Femoral Tunnel Placement Research Articles

Accuracy of transportal femoral aimer in placement of femoral tunnel during arthroscopic anterior cruciate ligament reconstruction: An observational study

Objectives: Incorrect placement of the femoral tunnel can result in failure of anterior cruciate ligament reconstruction. Several techniques have been described in literature to make accurate femoral tunnel. Although eyeballing and femoral offset aimer are commonly used, they are considered to be less accurate if used in isolation. To the best of our knowledge, no study has evaluated the use of combination of eyeballing and offset aimer to make the femoral tunnel. This study aims to evaluate the position of femoral tunnel made by combination of eyeballing and femoral offset aiming device. Materials and Methods: Post-operative radiographs of 50 patients were assessed. True anteroposterior (AP) and lateral view radiographs were used to evaluate the placement of the femoral tunnel using standard methods. The outcome was assessed and compared with the standard location of femoral tunnel as described by Harner et al. and Aglietti et al. Ease of making femoral tunnel and posterior blowout were recorded. Data analysis was performed using Statistical Package for the Social Sciences version 25 statistical analysis software. Results: In the coronal plane (AP view), the mean position of the femoral tunnel from the lateral cortex was at 35.09% ± 3.9% point. In AP plane (lateral view), the mean position of the femoral tunnel was at 80.01% ± 8.02% posteriorly along the Blumensaat’s line. None of the cases had posterior blowout and the technique was said to be easy. Conclusion: Eyeballing supplemented with transportal femoral offset aimer is an easy and accurate method of placing femoral tunnel and avoids posterior wall blowout.

Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal

Arthroscopic ACL reconstruction is the current standard care of treatment for anterior cruciate ligament (ACL) injuries. Modified transtibial (mTT) and anteromedial portal (AMP) techniques aim at the anatomical placement of femoral tunnel. Controversy existed in the literature with regard to the outcome of these techniques. Hence, we designed a retrospective comparative study to analyse the clinical and functional outcomes of mTT and AMP techniques. We hypothesized that there would be no difference between the clinical and functional outcomes in mTT and AMP techniques. This retrospective observational study was conducted in consecutive patients who underwent arthroscopic ACL reconstruction using semitendinosus-gracilis (STG) quadrupled graft in our tertiary care centre with a minimum follow-up of two years. Out of 69 patients, 37 had undergone ACL reconstruction by mTT technique and remaining by AMP technique. All the patients were assessed clinically by anterior drawer, Lachman’s, pivot shift and single-legged hop test. Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) subjective knee evaluation score were used for the functional status. Knee instability was assessed objectively by KT-1000 arthrometer. There was no statistically significant difference in baseline demographic characteristics between mTT and AMP groups. At the end of 2 years, no statistically significant difference was noted in the anterior drawer and Lachman’s test. Though not significant, IKDC scores and Lysholm’s scores showed a better outcome in the AMP group when compared to the mTT group. AMP group showed significantly better outcome with KT-1000 arthrometer. Based on the results obtained, we presume that overall both mTT and AMP have similar functional outcome. However, as AMP technique offers significantly improved subjective rotational stability on pivot shift test, better hop limb symmetry index and KT 1000 readings compared to mTT, we suggest AMP over mTT.

Usage of Accessory Anteromedial Portal for Anatomical Placement of Femoral Tunnel in Transportal Anterior Cruciate Ligament Reconstruction: A Prospective Study.

Background and objectiveThe anterior cruciate ligament (ACL) has an essential role in preserving the function and stability of the knee joint. It acts primarily to prevent anterior tibial translation. Arthroscopic ACL reconstruction using quadrupled hamstring graft is the widely practiced modality for treating ACL injuries nowadays. The objective of this study was to assess the functional outcomes of ACL reconstruction using the transportal approach for a femoral tunnel through an accessory anteromedial portal (AAM).Materials and methodsThis prospective study included 35 patients who met the inclusion criteria. All patients underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft via transportal technique for femoral canal reaming through AAM. Patients were assessed for the functional outcome for a year using the Tegner-Lysholm knee scoring system.ResultsThe analysis of the studied cases revealed that the mean age of the patients was around 27 years. Males were affected more than females. The left side (77.14%) was affected more than the right side (22.86%); 54.28% of patients had a history of road traffic accidents (RTAs). Preoperatively, 19 (54.28%) patients had poor and 16 (45.72%) patients had fair Tegner-Lysholm scores. After one year of follow-up, 29 (82.85%) of the patients had an excellent score as per the Tegner-Lysholm scoring system. Three patients had knee pain and thigh muscle wasting (2-3 cm), and two of them also had a sense of giving away during follow-up.ConclusionAnatomical reattachment of tendon graft for ACL reconstruction at femoral and tibial footprints is indispensable for good functional outcome and knee kinematics, and the usage of the AAM provides good visualization of femoral footprint and ease to surgeons during ACL reconstruction for making a near-accurate femoral tunnel and thereby achieving better outcomes.

