Ligament Deficiency, Part 1: Effects on the Tibiofemoral Relationship Before and Immediately After Anatomic ACL Reconstruction With Autologous Hamstring Grafts.

Background:It remains unclear whether the tibiofemoral relationship in the sagittal plane is restored after anatomic anterior cruciate ligament (ACL) reconstruction, particularly in cases of chronic ACL deficiency (ACLD).Hypothesis:Patients with long-term ACLD will exhibit an anteriorly subluxed tibia both preoperatively and immediately postoperatively, even after anatomic reconstruction.Study Design:Cohort study; Level of evidence, 2.Methods:In total, 358 patients who had undergone anatomic ACL reconstruction with autologous semitendinosus grafts were divided into 5 groups based on chronicity of ACLD: (1) 0 to 6 months, (2) 6 months to 1 year, (3) 1 to 2 years, (4) 2 to 5 years, and (5) longer than 5 years. Preoperatively and immediately postoperatively, all patients underwent lateral radiography in extension to evaluate the tibiofemoral relationship, specifically with regard to anterior tibial subluxation (ATS), space for the ACL (sACL), and extension angle. Demographic and radiographic factors were compared among the 5 groups.Results:Preoperative ATS values in groups 4 (mean ± SD, 2.9 ± 2.1 mm) and 5 (2.6 ± 1.9 mm) were significantly greater than in group 1 (1.6 ± 1.9 mm). Postoperatively, the tibia was posteriorly overconstrained in all groups, and there was no difference in immediately postoperative ATS among the 5 groups. Further evaluation of the tibiofemoral relationship in the sagittal plane revealed that the mean preoperative side-to-side difference in sACL (sACL-SSD) was greater in groups 4 (2.5 ± 1.6 mm) and 5 (2.2 ± 1.7 mm) than in group 1 (1.2 ± 1.5 mm). Immediately after ACL reconstruction, however, there were no group-dependent differences in sACL-SSD. No significant group-dependent differences were found for extension deficit.Conclusion:Chronicity of ACLD had an effect on the preoperative tibiofemoral relationship in the sagittal plane, including ATS and sACL-SSD, especially in patients with ACLD longer than 2 years. However, preoperative extension deficit was not influenced by chronicity. Immediately postoperatively, chronicity did not affect the ability of anatomic ACL reconstruction to reduce subluxation.

Clinical Outcomes of Single Anteromedial Bundle Biologic Augmentation Technique for Anterior Cruciate Ligament Reconstruction With Consideration of Tibial Remnant Size

The primary aim of this study was to evaluate the functional outcomes, knee stability, complications, and reoperations associated with anatomic anterior cruciate ligament (ACL) reconstruction using the single anteromedial bundle biological augmentation (SAMBBA) technique in a consecutive series of 128 patients with a minimum follow-up of 24months. A secondary aim was to compare larger preserved ACL remnants with smaller preserved remnants. Patients who underwent primary anatomic ACL reconstruction using the SAMBBA technique from July 2013 to October 2014 were analyzed. Exclusion criteria were (1) age <16years, (2) revision cases, (3) multiple ligament injuries, (4) chondral lesions greater than grade 2 according to the Outerbridge classification, (5) additional injuries to the collateral ligaments greater than grade 2, or (6) a history of a contralateral ACL injury. Clinical assessment including evaluation of side-to-side difference and functional outcome measures with the International Knee Documentation Committee (IKDC) subjective score and the Tegner Activity Scale were used to evaluate outcomes before surgery and at the last follow-up. Any subsequent surgical procedures were systematically recorded during the study period. The patients were also divided in 2 groups according to their ACL remnant size, ≥50% or <50%, and compared. Of the 135 patients who underwent primary SAMBBA technique, 128 patients returned to final follow-up, with a mean follow-up of 31.7months (range, 24-44.3). At last follow-up, the IKDC score significantly improved from 54.1 ± 15.1 to 92.5 ± 11.4 (P< .001); the Tegner activity score (6.4 ± 1.2) was similar (P= .3) to the preinjury score (6.5 ± 1.2). Side-to-side laxity significantly improved from 6.7 ± 1.2mm to 0.7 ± 1mm(P < .001). Twenty-four subsequent surgeries (18.7%) were performed including 10 meniscal procedures, 7 ACL revisions, 5 arthroscopies for cyclops lesions, one microfracture, and one manipulation under anaesthesia. The side-to-side laxity (P= .30) and rates of reoperation (P= .65), graft failure (P=.45), and cyclops lesions (P= .67) were not significantly different between ≥50% or <50% ACL remnant groups. The results of this study demonstrate that primary anatomic ACL reconstruction using the SAMBBA technique significantly improved clinical and functional outcomes between baseline and follow-up at a minimum of 24months. A low rate of complications was observed with this technique. No significant differences between large and moderate size ACL remnants were detected for all outcome measures. Level IV case series with subgroup analysis.

