Tibial Tunnel Drilling Research Articles

Patient and Operative Risk Factors for Osteoarthritis After Primary Anterior Cruciate Ligament Reconstruction: A Cohort Study of 41,976 Patients

Background: The reported incidence of posttraumatic knee osteoarthritis (PTOA) after primary anterior cruciate ligament reconstruction (ACLR) varies considerably. Further, there are gaps in identifying which patients are at risk for PTOA after ACLR and whether there are modifiable factors. Purpose: To (1) determine the incidence of PTOA in a primary ACLR cohort and (2) identify patient and perioperative factors associated with the development of PTOA after primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Kaiser Permanente ACLR Registry were used to conduct a cohort study. Patients who had undergone primary ACLR without a previous diagnosis of osteoarthritis were identified (2009-2020). The crude incidence of PTOA was calculated using the Aalen-Johansen estimator with a multistate model. The association of patient and operative factors with the development of PTOA after primary ACLR was modeled as a time to event using multistate Cox proportional hazards regression. Models stratified by age (<22 and ≥22 years) were also conducted because of the effect modification of age. Results: The study sample included 41,976 cases of primary ACLR. The incidence of PTOA was 1.7%, 5.1%, and 13.6% at 2, 5, and 10 year follow-ups, respectively. Risk factors for PTOA that were consistently identified in the overall cohort and age-stratified groups included a body mass index ≥30 versus <30 and an allograft or quadriceps tendon autograft versus a hamstring tendon autograft. Patients presenting with knee pain after ACLR were further identified when considering postoperative factors. Other risk factors for PTOA in the overall cohort included age ≥22 versus <22 years, bone–patellar tendon–bone autograft versus hamstring tendon autograft, hypertension, cartilage injury, meniscal injury, revision after primary ACLR with concomitant meniscal/cartilage surgery, multiligament injury, other activity at the time of injury compared with sport, and tibial tunnel drilling technique rather than the anteromedial portal. Conclusion: Knee pain after ACLR may be an early sign of PTOA. Surgeons should consider the adverse associations of a higher body mass index and an allograft or quadriceps tendon autograft with the development of PTOA, as these were factors identified with a higher risk, regardless of a patient’s age at the time of primary ACLR.

The tibial capsular reflection and septum in posterior compartment are safe and reliable soft-tissue landmark for tibial tunnel drilling in posterior cruciate ligament reconstruction.

To investigate the validity of using tibial capsular reflection and septum in the posterior compartment as landmark during posterior cruciate ligament (PCL) reconstruction (PCLR). Anatomic measurements were obtained for 12 fresh human cadaveric knee specimens to observe the spatial position of the tibial insertion of the PCL in relation to the posterior septum and the capsular reflection in the posterior compartment. Sixty patients who underwent reconstruction of the PCL between 2020 and 2023 were also retrospectively investigated. The tibial tunnel was replaced in all patients using the same method (with reference to the tibial capsular reflection and the posterior septum). The placement of the tibial tunnel was assessed using X-ray fluoroscopy intraoperatively and computed tomography and three-dimensional reconstruction postoperatively. All fibres in the tibial insertion of the PCL in the 12 cadaveric specimens were located in the posteromedial compartment, adjacent to the posterior septum. The inferior border of the PCL insertion is adjacent to the tibial capsular reflection, which is attached at the champagne glass drop-off of the posterior tibia. In our previous cases, none of the patients experienced postoperative or intraoperative complications such as neurovascular injury, and the angle between the pin and the PCL facet was 93.1 ± 3.9° as measured on intraoperative radiographs. The mean distance from the centre of the tibial tunnel outlet to the inferior border of the PCL insertion was 5.6 ± 1.1 mm, and the distance from the centre of the tibial tunnel outlet to the outer border of the PCL insertion as a percentage of the length of the inferior border of PCL insertion was 42.2 ± 6.3%. The tibial capsular reflection and septum in the posterior compartment are safe and reliable soft-tissue landmark for tibial tunnel drilling in PCLR. Level Ⅳ.

Satisfactory 5-year functional outcomes following primary ACL reconstructions from the UK National Ligament Registry.

