Anterior Cruciate Ligament Reconstruction Techniques Research Articles

Anatomical Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autografts: A Comparative Study of Three Different Techniques.

The ideal procedure for anterior cruciate ligament (ACL) reconstruction is one that can achieve anatomical restoration for a better ACL function. This retrospective comparative study was conducted to evaluate the objective and subjective clinical results of the conventional single-bundle femoral round (SBR) tunnel technique, the single-bundle femoral oval (SBO) tunnel technique, and the double-bundle (DB) surgical technique for anatomical ACL reconstruction with hamstring tendon autografts. Patients who underwent the SBO, SBR, and DB ACL reconstructions from January 2016 to August 2017 were included in this study. A total of 163 patients underwent different surgical techniques; 41 patients underwent the SBO procedure, 78 patients received SBR, and the remaining 44 patients underwent the DB procedure. The Lachman's test, pivot-shift test, Lysholm's score, International Knee Documentation Committee (IKDC) score, and Tegner's score were compared among groups postoperatively. KT-1000 was used to measure the anterior laxity of the knee. Magnetic resonance imaging was used to compare the ACL graft maturity. Second-look arthroscopy was conducted to compare the graft status and synovial coverage. Significant differences among groups were found with respect to the Lysholm's score, Tegner's score, and IKDC score. Patients in the SBO and DB groups acquired higher functional scores than the SBR group. More patients with positive pivot-shift test were observed in the SBR group than other groups at 12- and 24-month postoperative follow-ups. The postoperative KT-1000 was better in the SBO and DB groups than in the SBR group. The mean signal/noise quotient (SNQ) of the SBO group was 2.70 ± 0.92, significantly lower than 3.58 ± 1.21 of the SBR group. Despite a higher proportion of patients with grade B or C synovial coverage and partial graft injury found in the SBR group, there were no significant differences among the groups. The SBO and DB technique achieved better clinical results than the SBR technique. The SBO technique was indeed an ideal surgical procedure for ACL reconstruction provided that the shortcoming of DB technique must be taken into account. This is a Level III, retrospective comparative study.

Is the Independent Tape Reinforcement a valid technique to reduce the rerupture rate of ACL reconstructions? A technical instruction and case series with 2-year follow up

Aims and Objectives:Although there is an ongoing development in ACL reconstruction techniques, a rerupture rate up to 20% still is discussed in the literature. Is the ACL reconstruction using a quadriple semitendinosus in combination with a polyurethane tape reinforcement a valid technique to reduce the retare rate? A clinical trial with 35 Patients compared to 320 patients using an isolated semitendinosus reconstruction without internal bracing.Materials and Methods:Additionally, to the quadruple semitendinosus technique with cortical button fixation, the transplant is parallelly stabilized by a polyurethane tape which is individually fixed in the femoral button. The tape secures the transplant during the remodeling episode since repeated small tensions on the transplant during this time are discussed as a reason for a rerupture. In this prospective case series 35 patients were treated with this technique, reexamined and VAS, Tegner, KOOS Jr. and SANE are preoperatively, two and six weeks, three and six month and after one, two and five years recorded using a PROMS system. Clinical instability and proprioceptive function were also surveyed at these timepoints. The results and rerupture rates were compared with 320 patients of our database who underwent a comparable reconstruction without using the internal brace.Patients with fractures and multi-ligament injuries were excluded.Results:Until now no reruptures were reported, there are no significant subjective or objective differences compared to the group without internal bracing. The two years results are pending.Preoperatively the VAS score was 2.2 +/- 2.0. Two weeks after the surgery 2.1 +/- 1.8 and one year postoperatively 0.5 +/- 0.7. Tegner score preoperatively: 4.6 +/- 2.7 after one year 4.7 +/- 3.0. KOOS jun. improves in both groups around 15%.Conclusion:Until now the ACL reconstruction using an internal brace seems to be a safe and effective technique. Biomechanical studies show beneficial stabilizing results and a minor rerupture rate might be possible due to reduced microlesions during the remodeling period. The study is still ongoing, longtime results are pending.