Anterior Cruciate Ligament Reconstruction With Bone–Patellar Tendon–Bone Graft Through a Rectangular Bone Tunnel Made With a Rectangular Retro-dilator: An Operative Technique

Good clinical results have been reported with anatomic anterior cruciate ligament (ACL) reconstructions in which rectangular bone–patellar tendon–bone (BTB) grafts were fixed into rectangular bone tunnels made at anatomic ACL insertion sites of the femur and tibia (anatomic rectangular tunnel BTB ACL reconstruction). Notwithstanding these good results, some problems have remained unsolved, including procedural complexity and risk of damage to the femoral posterior tunnel wall, damage to nerves and blood vessels, and damage to cartilage. The purpose of this report is to present our technique of ACL reconstruction with BTB graft through a rectangular bone tunnel made with a rectangular retro-dilator. Our procedure may become a safe option for anatomic rectangular tunnel BTB ACL reconstruction because of the following advantages: (1) bone tunnels can be created more safely and accurately than in methods using transtibial and far medial portals, (2) the bone tunnel preparation procedure is less invasive than the standard outside-in method, (3) technical failure–related risks are lower because the guidewire is inserted only once, and (4) the operation time is shorter because the method is a single-bundle procedure.

Post-operative 3D CT feedback improves accuracy and precision in the learning curve of anatomic ACL femoral tunnel placement.

To evaluate the feedback from post-operative three-dimensional computed tomography (3D-CT) on femoral tunnel placement in the learning process, to obtain an anatomic anterior cruciate ligament (ACL) reconstruction. A series of 60 consecutive patients undergoing primary ACL reconstruction using autologous hamstrings single-bundle outside-in technique were prospectively included in the study. ACL reconstructions were performed by the same trainee-surgeon during his learning phase of anatomic ACL femoral tunnel placement. A CT scan with dedicated tunnel study was performed in all patients within 48h after surgery. The data obtained from the CT scan were processed into a three-dimensional surface model, and a true medial view of the lateral femoral condyle was used for the femoral tunnel placement analysis. Two independent examiners analysed the tunnel placements. The centre of femoral tunnel was measured using a quadrant method as described by Bernard and Hertel. The coordinates measured were compared with anatomic coordinates values described in the literature [deep-to-shallow distance (X-axis) 28.5%; high-to-low distance (Y-axis) 35.2%]. Tunnel placement was evaluated in terms of accuracy and precision. After each ACL reconstruction, results were shown to the surgeon to receive an instant feedback in order to achieve accurate correction and improve tunnel placement for the next surgery. Complications and arthroscopic time were also recorded. Results were divided into three consecutive series (1, 2, 3) of 20 patients each. A trend to placing femoral tunnel slightly shallow in deep-to-shallow distance and slightly high in high-to-low distance was observed in the first and the second series. A progressive improvement in tunnel position was recorded from the first to second series and from the second to the third series. Both accuracy (+52.4%) and precision (+55.7%) increased from the first to the third series (p<0.001). Arthroscopic time decreased from a mean of 105min in the first series to 57min in the third series (p<0.001). After 50 ACL reconstructions, a satisfactory anatomic femoral tunnel was reached. Feedback from post-operative 3D-CT is effective in the learning process to improve accuracy and precision of femoral tunnel placement in order to obtain anatomic ACL reconstruction and helps to reduce also arthroscopic time and learning curve. For clinical relevance, trainee-surgeons should use feedback from post-operative 3DCT to learn anatomic ACL femoral tunnel placement and apply it appropriately. Consecutive case series, Level IV.