The aim of this study was to describe the 10-year findings from the UK National Ligament Registry (NLR). A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary ACL reconstruction (ACLR) on the registry were included. Surgical characteristics were analysed, including surgeon grade and case volume, concomitant knee procedures, venous thromboembolic prophylaxis, graft characteristics, femoral and tibial tunnel drilling, and fixation methods. Clinical outcomes were collected preoperatively and at 6 months, 1 year, 2 yearsand 5 years following the index procedure. During the study period, 17,492 unilateral ACLR procedures were recorded. Autograft was used in 98%, most commonly a combined semitendinosus and gracilis graft (77%) or patella tendon graft (31%). Allograft was used in only 1% of the patients. In 52% of cases, ACLR was associated with an additional procedure, with isolated medial meniscal surgery being the most common (21%). Femoral tunnel drilling was mostly performed through an anteromedial portal (73%) and tibial tunnel drilling using an outside-in technique (92%). The most common method of femoral graft fixation was with an Endobutton fixed loop suspensory device (77%), while interference screws predominated for tibial tunnel fixation (86%). Patients who underwent ACLR surgery showed significant improvement in their functional outcome scores at six months, 1 year, 2 yearsand 5 years postoperatively. Data from the NLR shows a detailed description of the current trends and evolution of ACLR in the United Kingdom over the last 10 years. Satisfactory functional outcomes were observed 5 years postoperatively. This study provides useful information on the prevalence of ACL-associated injuries and current surgical techniques with the aim of improving the quality of clinical care and patients' outcomes. Moreover, it provides surgeons with a benchmark against which to compare current practices and functional outcomes following ACLR across the United Kingdom. Level III.

How To Avoid Suture Damage in Simultaneous Anterior Cruciate Ligament Reconstruction and Lateral Meniscal Posterior Root Reinsertion With the Transtibial Pullout Technique: A Technical Note

Lateral meniscus posterior root tears (LMPRTs) are estimated to occur in 7% to 12% of anterior cruciate ligament (ACL)-injured knees. This topic is of great interest because of their biomechanical consequences in terms of interruption of hoop stress distribution. If left unrepaired, the corresponding compartment is exposed to unfavorable contact dynamics, similar to those resulting from a total meniscectomy. This Technical Note describes a transtibial LMPRT repair using a Knee Scorpion and an 18-gauge spinal needle. It is a reproducible arthroscopic LMPR reinsertion technique combined with concomitant standard ACL + anterolateral ligament reconstruction with hamstring tendons and it describes how to safely avoid damage to root traction sutures during the ACL independent tibial tunnel drilling.

The Effect of Tibial Tunnel Drilling Technique on Retained Intra-Articular Bone Debris Following Anterior Cruciate Ligament Reconstruction

To assess the effect of tibial tunnel drilling technique (retro-drilled bone socket vs full tibial tunnel) on the presence and grade of postoperative, intra-articular bone debris following primary hamstring anterior cruciate ligament (ACL) reconstruction. This was a retrospective cohort study of primary hamstring autograft ACL reconstructions performed by 2 surgeons. Two blinded independent reviewers assessed the presence and length of retained intra-articular bone debris on the immediate postoperative lateral radiograph. Debris was graded according to a predefined 5-point ordinal grading system: grade 0 (no debris) to IV (severe debris). Results were analyzed according to the type of tibial tunnel; retro-drilled socket or full tibial tunnel using Kappa statistics and the Mann-Whitney U test. Sixty-five patients undergoing primary hamstring ACL were included (39 tibial socket: 26 full tibial tunnel). Bone debris was observed among the tibial socket technique in 29 of 39 instances (74.3%), compared with 14 of 26 (53.8%) instances for the full tibial tunnel technique (P= .09). Where there was measurable debris present, the tibial socket group had a mean length of bone debris of 13.7 ± 6.2 mm as compared with the full tibial tunnel, 10.0 ± 4.7 mm (P= .165). There were significant differences in bonedebris gradings between the 2 treatment groups, with tibial sockets having an overall greater grade (P= .04). A difference in the presence of, or length of, retained bone debris on the postoperative lateral radiograph was not demonstrated between the retro-drilled bone socket and full tibial tunnel techniques. However, when bone debris was present, greater grades of debris were seen in the retro-drilled socket group. III, retrospective, comparative study.