High incidence of tunnel collision in combined ACL reconstruction and LET

Aims and Objectives:Lateral extra-articular tenodesis (LET) procedures are being increasingly performed as concomitant procedures to both primary and revision intra-articular ACL reconstructions with the purpose of controlling excessive anterolateral rotatory instability and to reduce tension on the ACL graft.There is, however, a lack of evidence on benefits and pitfalls of different femoral LET attachment positions.The purpose of this study was to assess the risk of tunnel convergence in combined ACL and LET procedures comparing two different femoral attachment sites (Lemaire and MacIntosh).Materials and Methods:10 fresh-frozen cadaver knees were examined. In each specimen an anatomic ACL femoral tunnel and two LET tunnels were drilled applying the Lemaire and MacIntosh position. Following knee dissection, minimal distances between ACL and LET tunnels were directly measured on the lateral femoral cortex. Furthermore, computed tomography (CT) scans were obtained to measure inter-tunnel convergence and lateral femoral condyle (LFC) width. Based on the average LFC width, knees were divided into large and small knees to determine a relationship between knee size and tunnel convergence.Results:Convergence of ACL and LET tunnels occurred in 7 of 10 cases (70%) using the Lemaire attachment position. All tunnel collisions occurred directly on the lateral femoral cortex, while inter-tunnel conflicts were not observed. Collisions emerged in both, small (n=4) and large (n=3) knees. Critical tunnel convergence did not occur using the MacIntosh position. The mean minimal distance between the LET and ACL tunnel using the Lemaire and MacIntosh position was 3.1±4.6 mm and 9.8±5.4 mm, respectively.Conclusion:A high risk of tunnel convergence was observed in combined ACL and LET reconstruction using the Lemaire technique, independent of the knee size. LET femoral tunnel positioning according to the MacIntosh reconstruction can significantly reduce the risk of tunnel collision. These findings help to intraoperatively raise the awareness for the risk of tunnel convergence in combined ACL and LET procedures.Adjustments on ACL reconstruction techniques and especially on the femoral fixation have to be considered when applying an additional Lemaire reconstruction.

Chapter 5: Techniques For ACL Revision Reconstruction.

Anterior cruciate ligament (ACL) reconstruction is a commonly performed procedure, with an increasing frequency leading to an increased number of revision procedures. Etiologies for graft rupture are varied and can include technical issues, repeat trauma, and graft choice. The preoperative evaluation before a revision ACL reconstruction should include a detailed history and physical exam, as well as radiographs, magnetic resonance imaging to evaluate graft integrity and for concomitant injuries, as well as computed tomography to measure for bone tunnel osteolysis. Surgical techniques for revision ACL reconstruction include a 1-stage or 2-stage procedure with possible bone grafting and repair of associated injuries. Recent studies show worse clinical outcomes after a revision procedure; however, research continues to emerge with novel techniques and rehabilitation protocols to improve patient outcomes after revision ACL reconstruction.

Lateral Extra-articular Tenodesis in Anterior Cruciate Ligament Reconstruction.

A subset of patients have residual rotational laxity following anterior cruciate ligament reconstruction (ACLR) despite the evolution of ACLR techniques. In recent years, there has been increased interest in addressing residual laxity because it is associated with poor outcomes after ACLR. There is an expanding body of knowledge on the anatomy and biomechanics of the anterolateral soft tissue restraints in regard to their rotational control of the knee and this has reignited an interest in extra-articular reconstruction techniques for augmenting ACLR. Reconstruction techniques currently used can be broadly categorized as either lateral extra-articular tenodesis or anterolateral ligament reconstruction. In this review, we discuss the relevant anatomy, biomechanics, and rationale behind the indications and technique of our current extra-articular augmentation procedure.