Effects of initial graft tension on femoral tunnel widening after anatomic anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft.

The effects of initial graft tension upon tunnel widening (TW) following anatomic anterior cruciate ligament (ACL) reconstruction have not been elucidated. The purpose of this study was to retrospectively investigate the effect of two different graft-tensioning protocols upon femoral TW following anatomic ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft and a three-dimensional (3D) computed tomography (CT) model. Forty-three patients who underwent isolated ACL reconstruction using BPTB grafts were included in this study. In 18 out of the 43 patients, the graft was fixed at full knee extension with manual maximum pull (Group H). These patients were compared with 25 patients in whom the BPTB graft was fixed at full knee extension with 80-N pull (Group L). Tunnel aperture area was measured using 3D CT 1week and 1year postoperatively, thus enabling us to calculate the percentage change in the area of femoral tunnel aperture. Clinical assessment was performed 1year postoperatively, corresponding to the time period of CT assessment, and involved the evaluation of Lysholm score, anterior knee stability using a KneeLax3 arthrometer, and the pivot-shift test. When measured at 1year postoperatively, the mean area of the femoral tunnel aperture had increased by 78.6±36.8% in Group H when compared with at 1week postoperatively, whereas that of Group L had increased by 27.7±32.3%. Furthermore, TW (%) in Group H was significantly greater than that of Group L (P<0.001). No significant differences were detected between the two groups with regard to any of the clinical outcomes evaluated. High levels of initial graft tension resulted in greater TW of the femoral tunnel aperture following anatomical ACL reconstruction using BPTB grafts. However, such levels of graft tension did not affect clinical outcome.

Influence of the different anteromedial portal on femoral tunnel orientation during anatomic ACL reconstruction

ObjectiveThe purpose of this study was to evaluate the effect of femoral tunnel orientation, drilled through the accessory anteromedial (AAM) portal or the high AM portal in anatomic anterior cruciate ligament (ACL) reconstruction. MethodsIn 16 cadaver knees, using o'clock method, centers of the ACL femoral footprint were drilled with an 8-mm reamer via an AAM portal (eight knees) or a high AM portal (eight knees). Computed tomography (CT) scans were taken of each knee. Three-dimensional (3D) models were constructed to identify the femoral tunnel orientation and to create femoral tunnel virtual cylinders for measuring tunnel angles and length. ResultsIn two of the 16 specimens, we observed a posterior femoral cortex blowout (PFCB) when drilling through a high AM portal. When drilled through the high AM portal, the femoral tunnel length was significantly shorter than when using an AAM portal (30.3 ± 3.8 mm and 38.2 ± 3.1 mm, p < 0.001). The femoral tunnel length was significantly shorter in the group with PFCB compared to the group with no PFCB (25.9 ± 0.6 mm and 35.5 ± 4.5 mm, p = 0.011). The axial obliquity of the high AM portal was significantly higher than that of the AAM portal (52.2 ± 5.9° and 43.0 ± 2.3°, p = 0.003). ConclusionsIn anatomic ACL reconstruction, a mal-positioned AM portal can cause abnormal tunnel orientation, which may lead to mechanical failure during ACL reconstruction. Therefore, it is important to select accurate AM portal positioning, and possibly using an AAM portal by measuring an accurate position when drilling a femoral tunnel in anatomic ACL reconstruction.