A balance between native footprint coverage and overlap of the anterolateral meniscal root in tibial tunnel positioning during anterior cruciate ligament reconstruction: A 3D MRI study

BackgroundTibial footprint of anterior cruciate ligament (ACL) is situated close to the anterior lateral meniscal root (ALMR) attachment. PurposeTo investigate the impact of the size and location of the tibial tunnel for ACL reconstruction on the ACL footprint coverage and overlap to the ALMR. Study designControlled laboratory study. MethodsTwenty knee MRI scans from twenty healthy subjects were recruited, and three-dimensional (3D) tibia models were created to show the tibial attachment sites of ACL and ALMR. Surgical simulation of the tibial tunnel drilling was performed on each 3D model, entering the joint at an angle set at 60 degrees from the tibial plateau plane and 55 degrees from the posterior tibial condylar axis, with analysis for six different drill sizes; 7.5, 8, 8.5, 9, 9.5 and 10 mm; and nine locations; the center of the ACL attachment and eight locations 2% of the tibial width apart surrounding it. The width of the tibial plateau, the distance between ACL and ALMR attachment centers, and the size and location of the potential tibial tunnel were evaluated to determine association with the area of the ACL footprint coverage and ALMR overlap using a linear mixed effects model. ResultsA large tunnel (p <.001), a central and anterior location (p <.029), and small tibial width (p =.015) were all associated with larger coverage of the ACL footprint. A large tunnel (p <.001), posteriorly and laterally located (p ≤ 0.001), and a small distance between the ACL and ALMR centers (p =.001) were significantly associated with a larger ALMR overlap. The association of the tunnel size to ALMR overlap reduced with a medial tunnel location. ConclusionsThe short distance between the centers of the ALMR attachment and native ACL footprint suggests that the ALMR will always be susceptible to overlap when the tibial tunnel is drilled in ACL reconstruction. Small alterations in tunnel location can lead to a statistically significant alteration with the amount of ALMR overlap. To minimize this overlap, whilst maintaining acceptable coverage of the ACL footprint, a tibial tunnel positioned in a medial or anteromedial location from the center of the ACL footprint is recommended.

All-Inside Tibial Tunnel Drilling: How to Calculate a Safe Drilling Length to Avoid Anterior Cortex Violation

The all-inside technique for bone tunnel drilling during ligament reconstruction procedures (ACL, PCL etc.) is gaining popularity as a bone preserving, less invasive technique with the potential for more rapid recovery. To preserve the advantages of closed-socket tunnels, it is essential not to violate the cortex during retro-drilling. The risk of cortical breach is higher with the tibial tunnel compared to the femoral one due to the obliquity of the tunnel relative to the cortex. Our purpose is to introduce a trigonometric formula, which allows the surgeon to calculate the safe tibial tunnel drilling length during all-inside ligament reconstruction and explain its proof.

The Sironix ACL Jig: A Solution for Tibial Tunnel Angle and Length

Anterior cruciate ligament (ACL) reconstruction is widely performed arthroscopic procedures amongst sportspersons to prevent worsening of knee joint injury. The Sironix ACL jig is a novel approach to ensure an appropriate angle for accurate placement and drilling of tibial and femoral tunnels, that is a critical step for stronger and stable ACL graft fixation. It is designed as a patented jig with a three-point arm contact system. The three reference points serve as a continuous visual feedback on the angle of approach during surgery and minimize the parallax errors. Sironix ACL jig helps the orthopaedic surgeon in deciding the feasibility of a single bundle or double bundle ACL technique, facilitates varying technique choices for drilling, including inside-out and outside-in, accurately determines the tibial and femoral tunnel positioning in arthroscopic or open ACL reconstruction and therefore increases the procedural convenience.

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.

Inside-out Tibial Tunnel Drilling Technique for All-inside Anterior Cruciate Ligament Reconstruction

All-inside anterior cruciate ligament reconstruction passed through a series of modifications over the past 2 decades, maintaining 2 common factors: half tunnels in both the femur and tibia and introduction of the graft into the knee through an arthroscopic portal. One of the disadvantages noted with this technique is the excessive cost of the instrumentation needed to perform it and its economic impact on the health care system. We describe a modification of the original technique, both maintaining the cortical bone in an intact state and avoiding the retrograde drill aiming device.