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 < 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.
 PURPOSE: This study aims to assess the risk of posterolateral structure injury in ACL reconstruction using transportal technique.
 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.
 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.
 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.

Hamstring grafts for anterior cruciate ligament reconstruction show better magnetic resonance features when tibial insertion is preserved.

Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the "Graft" was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The "Tibial Tunnel" was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0-10. Tunnel and graft positioning were evaluated. At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months (p = 0.008) and 18-months (p = 0.028), the tunnel was significantly smaller (p < 0.05) and less enlarged at both follow-ups (p < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months (p < 0.05). The total score of the non-detached group saw a significant improvement at 4-months (p = 0.006) that remained stable at 18-months (n.s.). Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. IV.

CHALLENGES IN SMALL KNEE ARTHROSCOPY: A QUALITATIVE AND QUANTITATIVE PEDIATRIC CADAVERIC EXPERIENCE

Background:Arthroscopy may be utilized for treatment of septic arthritis of the pediatric knee, with success reported in ages from 3 months to 12 years. There is limited data on the ability to arthroscopically assess articular structures and ensure adequate evaluation without arthrotomy.Hypothesis/Purpose:The purpose of this study is: (1) utilize arthroscopy in small cadaveric knees to improve qualitative and quantitative knowledge of pediatric articular structures and (2) to obtain pilot data for common procedures performed in pediatric patientsMethods:Five small pediatric cadaveric specimens (1-4 years) underwent arthroscopy (2.7 mm Stryker arthroscope). Medial and lateral compartments were assessed for meniscus size/mobility/height, compartmental joint space, ACL insertion, patellar chondral height and length, and position of the medial patellofemoral ligament were recorded. Utilizing standard anterior medial and lateral portals, the ability to visualize the structures of the posteromedial and posterolateral compartments was recorded. Procedures pertinent to immature ACL reconstruction and meniscal repair (unstable discoid) were critically evaluated to provide source data for future work.Results:Prior to arthroscopy, all specimens underwent volume-assessed knee insufflation (average 11.4 cc normal saline). Arthroscopic visualization of the menisco-capsular attachment was possible posteromedially in 4/6, and posterolaterally in 5/6 knees. Qualitative arthroscopic relationships were similar to adult references; including patellar-trochlear articulation and lateral meniscal positional relationship to the ACL insertion (see Figure 1). The ACL center was within 2 mm of the posterior aspect of the anterior horn of the lateral meniscus in all specimens. The average height of the medial compartment space under valgus load was 1.5 mm (1 – 2 mm), and lateral space under varus was 2.2 mm (2-3 mm); further emphasizing the need for small joint instruments. The width of the medial and lateral menisci are noted in Table 1. All-inside meniscal devices designed for skeletally mature specimens should be used with caution (Figure 1). Traditionally described inside-out technique for immature ACL reconstruction with an iliotibial band demonstrated significant proximity of the passing device to the neurovascular bundle (Figure 1).Conclusion:The entirety of the small knee is assessable via standard diagnostic arthroscopy, when a 2.7mm arthroscope is utilized. These findings suggest that intra-articular pathology can be reliably identified utilizing this surgical technique. However, the ability to work on the infant meniscus and cartilage with standard arthroscopic instruments is likely limited given the constraints of joint height.Table 1.Meniscal width of the medial and lateral meniscus as measure by a microprobe. Figure 1.Arthroscopic and gross images of an infant cadaveric knee 11 year old). (A) ACL insertion into the tibia. Note the relationship of the anterior horn of the lateral meniscus to the ACL Insertion. (B) The patellocrochiear articulation with a well formed troctilea, (C) Medial patellofemoral ligament as it inserts onto the patella. Marking in the ligament 1') indicates centroid of the ligament based on superficial anatomy. (D) Pilot study of placement of an all-inside meniscal repair device (Stryker AIR) The size of implant is 70% of the height of the lateral meniscus, .1E) Image of a dissected popliteal fossa of a small knee. Curved clamp )black arrow) was placed as if to facilitate passage of the !Thin a extra-articular ACL reconstruction with the dicta:fiat hand. Note the proximity to the posterior neurovascular structures (Yellow = artery; blue = nerve).