Three-Dimensional Reconstruction Computed Tomography Evaluation of the Tunnel Location and Angle during Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Purpose:Tibial tunnel-independent drilling has attracted increased interest in recent years for anatomic anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the geometry and position of the femoral tunnel between the anteromedial portal (AMP) and outside-in (OI) techniques after anatomic single-bundle ACL reconstruction.Methods:We prospectively evaluated 82 patients undergoing single-bundle ACL reconstruction with hamstring tendon autografts using either the AMP (n=40) or OI (n=42) technique. The locations of the tibial and femoral tunnel apertures were assessed by immediate postoperative 3-dimensional computed tomography (3D CT) imaging with OsiriX imaging software. The femoral graft bending angle, femoral tunnel aperture shape (height/width ratio), femoral tunnel length, and posterior wall breakage were also measured.Results:The two techniques did not differ significantly in the femoral tunnel position perpendicular to the Blumensaat line. However, the mean femoral tunnel position parallel to the Blumensaat line was more caudally positioned in the AMP group than in the OI group (P=0.025) The two groups did not differ significantly in tibial tunnel position. The mean femoral tunnel length did not differ between the AMP (36.1±0.33 mm) and OI groups (35.6±0.37 mm; P=0.548) The mean femoral graft angle in the OI group (99.6°±7.1°) was significantly more acute than that of the AMP group (108.9°±10.2°) (p < 0.0001). The mean height/width ratio of the AMP group (1.21±0.20) was significantly more ellipsoidal than that of the OI group (1.07±0.09) (p < 0.0001). Posterior wall breakage was detected in 3 cases (7.5%), all in the AMP group.Conclusions:After single-bundle anatomic ACL reconstruction, 3D CT showed a significantly shallower femoral tunnel in the AMP group than in the OI group. The AMP group had a more ellipsoidal femoral tunnel with a risk of posterior wall breakage than the OI group. The OI group showed a more acute bending angle of the femoral tunnel than the AMP group.The femoral graft bending angle planeThe femoral graft bending angle plane, in which the centers of the extra- and intra-articular apertures of the femoral tunnel and the center of the intra-articular aperture of the tibial tunnel were viewed together, was selected to measure the femoral graft bending angle.three-dimensional computed tomographyOn the lateral femoral side of three-dimensional computed tomography, the location of the transtibial and tibial independent femoral tunnel are shown. The location of the tunnels was quantified and presented as the percentage distance from the deepest subchondral contour and the intercondylar notch roof to the center of the tunnel

Functional and computed tomography correlation of femoral and tibial tunnels in single-bundle anterior cruciate ligament reconstruction: Use of accessory anteromedial portal.

Background:An accessory anteromedial portal (AAMP) has been shown to be effective in placing an anatomically ideal femoral tunnel. It is well known that this is due to the independent femoral drilling which is possible with the AAMP. However very little is known regarding the significance of this reconstruction technique in influencing the functional outcomes of anatomic anterior cruciate ligament reconstruction (ACLR). This study documents the influence of tibial and femoral tunnel positions on functional outcomes of anatomic ACLR using the AAMP.Materials and Methods:41 patients who underwent anatomic ACLR between 2011 and 2013 were included in this prospective cohort study. The primary outcome involved the documentation of femoral and tibial tunnel positions with volume rendering imaging using a three-dimensional computed tomography (3D-CT) done at the end of 1 year. The tunnel position evaluations from the CT images were performed by an independent observer specializing in radiodiagnosis. Functional outcome measures included preoperative and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores (subjective) documented by an independent investigator who was not involved with the surgical procedure, at the end of 1 year.Results:The minimum followup was 1 year. All patients achieved good clinical and functional outcomes postoperatively with no reported complications. Tunnel position evaluations with 3D-CT revealed the average tibial tunnel distance to be 15.5 mm (standard deviation [SD] =2.52) from the anterior border of the tibial plateau and the average femoral tunnel distance to be 14.33 mm (SD = 2.6) from the inferior margin of the medial surface of lateral femoral condyle and 13.72 mm (SD = 2.8) from the posterior margin of the medial surface of lateral femoral condyle. The average tunnel diameters were found to be 7.9 mm (SD = 0.72) for the tibial tunnels and 8.6 mm (SD = 1.07) for the femoral tunnels. Statistically significant correlation between the tibial tunnel distance and the IKDC scores with anterior placement of tibial tunnel were found; however, no such statistical relationship were found between the femoral tunnel positions and the functional outcome measures.Conclusion:AAMP gives an ideal approach to drill the femoral tunnel independently. However, the influence of this tunnel placement on long term functional outcomes of ACLR needs to be assessed on larger cohort of patients.

Clinical and arthrometric outcomes of an anatomic outside-in single-bundle anterior cruciate ligament reconstruction using a retrodrill

BackgroundThe 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. MethodsProspective 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. Results275 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. ConclusionOI single bundle anatomic ACL reconstruction using a retrodrill is a valid and safe option that avoids the complications reported with the AMP technique.

Clinical advantages of image-free navigation system using surface-based registration in anatomical anterior cruciate ligament reconstruction.