CT Scan Assessment of Femoral Tunnel Location in ACL Reconstruction Performed During Initial Phase of the Learning Curve

Introduction:During anterior cruciate ligament (ACL) reconstruction, femoral tunnelling is one of the most imperative stage. The success of surgical reconstructions of the ACL depends on the accurate restoration of its anatomy. The significance of the location of the hole drilled in femur has been repeatedly highlighted in ACL reconstruction. Incorrect tunnel placement is not infrequent, and even with diligent training, and aids, surgeons may still have difficulty in correctly positioning tunnels intra-operatively. Usually susceptible are surgeons in initial phase of the learning curve.Objective:To determine the susceptibility of surgeons in initial phase of learning curve while drilling femoral tunnel.Methods:All patients diagnosed with ACL rupture at a single institution between August 2018 and September 2019 were considered for the study. The surgeons who were relatively new out of their fellowship and training programmes (average of less than one years of independent practice) performed all surgical reconstructions, the number of reconstructions done independently was also taken into consideration (average of less than five independent procedures done before commencement of this study). We used anatomic free hand technique using bony and anatomic indicators as our markers, assisted by ruler, to drill femoral tunnel. Every subject had an 128 slice 3D CT-Scan done in immediate post-op period. High resolution 3-Dimensional view was created of the knee to evaluate the tunnel location. The position of the femoral tunnel was evaluated using the Bernard and Hertel quadrant method. The Femoral tunnel location was expressed in terms of its distance from the notch and posterior wall of condyle, the results were expressed in terms of percentage.Results:A net total of 32 patients were included who underwent single bundle ACL reconstruction. In our study, measurement of femoral tunnel placement was - depth 37.1% and height 24.6%, represented as percentage depth (deep to shallow (t)) and height (high to low (h)). Our results were compared with other established studies. The value of height was near to that mentioned in literature; whereas the value of depth was shallower (or distal) when compared to established literature with average location being 10.7% shallower (or distal) to anteromedial bundle insertion mentioned in study by Colombet et al and 4.8% shallower when compared to study by Zantop et al. When compared to study by Bernard and Hertel the location is 12.3% shallower. The reason for comparison with anteromedial bundle is that in single bundle anatomical reconstruction Pearle et al , Segawa et al and Simmons et al advocate it to be anteromedial.Conclusion:The surgeons in initial phase of their learning curve may be more prone to shallow (non anatomic) location of femoral tunnel during single bundle ACL reconstruction. We infer that this discrepancy in proximal (deep) to distal (shallow) orientation is due to fear of posterior wall blow out, that is the violation of the posterior femoral cortex, a known intraoperative complication in ACL reconstruction.

Non-anatomic tunnel position increases the risk of revision anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) graft failure is a complication that may require revision ACL reconstruction (ACL-R). Non-anatomic placement of the femoral tunnel is thought to be a frequent cause of graft failure; however, there is a lack of evidence to support this belief. The purpose of this study was to determine if non-anatomic femoral tunnel placement is associated with increased risk of revision ACL-R. After screening all 315 consecutive patients who underwent primary single-bundle ACL-R by a single senior orthopedic surgeon between January 2012 and January 2017, 58 patients were found to have both strict lateral radiographs and a minimum of 24months follow-up without revision. From a group of 456 consecutive revision ACL-R, patients were screened for strictly lateral radiographs and 59 patients were included in the revision group. Femoral tunnel placement for each patient was determined using a strict lateral radiograph taken after the primary ACL-R using the quadrant method. The center of the femoral tunnel was measured in both the posterior-anterior (PA) and proximal-distal (PD) dimensions and represented as a percentage of the total distance (normal center of anatomic footprint: PA 25% and PD 29%). In the PA dimension, the revision group had significantly more anterior femoral tunnel placement compared with the primary group (38% ± 11% vs. 28% ± 6%, p < 0.01). Among patients who underwent revision; those with non-traumatic chronic failure had statistically significant more anterior femoral tunnel placement than those who experienced traumatic failure (41% ± 13% vs. 35% ± 8%, p < 0.03). In the PD dimension, the revision group had significantly more proximal femoral tunnel placement compared with the primary group (30% ± 9% vs 38% ± 9%, p < 0.01). In this retrospective study of 58 patients with successful primary ACL-R compared with 59 patients with failed ACL-R, anterior and proximal (high) femoral tunnels for ACL-R were shown to be independent risk factors for ACL revision surgery. As revision ACL-R is associated with patient- and economic burden, particular attention should be given to achieving an individualized, anatomic primary ACL-R. Surgeons may reduce the risk of revision ACL-R by placing the center of the femoral tunnel within the anatomic ACL footprint. Level III.