ACL LENGTH IN PEDIATRIC POPULATIONS: AN MRI RETROSPECTIVE STUDY

Background:Young athletes have the highest rates of primary and recurrent anterior cruciate ligament (ACL) tears, and recent research has identified graft diameter as a predictor of graft failure. Newer ACL reconstruction techniques have been developed to increase graft diameter and reduce re-rupture rates. Graft diameter can be modified based upon graft length, number of graft strands/configuration, and native ACL length. While the ACL has been well-studied in adult populations, there is limited research examining the ACL dimensional characteristics in a pediatric population. Appropriate preoperative anatomic dimensions may help surgeons plan for optimal graft length, diameter and bundle arrangementPurpose:To develop MRI-based predictors of native ACL graft length in pediatric populations and enhance preoperative planning to optimize graft length, strand configuration and graft diameter to lower the risk of recurrent ACL injury.Methods:One hundred and ten subjects were included from the STRIDE database (64 females and 46 males, median age 10 years, range 1-13 years). Our exclusion criteria were if the subjects had musculoskeletal diseases or history of knee injury. Using MRIs, researchers evaluated ACL length, sagittal and coronal inclination of the ACL, inclination and width of the intercondylar notch, depth and width of the femoral condyles, and the medial and lateral tibial slopes. Association between measurements, sex, and age were investigated using linear and multivariate regression models.Results:When examining the predictors for ACL length by sex, the best predictor (R⁁2 = 0.65) for female ACL lengths was the depth of the lateral femoral condyle taken in the sagittal view (p<0.001). Other predictors that were statistically significant (p < 0.005) were distal femoral condylar width (R⁁2 = 0.62), age (R⁁2 = 0.52), and coronal notch width (R⁁2 = 0.15). For males, the best predictor (R⁁2 = 0.70) of ACL length was the distal femoral condyle width as viewed coronally (p < 0.001). Other statistically significant predictors (p < 0.005) of male ACL lengths were lateral femoral condyle depth (R⁁2 = 0.62), age (R⁁2 = 0.48), and coronal notch width (R⁁2 = 0.20).Conclusion:When predicting the ACL length in pediatric populations, femoral condylar depth and width, and patient age may be valuable predictors for those undergoing ACL reconstructions. Surgical planning to maximizing graft diameter is contingent upon native ACL graft length, and the use of this information to optimize graft utilization may lower the rates of ACL graft failure in the highest risk pediatric populations.Tables/Figures:Table 1.1.Predictors of ACL Length Figure 1.2.Figure 1.3.

Application of two types of suspensory fixation in reconstruction of anterior cruciate ligament with a semitendinosus-gracilis graft: A randomized prospective study

Background/Aim. Injury to the anterior cruciate ligament (ACL) of the knee is the most common ligament injury that requires operative treatment. So far, multiple ACL reconstruction (ACLR) techniques using a variety of graft types and implants that fixate the grafts have been described. The aim of the study was to compare two different ACLR techniques using two implant types for suspensory graft fixation in the femoral tunnel. Methods. This randomized-prospective study encompassed 60 patients/subjects who underwent ACLR in the period between January 2015 and December 2017 at the Department of Orthopaedics and Traumatology of Military Hospital ?Dr Vladan Djordjevic? Nis. The ACLR in all patients included in the study was per-formed using a quadruple semitendinosus-gracilis (STG) graft with two types of suspensory fixation on the lateral femoral cortex, whereas the graft fixation in the tibial tunnel was performed using an osteoconductive bioresorbable screw. The post-operative knee stability was assessed 24 months after surgery using the Lachman test and the lateral pivot shift test, as well as the KT-1000 arthrometer test. Results. In patients whose graft was fixated using a fixed-length loop implant, the mean post-surgery knee stability, measured with the KT-1000, was 1.167 ? 0.780; in patients whose graft was fixated using an adjustable-length loop implant, the mean value of the KT-1000 was 1.100 ? 0.894 (p = 0.605). The mean post-surgery International Knee Documentation Committee (IKDC) score for the fixed-length loop group was 84.887 ? 9.0207, while for the adjustable-length loop the score was 88.327 ? 7.302. The mean Lysholm score was 93.50 ? 6.872 for the fixed-length loop group of patients and 94.00 ? 5.527 for the adjustable-length loop group of patients. Conclusion. Both types of implants can be used with success during ACLR, because the functional results of operative treatment using both implants were identical after surgery.