To evaluate the clinical advantages of a navigation system developed with an emphasis on attaining an appropriate femoral tunnel length and posterior wall margin with no posterior wall blowout, as well as having accurate tunnel positioning, in anatomical anterior cruciate ligament reconstruction (ACLR). Ten freshly frozen human knees were transected at mid-femur and mid-tibia. Each knee specimen underwent arthroscopic single-bundle anterior cruciate ligament reconstruction using the outside-in technique, with two knees by manual ACLR (control group) and another eight knees by only the navigational ACLR without arthroscopic assistance (experimental group). The position/orientation information of tunnel entry point, tunnel length, and posterior wall distance of pre-, intra-, and postoperative tunnel were recorded, and the reliability and errors among them were evaluated. From comparison of the 3D models for preoperative planning and postoperative reconstruction, the mean differences for navigational femoral tunnelling and arthroscopic-assisted femoral tunnelling were recorded, respectively: (1) tunnel entry position, 1.4mm (SD 0.3) versus 4.9mm; (2) tunnel length, 0.7mm (SD 0.2), similar to 0.6mm in arthroscopic-assisted femoral tunnelling, and (3) posterior wall distance, 0.5mm (SD 0.2), much smaller than 4.7mm for arthroscopic-assisted femoral tunnelling. The intraclass correlation coefficients, calculated to determine the accuracy and reliability of navigational femoral tunnelling, showed excellent internal consistency that ranged from 0.965 to 0.989 for tunnel length and from 0.810 to 0.953 for posterior wall distance. Navigation systems with enhancement of the registration accuracy by the developed system are feasible in anatomical ACLR, in reducing surgical failures such as short tunnel length or posterior wall breakage of distal femur. The present study revealed that computer navigation could aid in avoiding major mistakes in exact positioning and posterior wall blowout and help in attaining appropriate length for femoral tunnelling in anatomical ACLR.

Clinical and Functional Outcome of All-Inside Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years’ Follow-up

To evaluate the clinical and functional outcomes for anatomic anterior cruciate ligament (ACL) reconstruction using the all-inside technique with a minimum follow-up of 24 months. Patients undergoing anatomic ACL reconstruction via the all-inside technique between January 2011 and October 2012 were reviewed for inclusion in this study. Functional outcome measures, including the Lysholm score, International Knee Documentation Committee score, visual analog scale score, and Tegner Activity Scale, were used to evaluate outcomes before surgery and at 3, 6, 12, and > 24 months. At final follow-up, anteroposterior knee stability was assessed with KT-2000 (MEDmetric, San Diego, CA) measurements. Of the 92 patients who underwent primary all-inside ACL reconstruction, 79 patients returned to final follow-up with a minimum of 2 years. There were 53 men and 26 women with a mean age of 29 years (range, 18 to 54 years) and a mean follow-up of 29 months (range, 24 to 45 months). The International Knee Documentation Committee score (44.6 v 89.7, P < .0001), Lysholm score (53.4 v 93.1, P < .001), visual analog scale score (5 v 0.1, P < .001), and Tegner activity score (2 v 6, P < .001) showed a significant improvement between baseline and final clinical follow-up. The mean side-to-side KT-2000 difference at final follow-up was 1.7 mm (range; 0 to 6 mm). Overall 10 patients (12.7%) sustained an ACL graft rerupture after a mean of 17.6 months (range, 6.9 to 28.6 months). The current data support our first hypothesis that primary anatomic ACL reconstruction using the all-inside technique leads to improved functional outcomes between baseline and clinical follow-up at 24 months. Further, there was no difference in knee stability between the ACL reconstructed- and the contralateral normal knee at 24 months, which confirms our second hypothesis.