306 Anterior Cruciate Ligament Graft Rupture: Analysis of Anteromedial Versus Trans-Tibial Portal Technique for Femoral Tunnel Placement in 473 Patients

Abstract Introduction Correct femoral tunnel position in anterior cruciate ligament reconstruction (ACLR) is critical in obtaining good clinical outcomes. We aimed to delineate whether any difference exists between the anteromedial and trans-tibial portal femoral tunnel placement techniques on the primary outcome of ACLR, graft rupture. Method Adult patients (&amp;gt;18 years old) who underwent primary ACLR between January 2011 - January 2018 were identified and divided based on portal technique (anteromedial v trans-tibail). The primary outcome measure was graft rupture. Univariate analysis was used to delineate association between independent variables and outcome. Binary logistic regression was utilised to delineate odds ratios of significant variables. Results 473 patients were analysed. Median age at surgery was 27 years old (range 18-70). 152/473 (32.1%) patients were anteromedial group compared to 321/473 (67.9%) trans-tibial. 25/473 (5.3%) patients sustained graft rupture. Median time to graft rupture was 12 months (IQR 9). A higher odd for graft rupture was associated with the anteromedial group, which trended towards significance (OR 2.03; 95% CI 0.90 - 4.56, p = 0.081). Conclusions There is no statistically significant difference in ACLR graft rupture rates when comparing anteromedial and trans-tibial portal technique for femoral tunnel placement. There was a trend towards higher rupture rates in the anteromedial portal group.

Does Deviation of Femoral and Tibial Tunnel Placement Leads to Poor Short Term Functional Outcomes in Arthroscopic Anterior Cruciate Ligament Reconstruction?

Does Deviation of Femoral and Tibial Tunnel Placement Leads to Poor Short Term Functional Outcomes in Arthroscopic Anterior Cruciate Ligament Reconstruction?

Anatomic all-epiphyseal ACL reconstruction with "inside-out" femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24months after reconstruction.

To understand if anatomic physeal-sparing ACL reconstruction in the immature host preserves range of motion, permits a return to sports, and avoids limb length discrepancy and accelerated intra-articular degeneration with a cross-sectional radiographic, physical examination and patient-reported outcomes analysis. A cross-sectional recall study included 38 patients aged 7-15 who underwent all-epiphyseal ACL reconstruction with hamstring allograft performed by a single surgeon at a large academic medical center. All-epiphyseal reconstructions were performed using a modified Anderson physeal-sparing technique, with the femoral tunnel placed using an "inside-out" technique. Assessments consisted of a physical exam, long leg cassette radiographs, KT-1000 measurements, subjective patient metrics, and magnetic resonance imaging. Thirty-eight (56.7%) of 66 eligible patients returned for in-person clinical and radiographic exams. Patients were 11.4 ± 1.8years at the time of surgery. Five patients were females (13.2%). Mean follow-up was 5.5 ± 2.4years. ACL re-injuries occurred in four patients (10.5%), all of whom underwent revision reconstructions. Thirty-three of the remaining 34 (97.1%) patients returned to sports following their reconstruction, and 24 (70.6%) returned to their baseline level of competition. Mean limb length discrepancy (LLD) was 0.2 ± 1.4cm. Nine patients had an LLD of > 1cm (26.5%), which occurred at an equivalent age as those with < 1cm LLD (10.8 ± 2.0 vs. 11.7 ± 1.7, n.s.). Pre-operative Marx scores (13.1 ± 3.5) were not significantly different from post-operative values (12.3 ± 5.1, n.s.). Patients who required ACL revisions had significantly lower Marx scores than those with intact primary grafts (8.3 ± 7.1 vs. 13.4 ± 4.5, p = 0.047). Cohort mean International Knee Documentation Committee (IKDC) score was 89.7 ± 12.7. Anatomic all-epiphyseal anatomic ACL reconstruction appears to be useful in patients with significant projected remaining growth, with good return-to-sport outcomes and minimal risk of clinically significant physeal complications. However, given the limited patient recall possible in the present study, further large sample size, high-quality works are necessary to validate our findings. Level IV.

Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft: Challenges and Solutions of Medial Independent Femoral Tunnel Drilling

Background: As the main translational and rotatory stabilizer of the knee, the anterior cruciate ligament (ACL) plays a critical role in knee biomechanics. Anterior cruciate ligament ruptures generally require surgical attention for not only restoration of knee stability but also prevention of meniscal and chondral injuries. There are countless options for both the surgeon and the patient when contemplating graft choice and surgical technique for ACL reconstruction. However, the literature assessing the outcomes following various autografts has varied with some studies citing no significant difference in clinical and patient-reported outcomes, while others showing notable advantage when using bone–patellar tendon–bone (BPTB) autograft. In addition, there have been challenges associated with femoral tunnel placement using an anteromedial portal technique. Indications: In this study, we present a young female patient with a history of remote mid-substance ACL tear now presenting with worsening knee instability and a bucket-handle medial meniscus tear as a sequela of the incompetent ACL. After extensive discussion regarding the treatment options, patient had decided to proceed with surgical intervention with a BPTB autograft using the anteromedial portal technique for femoral tunnel placement and compression technique with bio-absorbable interference screw fixation. Results: Bone–patellar tendon–bone autograft has been noted to have lower risk of revision when compared with other graft options. Discussion: In this surgical technique study, we underline the importance of peritenon handling. We highlight the use of a 70-degree arthroscope to improve posterolateral wall visualization during femoral tunnel placement as well as for inspection of the reamed tibial tunnel. We also provide technique commentary and solutions for management of the medial femoral condyle (MFC) articular surface and femoral tunnel placement using an anteromedial portal technique. Last, we review graft-related outcomes, postoperative management, and rehabilitation protocol.

Clinical outcomes of primary anatomic all-inside Anterior Cruciate Ligament reconstruction using the TransLateral technique: A minimum one-year follow-up study

BackgroundAnatomic all-inside Anterior Cruciate Ligament (ACL) reconstruction using the TransLateral technique is relatively new. This technique utilises single tendon autograft and instruments permitting inside-to-out drilling to create retrograde sockets. Few studies have investigated clinical outcomes following this technique. We investigate clinical outcomes in patients who underwent primary anatomic all-inside ACL reconstruction using the TransLateral technique with a minimum one-year follow-up. MethodsInterrogation of our prospectively maintained database identified patients who underwent surgery from June 2013 to December 2017. Patients were followed up clinically and using patient-reported outcome measures (PROMS) including EQ-5D, KOOS, IKDC and Tegner scores from the National Ligament Registry. Paired two-tailed Student t-test was used to assess for clinical significance. ResultsOne hundred forty-one cases with a mean age of 30 years (range 16.0–60.2) and mean follow-up of 17.4 months (12.1–75.2) were included. Grafts included isolated quadrupled semitendinosus (n = 115) and both quadrupled semitendinosus and gracilis (n = 26). One hundred and two patients (72.3%) had complete peri-operative PROMS. Mean increases in EQ-5D VAS and IKDC scores were 18.9 and 29.2 points (p < 0.001). Significant peri-operative improvements were observed for all KOOS domains (p < 0.001). Median Tegner activity score increased by two levels (p < 0.001). Incidence of graft re-rupture was 5.7% (n = 8), all were following significant knee trauma and seven cases were mid-bundle femoral tunnel placements. ConclusionsAll-inside ACL reconstruction using the TransLateral technique demonstrates good clinical and functional outcomes with low complication and failure rate. Mid-bundle femoral tunnel placements have been abandoned in favour of placement deep within the anteromedial bundle footprint.

Radiographic Reference Points Do Not Ensure Anatomic Femoral Fixation Sites in Medial Patellofemoral Ligament Reconstruction: A Quantified Anatomic Localization Method Based on the Saddle Sulcus