Three-Dimensional Magnetic Resonance Imaging for Guiding Tibial and Femoral Tunnel Position in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study.

Background:Femoral and tibial tunnel malposition for anterior cruciate ligament (ACL) reconstruction (ACLR) is correlated with higher failure rate. Regardless of the surgical technique used to create ACL tunnels, significant mismatches between the native and reconstructed footprints exist.Purpose:To compare the position of tunnels created by a standard technique with the ones created based on preoperative 3-dimensional magnetic resonance imaging (3D MRI) measurements of the ACL anatomic footprint.Study Design:Controlled laboratory study.Methods:Using 3D MRI, the native ACL footprints were identified. Tunnels were created on 16 knees (8 cadavers) arthroscopically. On one knee of a matched pair, the tunnels were created based on 3D MRI measurements that were provided to the surgeon (roadmapped technique), while on the contralateral knee, the tunnels were created based on a standard anatomic ACLR technique. The technique was randomly assigned per set of knees. Postoperatively, the positions of the tunnels were measured using 3D MRI.Results:On the tibial side, the median distance between the center of the native and reconstructed ACL footprints in relation to the root of the anterior horn of the lateral meniscus medially was 1.7 ± 2.2 mm and 1.9 ± 2.8 mm for the standard and roadmapped techniques, respectively (P = .442), while the median anteroposterior distance was 3.4 ± 2.4 mm and 2.5 ± 2.5 mm for the standard and roadmapped techniques, respectively (P = .161). On the femoral side, the median distance in relation to the apex of the deep cartilage (ADC) distally was 0.9 ± 2.8 mm and 1.3 ± 2.1 mm for the standard and roadmapped techniques, respectively (P = .195), while the median distance anteriorly from the ADC was 1.2 ± 1.3 mm and 4.6 ± 4.5 mm for the standard and roadmapped techniques, respectively (P = .007).Conclusion:Providing precise radiological measurements of the ACL footprints does not improve the surgeon’s ability to position the tunnels. Future studies should continue to attempt to provide tools to improve the tunnel position in ACLR.Clinical Relevance:This cadaveric study indicates that despite the use of 3D MRI in understanding the ACL anatomy, re-creating the native ACL footprints remains a challenge.

Soaking of the graft in vancomycin dramatically reduces the incidence of postoperative septic arthritis after anterior cruciate ligament reconstruction.

To determine and compare the incidence of postoperative septic arthritis following anterior cruciate ligament reconstruction (ACLR) with and without soaking of the graft in vancomycin solution prior to implantation in a large single-centre case series. From 2004 to 2019, a total of 10,516 primary ACLR were performed and reviewed with regard to the occurrence of postoperative septic arthritis. From February 2017 onwards, all grafts were wrapped in a vancomycin-soaked (5mg/ml) gauze swab between harvest and implantation (2294 patients, treatment group (2), prospectively followed). These were compared to 8222 patients before that date (control group (1), retrospectively evaluated). The technique of ACLR did not significantly change during the years of the study. There was no difference between the groups with regard to graft choice: Hamstring tendons were used in 99% and quadriceps tendons were used in 1% in both groups, respectively (n.s.). Routine follow-up examination was performed at 6weeks (follow-up rate 97.1%) postoperatively. Patients with no treatment for septic arthritis at that time were classified as non-infected. There were 35 cases of postoperative septic arthritis in group 1 (incidence: 0.4%), and none in group 2 (incidence 0.0%), respectively. The difference was significant (p < 0.001). Soaking of the graft in vancomycin solution prior to implantation dramatically reduces the incidence of postoperative septic arthritis in primary ACLR and should, therefore, be used in prevention of this major complication. III.