Revision Anterior Cruciate Ligament Reconstruction Outcomes in Younger Patients: Medial Meniscal Pathology and High Rates of Return to Sport Are Associated With Third ACL Injuries

Background: There are limited data evaluating the outcomes of revision anterior cruciate ligament (ACL) reconstruction surgery in younger patients despite recent reports that the rates of graft rupture are higher in young cohorts. Purpose: To explore the outcomes of revision ACL reconstruction surgery in younger patients with the specific aims of determining the rates of third ACL injury and whether knee pathology at the time of revision surgery and return to sport were associated with further injury. Study Design: Case-control study; Level of evidence, 3. Methods: The study cohort consisted of 151 consecutive patients who were aged 25 years or younger at the time of their first revision ACL reconstruction. The number of subsequent ACL injuries (graft rerupture or contralateral injury to the native ACL) was determined at a mean follow-up time of 4.5 years (range, 2-9 years). Surgical details were recorded, along with a range of sport participation outcomes. Contingency tables were used to assess the associations between subsequent ACL injury and return to sport, knee pathology, and the drilling of new femoral or tibial tunnels at revision surgery. Results: The follow-up rate was 85% (128/151). Graft reruptures occurred in 20 patients (16%) at a mean time of 2 years after revision surgery. Contralateral ACL injuries occurred in 15 patients (12%) at a mean time of 3.9 years. The total number of patients who had a third ACL injury was 35 (27%). There was a significant association between having medial meniscal pathology and sustaining a graft rerupture (P = .03), but there was no association between graft rerupture and using the same tunnels from the primary procedure at revision surgery. After revision reconstruction, 68% of patients (95% CI, 55%-71%) returned to their preinjury level of sport, compared with 83% (95% CI, 69%-84%) after primary reconstruction in the same patients. Those who had a third ACL injury had a significantly higher rate of return to preinjury sport (83%) after the revision procedure than did the group that did not have further ACL injuries (62%, P = .02). Conclusion: Younger patients are at significant risk of having multiple ACL injuries. The high rate of third ACL injuries presents a significant issue for future knee health in these young athletes. Medial meniscal pathology and returning to high-risk sport are factors that are significantly associated with the high multiple ACL injury rate in the young.

Anatomic all-epiphysial tibial tunnels for anterior cruciate ligament reconstruction in skeletally immature knees may be placed without damaging the anterior meniscus root

ObjectivesThe purpose of this study was to evaluate the spatial relationship of the anterior horns of the menisci and the tibial tunnel during all-epiphysial drilling of skeletally immature specimens and identify any iatrogenic damage or destabilisation to the meniscus and meniscal root.MethodsFour skeletally immature cadaveric knee specimens (aged 9–11 years) were used to create three-dimensional models from CT images. All-epiphysial anterior cruciate ligament (ACL) tibial tunnel drilling was performed in 14 specimens (aged 7–11 years), entering the joint surface at the ACL footprint and avoided the proximal tibial physis. The anterior meniscal roots and horns were closely inspected visually and probed for stability, prior to drilling. After drilling, the meniscus and attachment points were re-evaluated for damage to the meniscus, meniscus root and probed to evaluate for destabilisation.ResultsAll-epiphysial tunnels entered the joint at the anatomic ACL tibial footprint. Direct visual inspection of the menisci demonstrated an absence of damage to either meniscus or anterior horn regions in all specimens. Probing and traction of the medial and lateral meniscal tissue did not demonstrate evidence of instability or destabilisation of the anterior horn or meniscus root before or after drilling. All tunnels were circumferentially intact at the joint surface, with no evidence of superior tunnel perforation due to shallow tunnel angle.ConclusionIn this study, tunnel placement did not produce damage to either meniscus, nor noticeably destabilise the meniscal roots. This study also demonstrated that drill holes can be placed within the ACL footprint without entering the joint on the proximal tibia surface anterior to the ACL attachment, although the ‘safe zone’ for drill hole placement is limited. All-epiphysial ACL tibial tunnels can create a large aperture at the tibial joint surface, but these tunnels can be placed at the anatomic footprint of the ACL, without causing gross anterior medial or lateral meniscus horn or root injury.