Background: Medial patellofemoral ligament (MPFL) reconstruction is one of the main treatments for lateral patellar translation. Based on intraoperative true lateral radiographs, the accepted methods for femoral MPFL tunnel location are potentially inaccurate. Direct assessment of anatomic characteristics during surgery through palpation of the anatomic landmarks involving the saddle sulcus might help eliminate tunnel malposition. Hypothesis: The saddle sulcus is a reliable osseous landmark where the MPFL attaches for tunnel placement. Study Design: Descriptive laboratory study. Methods: A total of 9 fresh-frozen unpaired human cadaveric knees were dissected; MPFL insertion point and relative osseous structures were marked. Three-dimensional images and transformed true lateral radiographs were obtained for analysis; 3 previously reported radiographic reference points for MPFL femoral tunnel placement were determined on all images and compared with the anatomic insertion. Results: A saddle sulcus consistently existed where the MPFL was attached, located at 11.7 ± 5.9 mm from the apex of the adductor tubercle (AT) to the medial epicondyle (ME), 62.8% of the average distance between the apexes of the AT and ME, and 5.6 ± 2.8 mm perpendicular-posterior to the border connecting the AT and ME. The reported radiographic reference points were located at average distances of 6.2 ± 3.2 mm (Schöttle method), 5.9 ± 2.3 mm (Redfern method), and 7.3 ± 6.6 mm (Fujino method) from the saddle sulcus center on the true lateral radiographs. Conclusion: The saddle sulcus was a reliable landmark where the MPFL was anatomically attached, located approximately 12 mm from the AT to the ME (approximately 60% along a line from the AT to the ME) and 6 mm perpendicular-posterior to the border connecting the apexes of the AT and ME. Additionally, the saddle sulcus position presented variability on the femoral aspect of different knees. All of the average direct distances from the sulcus to the reference radiographic points exceeded 5 mm, and tunnel localizations on a true lateral radiograph were inaccurate. Clinical Relevance: This study demonstrates the potential precise position of the saddle sulcus, according to the ME and AT, as a reliable anatomic landmark for MPFL femoral tunnel location. Radiographic reference points were not accurate during MPFL reconstruction. Direct palpation of the landmarks might be effective for femoral MPFL tunnel placement.

The risk of graft impingement still exists in modern ACL surgery and correlates with degenerative MRI signal changes.

Anatomic tunnel placement in ACL reconstruction is crucial to restore knee function. The aims of this study were to (i) evaluate the accuracy of tunnel placement for primary state-of-the-art ACL reconstruction, and (ii) examine the correlation between incorrect tunnel placement, graft appearance, and notch impingement. In this retrospective study, all patients underwent primary single-bundle ACL reconstruction with independent drilling of the femoral and tibial tunnels according to anatomical landmarks. The accuracy of tunnel placement and the rate of notch impingement were analysed with MRI. The study cohort was subdivided according to the morphology of the graft: intact, degeneration, and re-rupture. The objective outcome was evaluated with the IKDC objective score, and the subjective outcomes were evaluated with the IKDC subjective score, the Lysholm knee score, the KOOS, and the Tegner activity scale score. Eighty-seven consecutive patients with a mean follow-up of 3.8 ± 1.4years were evaluated. There was no significant difference among the groups concerning the baseline characteristics. The re-rupture rate was 9.2%. The position of the femoral tunnel was correct in 92% of the patients, and the position of the tibial tunnel was correct in 93% of the patients. In the intact group, impingement was not found in any of the cases, whereas the rate of impingement in the degeneration (65%) and re-rupture (80%) groups was significantly higher than that in the intact group (p < 0.001). The risk of impingement was more likely with femoral (71% vs. 13%, p < 0.001) or tibial (100% vs. 11%, p < 0.001) malpositioning. The objective IKDC score was A in 52 patients (60%), B in 26 patients (30%), and C in 9 patients (10%). The average subjective IKDC score, Lysholm score, and KOOS were comparable in the intact and degeneration groups but significantly lower in the patient group with newly diagnosed re-ruptures (p = 0.05). The Tegner activity scale score was comparable in all three groups. Even though the accuracy of femoral tunnel placement in modern single-bundle ACL reconstruction is greater, the risk of malpositioning and graft impingement remains. In our patient cohort, there was a clear correlation between ACL graft impingement, degenerative changes in MRI, and incorrect tunnel positioning. The surgeon must focus on accurate tunnel placement specific to individual patient anatomy. Level III.

Is viewing the femoral footprint end on while drilling the femoral tunnel in an ACL reconstruction more accurate ?