A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction.

A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry. This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes. The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%). The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR. Retrospective case series; level of evidence, 4.

Anterior Cruciate Ligament Reconstruction Using a Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel

According to recent anatomic studies, the anterior cruciate ligament (ACL) appears to be a flat, “ribbon-like” structure, with a thin, oval-shaped insertion on the femur and a C-shaped tibial insertion. According to this anatomy, we describe an ACL-reconstruction technique that aims to approximate this natural anatomy. The basic principle of this technique is not to use conventional round tunnels but create tunnel shapes that resemble more closely the original ACL insertion sites. Using either a rectangular quadriceps tendon graft or a “flat” hamstring graft may not only provide a biomechanical advantage with increased rotational stability but also improve bone–tendon healing due to increased bone–tendon contact and decreased diffusion length. Creating a C-shaped tibial tunnel also avoids laceration of the anterior horn of the lateral meniscus, which is frequently harmed during conventional tibial tunnel drilling.

Prediction of clinical outcomes of single- and double- bundle anterior cruciate ligament reconstruction techniques using magnetic resonance imaging.

The objective of the study is to compare the clinical results of the single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) repairing techniques using magnetic resonance imaging (MRI). Thirty-eight patients were randomized by block randomization into two different groups of ACL reconstruction: DB (n=19) and SB techniques (n=19). MRI evaluation and clinical examination with modified Cincinnati Knee Rating Score and Lysholm knee scores were performed pre-operatively and at the end of a follow-up period of 36 months. No significant differences were found in the ACL angle, posterior cruciate ligament angle, and tibial translation between the DB and the SB groups. Regarding the clinical scores, there were no significant differences between the techniques. As for the correlation of radiologic results with clinical scores in the SB group, there was a strong and significant correlation between the post-operative ACL angle values and the Lysholm clinical score (r=-0.66; p=0.002). The post-operative ACL angle can predict the degree of clinical recovery in patients undergoing SB ACL reconstruction.

Radial Distortion of the Arthroscopic Transtibial Portal: A 2-Dimensional in Vitro Model

Purpose: To make the positioning of the anterior cruciate ligament (ACL) transplants as precise as possible, it is necessary to better visualize the foot-print. Identifying anatomic sites is complicated by image distortion inherent in arthroscopy. The standard “Outside-In” ACL reconstruction technique involves drilling a tunnel, i.e. an aperture on the surface of the tibia for the purpose of placing the bone-tendon-bone transplant. This operative technique opens another approach to the inside of the knee, through the tibial plateau (Transtibial-TT). The aim of this manuscript is to assess optimal arthroscopic visibility by calculating radial distortion, arthroscopy insertion positions and different knee bending angles. Methods: We used a standard dot array calibration pattern, an arthroscopic imaging system and Sawbones knee models. The standard deviation and relative standard deviation of distances obtained at distortion of the images were calculated. Results: All captured imagines have shown the effect of distortion so called fish-eye view, i.e. the imagines at periphery were more curved and compressed. Conclusion: The least distorted arthroscopic image of the femoral ACL footprint can be obtained when using the TT portal and by bending the knee between 90° and 130° with a 30° arthroscope. Also, the best visualization is performed by drilling the tibia under the angle 0° in the sagittal plane and 23° in the coronal plane in comparison to the tibial surface.