Does retrograde tibial tunnel drilling decrease subchondral bone lesions during ACL reconstruction? A prospective trial comparing retrograde to antegrade technique

BackgroundThe main goal of this study was to assess iatrogenic subchondral bone lesions following three different anterior cruciate ligament (ACL) reconstruction techniques and their association with early postoperative pain. MethodsA multicenter prospective comparative study was conducted in 2012. Each center performed a specific ligamentoplasty technique: two used retrograde and the other antegrade tibial tunnel drilling. Peri- and postoperative analgesia and systematic early postoperative magnetic resonance imaging (MRI) protocols were standardized. The main assessment criterion was tibial subchondral lesions (microfractures or bone oedema) on MRI during the first postoperative week. Secondary criteria were the assessment of postoperative pain for two days using a Visual Analogical Scale (VAS 0–10) and consumption of analgesics. ResultsForty-three patients were included in three centers, 15 in the “antegrade group” and 28 in the “retrograde group”, mean age is 32.5±9.1years, 14 women/29 men. All included patients underwent postoperative MRI. There were no subchondral tibial microfractures, but oedema was significantly more frequent in the antegrade group (p=0.0001). Tibial subchondral oedema was correlated to greater early postoperative pain (p=0.01). Multivariate analysis identified tibial tunnel diameter as an independent factor of early postoperative pain. The smaller the tibial tunnel diameter, the greater the mean early postoperative pain (≤8mm (18 patients) 3.4±1.5 vs. >8mm (25 patients) 1.8±1.7, p=0.004) and the more frequent the presence of edemas (10/18 vs. 2/25, p=0.001). ConclusionThe present clinical study confirmed the benefit of retrograde tibial tunnel drilling for tibial subchondral bone lesions and showed a correlation between these lesions and early postoperative pain. Level of evidenceII; therapeutic study — prospective cohort study.

Posterolateral portal tibial tunnel drilling for posterior cruciate ligament reconstruction: technique and evaluation of safety and tunnel position.

To evaluate the safety for neurovascular structures and accuracy for tunnel placement of the posterolateral portal tibial tunnel drilling technique in posterior cruciate ligament (PCL) reconstruction. Fifteen fresh-frozen human cadaveric knees were used. The tibial tunnel for the PCL was created using a flexible reamer from the posterolateral portal. Then, the flexible pin was left in place, and the distance from the posterolateral portal, the flexible pin, and the tibial tunnel to the peroneal nerve and popliteal artery was measured. Additionally, the distance between the tibial tunnel and several landmarks related to the PCL footprint was measured, along with the distance from the exit point of the flexible pin to the superficial medial collateral ligament and gracilis tendon. The peroneal nerve and the popliteal neurovascular bundle were not damaged in any of the specimens. The median (range) distance in mm from the peroneal nerve and popliteal artery to the posterolateral portal and flexible pin was: 52 (40-80) and 50 (40-61), and 35 (26-51) and 22 (16-32), respectively. The median (range) distance from the tibial tunnel to the popliteal artery was 21mm (15-38). The tibial tunnel was located at a median (range) distance in mm of 3 (2-6), 6 (3-12), 5 (2-7), 4 (1-8), 9 (3-10), 10 (4-19), and 19 (6-24) to the champagne-glass drop-off, lateral cartilage point, shiny white fibre point, medial groove, medial meniscus posterior root, lateral meniscus posterior root, and posterior aspect of the anterior cruciate ligament, respectively. The posterolateral portal tibial tunnel technique is safe relative to neurovascular structures and creates an anatomically appropriate tibial tunnel location. The clinical relevance of study is that this technique may be safely and accurately used in PCL reconstruction to decrease the risk of neurovascular damage (avoid use of a posteriorly directed pin), avoid the use of intraoperative fluoroscopy, and avoid the sharp turn during graft passage.