Introduction:Arthroscopic transportal ACL reconstruction traditionally involves viewing from the anterolateral portal and working from a portal on the medial side. This involves seeing the notch from the same side which evades an end on view of the whole lateral notch. Viewing from the medial side gives an end on view of the same. Working and viewing from the same side may create overcrowding of instruments. We overcame this by using a low far medial portal for drilling and viewing with a high anteromedial portal. We compared both techniques using 3D CT scans to analyse whether there was any difference in intended tunnel placements.Hypotheses:Viewing and working from the medial side would give a different tunnel position from viewing from the lateral and working from the medial portal.Methods:60 patients were recruited , equal numbers underwent transportal ACL reconstruction using semitendinosus and gracilis grafts by Technique A (Viewing from a high anterolateral portal just next to the patellar tendon at the level of the inferior pole of the patella and working from a low far medial portal) and Technique B (Viewing from high medial portal at the level of inferior pole of patella just next to the patellar tendon and working from a low far medial portal). Tunnels were made leaving 5 mm of back wall and just above the equator of the lateral aspect of the notch. 3 D CT scans were done 3 weeks after the surgery and location of the tunnels were studied using A modification of Edwards technique described by P Lertwanich et al,. A rectangle is drawn connecting the highest point of the lateral wall of the notch anteriorly, lowest point inferiorly, anterior and posterior most aspect after digitally subtracting the medial femoral condyle to expose the lateral aspect of notch. The footprint was covered by the best fit circle on a software, that covered all borders of the femoral tunnel. Centre of this circle was marked and perpendiculars bisecting it from the length and breadth of the rectangle were drawn. The centre of the femoral tunnel was expressed as a percentage from anterior and posterior.Results:60 knees were evaluated 52 right (Technique A: 27 and Technique B: 25) and 8 left knees ( Technique A :3 and Technique B:5 ). The mean age of the patients was 27.3 yrs ( Technique A : 26.7 yrs (Range 19-41yrs) and Technique B 27.6 yrs (Range 18-43yrs). There were 41 male and 19 female patients ( Technique A 18 males and 12 females, Technique B had 23 males and 7 females). Mean graft diameter was 8.8mm (range 7-10) in technique A and 8.6mm (range 8-10) in Technique B.MDS (Mean distance from superior margin)Technique A : 35.28 , Standard deviation (SD)6.7339, Technique B MDS 35.86, Standrad deviation9.4441Mean Distance from posterior margin (DP) :Technique A 35.83 ,SD:8.2008, Technique B 38.14 SD: 8.6991The t value for DS calculated is 0.2767, the P value is 0.7830 confidence interval is (-4.825, 3.653) . The t value for DP calculated is 1.060, the p value is 0.2937 confidence interval is (-6.682, 2.056)We concluded after applying the independent student t test that the p value is greater than 0.05. So mean distance of femoral tunnel from superior, posterior border in technique A does not differ significantly from mean distance of femoral tunnel from superior border, posterior border in technique BConclusion:An end on view while making the femoral tunnel does not give any added benefit in accuracy of femoral tunnel placement in this study.

No differences in clinical outcomes and graft healing between anteromedial and central femoral tunnel placement after single bundle ACL reconstruction.

The purpose of this study was to compare clinical outcomes and graft healing after anterior cruciate ligament (ACL) reconstruction with anteromedial and central femoral tunnel placement. During 2016 and 2018, 110 consecutive patients underwent single bundle ACL reconstruction; 85 patients met the inclusion criteria, and each patient underwent 3D-CT within 1week and MRI 1.5years after the operation. The central point of the femoral tunnel and signal/noise quotient (SNQ) of three regions of interest (ROI) in the intra-articular graft were measured to analyse the tunnel position and graft healing extent. Clinical assessments, including functional scores, KT-2000 arthrometer measurements and pivot-shift tests, were evaluated at the 2-year follow-up. Patients were divided into two groups depending on the femoral tunnel position: the anteromedial position group (Group A) and the centre position group (Group B). Seventy-one patients were available for the 2-year follow-up and MRI examination: 34 patients in Group A and 35 patients in Group B, and 2 patients were excluded for an eccentric tunnel position. No graft failure occurred, and compared with the preoperative assessment outcomes, the outcomes of both groups improved at the final follow-up. Group A was significantly better than Group B regarding the KT-2000 arthrometer measurements (P = 0.031). No significant differences were observed in terms of functional scores, pivot-shift test results, or the SNQ between groups. No differences in clinical outcomes or graft healing were found between AM and central femoral tunnel placements in single bundle ACL reconstruction. Therefore, satisfactory clinical outcomes, knee stability and graft healing can be obtained for both femoral tunnel placements. II.