All-inside Anterior Cruciate Ligament Reconstruction with Hamstring Autograft Consistently Yields Grafts with 8.0-mm Diameter or Larger

A minimum graft diameter of 8.0 mm for anterior cruciate ligament reconstruction (ACLR) is associated with lower risk of revision surgery. We previously described a technique for all-inside ACLR which incorporates the semitendinosus tendon (ST) and gracilis tendon (GT) in an eight-stranded autograft construct. We hypothesized that this technique would allow surgeons to follow a simple intraoperative algorithm to consistently achieve a graft diameter of 8.0 mm or larger without the use of allograft tissue.

Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation: A Surgical Technique

The anterior cruciate ligament (ACL) is the most common ligamentous knee injury and often is encountered in those participating in multidirectional sports. ACL reconstruction is the most commonly performed knee ligament reconstruction and employs a variety of surgical techniques but still is challenged by residual laxity and graft rupture. To help address and prevent future ACL failures, new repair and reconstruction techniques have been employed that incorporate suture augmentation (InternalBrace; Arthrex, Naples, FL), which protects the graft during healing and ligamentization. Our goal of this article is to provide a surgical technique of suture augmentation with ACL reconstruction.

Oval femoral tunnel technique is superior to the conventional round femoral tunnel technique using the hamstring tendon in anatomical anterior cruciate ligament reconstruction.

This study was conducted to compare the efficacy between the oval femoral tunnel technique and the conventional round femoral tunnel technique in ACL reconstruction using an autologous hamstring tendon on the basis of the postoperative clinical outcomes and ACL graft tendon maturity. The hypothesis was that ACL reconstruction performed using the oval femoral tunnel technique was better than that performed using the round femoral tunnel technique in clinical functions and graft maturity. One hundred and eight patients who underwent anatomical single-bundle ACL reconstruction were included in this study and the follow-up period was at least 2years. Thirty-nine patients admitted between February and August in 2016 were included in the oval femoral tunnel group and 69 patients admitted between September 2016 and March 2017 were included in the round femoral tunnel group. The Lachman test result, pivot-shift test result, Lysholm score, IKDC score, and VAS score were used for the clinical evaluation. An objective assessment of anteroposterior stability was performed using a KT1000 arthrometer. Postoperative MRI was conducted to compare the ACL graft maturity differences between the oval femoral tunnel group and round femoral tunnel group, where the signal/noise quotient (SNQ) was calculated. In addition, second-look arthroscopy was conducted to compare the graft status and synovial coverage at 24months postoperatively. All the patients presented with significant improvement in all clinical scores from the preoperative period to the 24-month follow-up. During the postoperative follow-up period, no statistically significant differences were found between the two groups in terms of the VAS score, knee ROM, Lachman test results, and graft status determined in the second-look arthroscopic evaluation. The Lysholm score was 97.1 ± 3.9 and 94.8 ± 5.6 in the oval femoral tunnel group and round femoral tunnel group, respectively, at the 24-month follow-up (p = 0.031). The IKDC subjective score was 92.0 ± 2.6 and 89.0 ± 3.6 in the oval femoral tunnel group and round femoral tunnel group, respectively, at the end of the follow-up period (p < 0.001). Significantly more patients with 1-degree positive pivot-shift test results were observed in the round femoral tunnel group (10/65) than in the oval femoral tunnel group (1/37) at the end of the follow-up period (p = 0.048). The mean SNQ of the oval femoral tunnel group was 2.7 ± 0.9, which was significantly lower than that of the round femoral tunnel group (3.6 ± 1.1) at the 24-month postoperative follow-up (p < 0.001). Based on the clinical evaluations, MRI findings and second-look arthroscopy results of the two groups, the oval femoral tunnel technique yielded significantly better knee function and knee laxity restoration and more mature ACL grafts than the round femoral tunnel technique, whereas no significant differences were found at the second-look arthroscopy. III.