An Anterior Cruciate Ligament Reconstruction Technique With 4-Strand Semitendinosus Grafts, Using Outside-In Tibial Tunnel Drilling and Suspensory Fixation Devices

We describe an anatomic single-bundle anterior cruciate ligament reconstruction using a 4-strand semitendinosus graft fixed with 2 Pullup adjustable suspensory fixation systems (SBM, Lourdes, France). Outside-in full tibial tunnel drilling represents a secure option for length management of the graft. The preferred graft choice is a 4-strand semitendinosus autologous graft. A special technique is used to stitch the graft with a figure-of-8 stitch to load the 4 strands. The Pullup adjustable loop is equipped with 2 buttons of different sizes: a small button for the standard Pullup system on the femoral side and a large button for the Pullup XL system on the tibial side. With this method, graft tension is equally distributed among the 4 strands and the graft cannot bottom out in the tibial tunnel in case of inadequate graft length.

Arthroscopic assisted femoral tunnel drilling for the intra-articular anatomic cranial cruciate ligament reconstruction in dogs.

To develop and test an arthroscopic aiming device for extra- to intra-articular femoral tunnel drilling emerging at the center of the femoral insertion of the cranial cruciate ligament (CrCL) in medium to large breed dogs. Hindlimbs (n=12) of six cadaveric dogs (≥20kg bodyweight). One hindlimb from each cadaver was randomly chosen. On a standard medio-lateral stifle radiograph the caudo-cranial position of the CrCL center was measured and transferred onto an adjustable aiming device. After arthroscopic debridement of the CrCL the aiming device was hooked behind the lateral condyle and a 2.4mm guide pin was placed from extra- to intra-articular. The intra-articular position of the resulting bone tunnel was evaluated radiographically as well as compared to the anatomic CrCl center of the contralateral hindlimb using 3D renderings. According to the postoperative radiographs all six drill tunnels were located at or near the CrCL center. The median absolute 3D error from the anatomical center of the CrCL was 0.6mm (range: 0.2-0.9mm). Precise anatomic placement of the femoral tunnel for intra-articular repair of the CrCL was achieved using an adjustable aiming device. The proposed technique will reduce femoral tunnel misplacement when performing intra-articular CrCL repair in dogs. In combination with the published technique for arthroscopic tibial tunnel drilling using a similar aiming device, the technical requirements for arthroscopic assisted tunnel positioning for anatomical graft replacement are available.

Nonanatomic Anterior Cruciate Ligament Reconstruction With Double-Stranded Semitendinosus Grafts in Children With Open Physes

Background: Nonanatomic anterior cruciate ligament (ACL) reconstruction (ACLR) with double-stranded semitendinosus grafts in children with open physes has been described as a successful surgical technique in short-term follow-up clinical reports. Purpose: To evaluate the clinical outcomes of nonanatomic ACLR in children with open physes and a minimum of 15 years’ follow-up. Study Design: Case series; Level of evidence, 4. Methods: Twelve patients with an average age of 10.7 years (range, 8.3-12.4 years) underwent ACLR between 1991 and 1998. All patients were classified as Tanner development stage 2 or lower. The surgical technique involved transphyseal tibial tunnel drilling and over-the-top (OTT) femoral fixation using a double-stranded graft for all patients. Clinical outcomes were evaluated in terms of the manual Lachman test, pivot-shift test, return to sports activity, and International Knee Documentation Committee (IKDC) score at the end of growth and at a minimum 15-year follow-up (range, 15-22 years). Results: No clinically significant growth disturbance was observed. Ten patients had a grade A IKDC score, and 2 patients had a grade B IKDC score at the end of growth. There was no progression of laxity or modification of knee stability with growth. Three patients (25%) had ACL reruptures during sports activities after growth plate closure. All patients with reruptured ACLs underwent additional reconstructive surgery. Conclusion: Anterior cruciate ligament reconstruction using the OTT technique in the femur and the transphyseal technique in the tibia produces good results with regard to growth plate closure but a high failure rate in adulthood.