Differential anatomy within the femoral origin of the medial patellofemoral complex: Implications or reconstruction

Objectives:The medial patellofemoral complex (MPFC) includes the medial patellofemoral ligament (MPFL) and medial quadriceps tendon femoral ligament (MQTFL). Recent reports have described reconstruction of this fan-shaped ligament to treat patellar instability using a double stranded technique to recreate both components of the complex, with a common origin on the medial femur. Much effort has been placed on accurately identifying the “point” of femoral origin during reconstruction due to the influence of femoral tunnel position on MPFC graft function, however, the MPFC origin is elongated in nature. Therefore, the purpose of this study was to describe the shape and orientation of the MPFC origin and identify the difference between the most proximal and distal margins of the elongated femoral footprint.Methods:20 paired fresh frozen cadaveric knees were dissected. From an intraarticular approach, the MPFC was exposed and followed to its footprint on the medial femur. All other soft tissue was removed from the distal femur, and the footprint of the MPFC, the adductor tubercle and medial epicondyle were marked. Images of the medial femur were analyzed using Image J software. The length and width of the MPFC footprint was described to the nearest 0.1mm, as well as the angle of the long axis of the footprint relative to the axis of the femoral shaft (0.1 degrees). The position of the footprint’s most proximal and distal margins were identified and described in relation to the adductor tubercle and medial epicondyle. The positions for each were compared using paired t tests.Results:17 knees from 10 cadavers (7M, 3F, mean age 73.1) were included in this study. The MPFC femoral footprint had a length of 11.7mm+/-1.8mm (Range 9.6,15.7) and a width of 1.7mm+/-0.4mm (Range, 0.9, 2.2). The long axis of the footprint was found to lie at an angle 14.6+/-16.6 degrees anterior to the axis of the femoral shaft. The most proximal fibers originated 7.4mm+/-3.8mm anterior and 1.8mm+/-4.7mm distal to the adductor tubercle, and 4.1mm+/-2.6mm posterior and 8.4mm+/-5.6mm proximal to the medial epicondyle. The most distal fibers originated 4.9mm+/-4.2mm anterior and 1.3mm+/-4.3mm and distal to the adductor tubercle, as well as 7.1mm+/-2.4mm posterior and 0.5mm+/-5.6mm distal to the medial epicondyle. Overall, the distal margin of the footprint was 10.9mm+/-1.7mm distal (p<0.001) and 2.6mm+/-3.2mm more posterior (p=0.005) than the proximal margin of the MPFC origin.Conclusions:The femoral footprint of the MPFC is ribbon shaped, with the distal margin being 10.9 mm distal and 2.6 mm posterior to the proximal margin. This differential anatomy of the femoral origin suggest that MPFL and MQTFL reconstruction may require separate placements of the femoral tunnels to anatomically recreate these fibers. Further biomechanical studies are needed to determine the optimal femoral tunnel placement in the setting of double-limbed MPFC reconstruction, as well as the long term benefit of this technique in the treatment of patellar instability.

The location of the femoral ACL footprint center is different depending on the Blumensaat's line morphology.

The purpose of this study was to evaluate the difference in the center point of the femoral ACL footprint according to the morphological variations of the Blumensaat's line. Fifty-nine non-paired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. Digital images were evaluated using the Image J software. The periphery of the femoral ACL footprint was outlined and the center point was measured automatically. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill types (small and large hill types). The center of the femoral ACL footprint and hilltop placement were evaluated using the quadrant method. A quadrant grid was placed uniformly, irregardless of hill existence, and not including the articular cartilage. A correlation analysis was performed between the center point of the femoral ACL footprint and hilltop placement. The straight type consisted of 19 knees, and the hill type 40 knees (small hill type 13 knees and large hill type 27 knees). The center of the femoral ACL footprint (shallow-deep/high-low) in the straight and hill type knees was 33.7/47.6%, and 37.2/50.3%, respectively. In the hill type, the ACL footprint center was significantly more shallow when compared to the straight type. Significant correlation was observed between the center point of the femoral ACL footprint and hilltop placement of the Blumensaat's line. The center point of the femoral ACL footprint was significantly more shallow in the hill type knees when compared to the straight type. For clinical relevance, considering that the location of the femoral ACL footprint center is different depending on the Blumensaat's line morphology, to perform accurate ACL reconstruction, femoral ACL tunnel placement should be made based on Blumensaat's line morphological variations.

Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction.

The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms "anterior cruciate ligament reconstruction," "anatomic or anatomical," and "single bundle." Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow-deep direction (32.3%) and in a high-low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.

Techniques for Femoral Socket Creation in ACL Reconstruction.