Secure fixation of femoral bone plug with a suspensory button in anatomical anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft

the efficacy and safety of using a suspensory button for femoral fixation in anatomical anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) graft have not been established. The purpose of the current study was to evaluate bone plug integration onto the femoral socket and migration of the bone plug and the EndoButton (EB) (Smith & Nephew, Andover, MA, USA) after rectangular tunnel ACL reconstruction with BPTB autograft. thirty-four patients who underwent anatomical rectangular ACL reconstruction with BPTB graft using EB for femoral fixation and in whom three-dimensional (3D) computed tomography (CT) was performed one week and one year after surgery were included in this study. Bone plug integration onto the femoral socket, bone plug migration, soft tissue interposition, EB migration and EB rotation were evaluated on 3D CT. The clinical outcome was also assessed and correlated with the imaging outcomes. the bone plug was integrated onto the femoral socket in all cases. The incidence of bone plug migration, soft tissue interposition, EB migration and EB rotation was 15, 15, 9 and 56%, respectively. No significant association was observed between the imaging outcomes. The postoperative mean Lysholm score was 97.1 ± 5.0 points. The postoperative side-to-side difference, evaluated using a KT-2000 arthrometer, averaged 0.5 ± 1.3 mm. There were no complications associated with EB use. Imaging outcomes did not affect the postoperative KT side-to-side difference. the EB is considered a reliable device for femoral fixation in anatomical rectangular tunnel ACL reconstruction with BPTB autograft. Level IV, therapeutic case series.

Comparison of femur tunnel aperture location in patients undergoing transtibial and anatomical single-bundle anterior cruciate ligament reconstruction

Although three-dimensional computed tomography (3D-CT) has been used to compare femoral tunnel position following transtibial and anatomical anterior cruciate ligament (ACL) reconstruction, no consensus has been reached on which technique results in a more anatomical position because methods of quantifying femoral tunnel position on 3D-CT have not been consistent. This meta-analysis was therefore performed to compare femoral tunnel location following transtibial and anatomical ACL reconstruction, in both the low-to-high and deep-to-shallow directions. This meta-analysis included all studies that used 3D-CT to compare femoral tunnel location, using quadrant or anatomical coordinate axis methods, following transtibial and anatomical (AM portal or OI) single-bundle ACL reconstruction. Six studies were included in the meta-analysis. Femoral tunnel location was 18% higher in the low-to-high direction, but was not significant in the deep-to-shallow direction, using the transtibial technique than the anatomical methods, when measured using the anatomical coordinate axis method. When measured using the quadrant method, however, femoral tunnel positions were significantly higher (21%) and shallower (6%) with transtibial than anatomical methods of ACL reconstruction. The anatomical ACL reconstruction techniques led to a lower femoral tunnel aperture location than the transtibial technique, suggesting the superiority of anatomical techniques for creating new femoral tunnels during revision ACL reconstruction in femoral tunnel aperture location in the low-to-high direction. However, the mean difference in the deep-to-shallow direction differed by method of measurement. Meta-analysis, Level II.

Anatomic Single-bundle Anterior Cruciate Ligament Reconstruction Using the Flexible Drilling/Reaming system: A Preliminary Experience

Introduction: The purpose of anatomic anterior cruciate ligament (ACL) reconstruction is to restore the normal function of the ACL. Therefore, the ACL should be reconstructed at its original footprint. There are many different methods to create the femoral tunnel, including the transtibial, transportal, and outside-in techniques. Each method has different benefits and limitations. Thus, we used the flexible reamer system to perform the anatomic ACL reconstruction. Materials and methods: From May 2014 to Feb 2015, 26 patients in our hospital received single-bundle ACL reconstructions using the flexible reamer system. Twenty men and 6 women with a mean age of 30.6 years were included. The EndoButton was applied for femoral site fixation and tibial site was fixed with the PLLA-HA interference screw and one post screw. After the operation, the patients' knee joints were protected with the range of motion (ROM) brace at zero degree for 2 weeks. The range motion of the brace was subsequently adjusted to 60, 90, and 120 degrees at the 2nd, 4th, and 6th postoperative week, respectively. Results: No major complications, including wound infection, vascular or nerve injuries, were reported in these patients. However, breakage of the flexible guidewire occurred in one patient, which was smoothly resolved subsequently. The average femoral tunnel angle was measured. Post-operative three-dimensional computed tomography scans were also performed to check the femoral tunnel aperture location. Conclusion: Individualized anatomic ACL reconstruction is essential for ACL-deficient patients. With the flexible reaming system, the surgeon can easily create the femoral tunnel at the anatomic position. However, the surgeons should ensure the durability and sharpness of the guidewires and reamers by prior to the procedures.