Intra-articular calcifications following arthroscopic ACL reconstruction: prevalence and possible significance

The goal of our study was to determine the frequency of intra-articular calcifications on initial postoperative radiographs following arthroscopic ACL reconstruction, describe their appearance, hypothesize their etiology, and determine their significance. Review of records and post-operative radiographs for individuals undergoing arthroscopic ACL reconstruction at our institution identified 758 knees between November 2002 and April 2010. All patients underwent femoral and tibial tunnel drilling regardless of graft source. All but 23 underwent notchplasty. Intra-articular calcifications on initial postoperative radiographs were observed in 252 knees. The majority of calcifications were curvilinear, paralleling the posterior femoral condyles. Nineteen of the patients with calcifications on initial studies had repeat radiographs within 6years. The calcifications resolved in every case. This study shows that intra-articular calcifications are a common finding on initial post-operative radiographs following ACL reconstruction. We feel they are of doubtful clinical significance, and in our limited experience, they eventually resolve. They should not be confused with chondrocalcinosis or vascular calcification.

Prevalence of Nonanatomical Graft Placement in a Series of Failed Anterior Cruciate Ligament Reconstructions

Background Anterior cruciate ligament reconstruction employing transtibial tunnel techniques may result in less than ideal femoral and tibial vertical graft placement, with a residual pivot shift and instability symptoms. Hypothesis Nonanatomical graft placement is highly prevalent among knees with failed primary and revision anterior cruciate ligament grafts. Study Design Case series; Level of evidence, 4. Methods A total of 122 consecutive patients presented to the authors’ center with a failed anterior cruciate ligament reconstruction. Radiographs, magnetic resonance imaging, and operative reports were used to define graft placement. Arthroscopic confirmation of graft placement was obtained in 92 knees during subsequent revision surgery. A nonanatomical graft placement was assigned when ≥50% of the graft was outside of the native tibial and femoral insertions. All patients prospectively completed Cincinnati Knee Rating System questionnaires. Results A nonanatomical graft placement occurred in 107 of 122 (88%) knees; 61% of the grafts were entirely on the intercondylar femoral roof, and 35% extended posterior to the anterior cruciate ligament tibial attachment. A transtibial technique had been used in 83%. The mean values for the coronal and sagittal graft placement showed a significantly increased vertical orientation in comparison with a control group (P < .01). Forty-two of the 107 nonanatomical grafts had undergone 1 or more revisions without correction of the misplaced graft tunnels, and these subsequently failed. Conclusion The occurrence of nonanatomical graft placement in primary and revision knees may represent an inadequacy of transtibial tunnel drilling techniques to obtain graft placement within the native femoral and tibial footprints. In revision cases, the prior graft location requires close scrutiny so the new graft tunnels are placed at the native anterior cruciate ligament attachments. Independent drilling of tibial and femoral tunnels is recommended using either 2-incision or anteromedial portal techniques.

Development and In Situ Application of an Adjustable Aiming Device to Guide Extra‐ to Intraarticular Tibial Tunnel Drilling for the Insertion of the Cranial Cruciate Ligament in Dogs

To develop and test an arthroscopic aiming device for extra- to intraarticular tibial tunnel drilling emerging at the center of the tibial insertion (CenterTib) of the cranial cruciate ligament (CCL) in medium to large breed dogs. Descriptive experimental study. Fifty-two cadaveric hind limbs of dogs >or=20 kg BW. The mediolateral position and craniocaudal position (ccPos) of CenterTib in relation to the caudomedial meniscotibial ligament were measured on photographs of 46 dissected tibial plateaus. The proximal tibial depth (TibDepth) was determined on lateral radiographs and its correlation with ccPos was assessed using linear regression analysis. Extra- to intraarticular arthroscopic tibial tunnel drilling was performed in 6 independent cadaveric stifles. A C-guide with an adjustable craniocaudal offset was constructed and adjusted according to ccPos estimated based on TibDepth. The position of the resulting bone tunnels was compared with the position of the CenterTib. Pearson's correlation between TibDepth and ccPos was strong (R=0.86; P<.001). ccPos (y) as a function of TibDepth (x) can be expressed as y=-4.8+0.3x. Arthroscopic tunnel drilling resulted in a median deviation of the drill tunnels around the CenterTib of 1 mm. The regression equation and aiming device permit localization and targeting of CenterTib during extra- to intraarticular tibial bone tunnel drilling in vitro. The proposed technique may reduce tibial tunnel misplacement when performing intraarticular CCL repair using a tibial bone tunnel.