Anterior cruciate ligament (ACL) injury is common and affects a wide variety of individuals. An ACL reconstruction is the treatment of choice for patients with subjective and objective symptoms of instability and is of particular importance to cutting or pivoting athletes. With many variables involved in ACL reconstruction, femoral tunnel placement has been found to affect clinical outcomes with nonanatomic placement being identified as the most common technical error. Traditionally the femoral tunnel was created through the tibial tunnel or transtibial with the use of a guide and a rigid reaming system. Because of proximal, nonanatomic tunnel placement using the transtibial technique, the use of the anteromedial portal and outside-in drilling techniques has allowed placement of the tunnel over the femoral footprint. In this paper, we discuss the difference between the 3 techniques and the advantages and disadvantages of each. The authors then explore the clinical differences and outcomes in techniques by reviewing the relevant literature.

Correlation between Endobutton Position and Functional Outcome After ACL Reconstruction: Plain Xray Evaluation

Abstract: The correct positioning of the femoral tunnel and endobutton position determine the success of ACL reconstruction (ACLR). Improper femoral tunnel placement most common errors in failed ACLR. However, plain post-operative imaging in the early state is not routinely performed. EndoButton position evaluation by XRay was made because this technique was cheap and reliable in Indonesia. There is no consensus on the ideal positioning of EndoButton in compare with functional outcome after ACLR. The study aimed to evaluate anatomic positions of tunnel and fixation devices, and also provide a baseline examination for future controls regarding tunnel placement and fixation devices, and also evaluation functional outcome after ACL procedure and also evaluation of functional outcome after ACLR with IKDC score. Between February 2019 to July 2019, 20 patients aged 17 to 59 years, with post ACL reconstruction were involved in this study. We are evaluating sex, age, affected the side of the knee, complication after an operation, related activity with injury, and evaluation postoperatively with femoral angle measurement Xray AP and lateral view. We also evaluated and correlate post ACRL and functional outcomes with the International Knee Documentation Committee (IKDC) score. The mean age of patients was 28,38 ± 9,3 years, (87,15% men and 12,5% women). There is no complication after the operation in all patients. Nine patients (56,3%) affected on the left side, and seven patients (43,8%) affected right-sided. All patients are performed single-bundle augmentation techniques for ACL reconstruction. Five (31,3%) patient has history fall and eleven (68,8%) patients caused by sports activity. All patient has Femoral angle measurement from knee AP view x-rays more than 17o, with minimum 39o and maximum 54o, with mean 46,63 ± 4,2. From lateral x rays, we interpreted nine patients (45%) interpreted as shallow and high, and 55% others interpreted as deep and low (optimal). The mean of IKDC score pre-op was 58,1±4,6 and means IKDC postoperatively 6 months was 84,68 ± 5,1. There was a significant difference in functional outcome between optimal endobutton and not optimal endobutton position group with p-value &lt; 0,05. Early post-operative imaging (knee x-rays) provides useful information regarding tunnel placement and fixation devices. It also serves as a baseline examination for future reference. In this study, a single bundle ACL reconstruction shows a satisfying outcome. Keywords: Anterior cruciate ligament; knee; postoperative reconstruction; radiograph.

Iatrogenic Injury to the Posterolateral Knee During Anterior Cruciate Ligament Reconstruction with Anteromedial Portal Technique

BACKGROUND: Femoral tunnel reaming through anteromedial portal, also known as transportal technique, allows for anatomic femoral tunnel placement in restoring anterior cruciate ligament (ACL) kinematics. This procedure may cause iatrogenic injury to the posterolateral structures of the knee.&#x0D; PURPOSE: This study aims to assess the risk of posterolateral structure injury in ACL reconstruction using transportal technique.&#x0D; METHODS: ACL reconstruction using transportal technique was performed in 20 patients. Clinical and radiological examination was performed preoperatively and 1 month postoperatively. Clinical examination included any pain or paresthesia on posterolateral area of the knee, varus alignment of the knee, abnormal gait, and specific tests for posterolateral stability. Radiological evaluation was plain radiography and stress radiography for posterolateral stability, and magnetic resonance imaging (MRI) for assessing structural damage.&#x0D; RESULTS: Post-operative evaluation showed pain in posterolateral area in five patients, numbness on posterolateral knee in one patient, both pain and numbness in two patients and lateral gastrocnemius muscle injury on MRI in six patients. We did not find varus knee alignment and abnormal gait. Specific tests were negative in post-operative evaluation. Post-operative radiographic imaging did not show the sign of lateral widening.&#x0D; CONCLUSION: Femoral tunnel drilling using transportal technique in ACL reconstruction is safe even it might risk to damage lateral gastrocnemius muscle, according to clinical and MRI findings.