Tunnel Malposition Research Articles

Reconstruction itérative du ligament croisé antérieur par technique mono-faisceau selon un trajet « over-the-top »

PurposeIn revision anterior cruciate ligament reconstruction (ACLR), the single-stage technique and the over-the-top route (OTTR) procedure were usually selected for cases where the bone tunnel cannot be created at an anatomical position due to tunnel enlargement and overlap with the mal-positioned tunnel of primary reconstruction. The purpose of this study was to evaluate the clinical results of revision single-bundle ACL reconstruction using OTTR procedure and to compare the clinical results of OTTR procedure with those of anatomical single bundle revision reconstruction (SBR). HypothesisThe results of OTTR procedure are equivalent to that of SBR. MethodsSeventy-six revision ACL reconstruction knees from April 2002 to December 2012 were involved in our study. We focused on 21 knees which underwent surgery with SBR and 22 knees with OTTR using hamstring tendon. The clinical results were evaluated by means of the Lysholm score and the knee stability was assessed by the Lachman test, pivot-shift test and side-to-side difference by KT-2000 preoperatively and after 1year postoperatively. AP translation and rotational laxity using a navigation system were evaluated before and after revision ACL reconstruction under anesthesia in 8 cases of OTTR and in 6 cases of SBR. ResultsThere was no statistically significant difference between the OTTR and SBR regarding Lysholm score, Lachman test, pivot-shift test, ATT by KT-2000, and AP translation and rotational laxity with a navigation system. ConclusionsThe clinical results of OTTR are almost equivalent to those of SBR. For the cases in which it is impossible to create the femoral tunnel in an anatomical position, OTTR is a valuable revision ACL reconstruction method. Level of evidenceCase-control study Level III.

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.

Revision single-bundle anterior cruciate ligament reconstruction with over-the-top route procedure

PurposeIn revision anterior cruciate ligament reconstruction (ACLR), the single-stage technique and the over-the-top route (OTTR) procedure were usually selected for cases where the bone tunnel cannot be created at an anatomical position due to tunnel enlargement and overlap with the mal-positioned tunnel of primary reconstruction. The purpose of this study was to evaluate the clinical results of revision single-bundle ACL reconstruction using OTTR procedure and to compare the clinical results of OTTR procedure with those of anatomical single-bundle revision reconstruction (SBR). HypothesisThe results of OTTR procedure are equivalent to that of SBR. MethodsSeventy-six revision ACL reconstruction knees from April 2002 to December 2012 were involved in our study. We focused on 21 knees which underwent surgery with SBR and 22 knees with OTTR using hamstring tendon. The clinical results were evaluated by means of the Lysholm score and the knee stability was assessed by the Lachman test, pivot-shift test and side-to-side difference by KT-2000 pre-operatively and after 1 year post-operatively. AP translation and rotational laxity using a navigation system were evaluated before and after revision ACL reconstruction under anesthesia in 8 cases of OTTR and in 6 cases of SBR. ResultsThere was no statistically significant difference between the OTTR and SBR regarding Lysholm score, Lachman test, pivot-shift test, ATT by KT-2000, and AP translation and rotational laxity with a navigation system. ConclusionsThe clinical results of OTTR are almost equivalent to those of SBR. For the cases in which it is impossible to create the femoral tunnel in an anatomical position, OTTR is a valuable revision ACL reconstruction method. Level of evidenceCase-control study. Level III.

A Radiographic Assessment of Failed Anterior Cruciate Ligament Reconstruction

Background: Magnetic resonance imaging (MRI) showing an “intact” anterior cruciate ligament (ACL) graft may not correlate well with examination findings. Reasons for an ACL graft dysfunction may be from malpositioned tunnels, deficiency of secondary stabilizers, repeat injuries, or a combination of factors. Purpose: To evaluate the concordance/discordance of an ACL graft assessment between an arthroscopic evaluation, physical examination, and MRI and secondarily to evaluate the contributing variables to discordance. Study Design: Case series; Level of evidence, 4. Methods: A total of 50 ACL revisions in 48 patients were retrospectively reviewed. The ACL graft status was recorded separately based on Lachman and pivot-shift test data, arthroscopic findings from operative reports, and MRI evaluation and was categorized into 3 groups: intact, partial tear, or complete tear. Two independent evaluators reviewed all of the preoperative radiographs and MRI scans, and interrater and intrarater reliability were evaluated. Concordance and discordance between a physical examination, arthroscopic evaluation, and MRI evaluation of the ACL graft were calculated. Graft position and type, mechanical axis, collateral ligament injuries, chondral and meniscal injuries, and mechanism of injury were evaluated as possible contributing factors using univariate and multivariate analyses. Sensitivity and specificity of MRI to detect a torn ACL graft and meniscal and chondral injuries on arthroscopic evaluation were calculated. Results: The interobserver and intraobserver reliability for the MRI evaluation of the ACL graft were moderate, with combined κ values of .41 and .49, respectively. The femoral tunnel position was vertical in 88% and anterior in 46%. On MRI, the ACL graft was read as intact in 24%; however, no graft was intact on arthroscopic evaluation or physical examination. The greatest discordance was between the physical examination and MRI, with a rate of 52%. An insidious-onset mechanism of injury was significantly associated with discordance between MRI and arthroscopic evaluation of the ACL (P = .0003) and specifically with an intact ACL graft on MRI (P = .0014). The sensitivity and specificity of MRI to detect an ACL graft tear were 60% and 87%, respectively. Conclusion: Caution should be used when evaluating a failed ACL graft with MRI, especially in the absence of an acute mechanism of injury, as it may be unreliable and inconsistent.

MRI assessment of tibial tunnel and its relation to complication following arthroscopic reconstruction of anterior cruciate ligament

PurposeTo assess the role of MRI in evaluation of tibial tunnel and correlate findings with the rate of post anterior cruciate ligament (ACL) repair complication. Patients and methodsA prospective study recruited 34 patients, their ages ranged between 18 and 38years after arthroscopic repair of ACL. All patients were referred from the orthopedic department between July 2012 and July 2013 with symptoms and signs suspicious of complications. MRI knee was performed for all patients after meeting inclusion criteria. ResultsMRI was positive in 24 (70.6%) out of 34 patients. Graft impingement was the most frequently encountered complication representing 13/24 (54.1%). Graft disruption was encountered in 4/24 (16.7%). Graft stretching, arthrofibrosis and ganglion cyst were seen in two patients for each (8.3%). One patient had abnormal graft signal without disruption (4.1%). The remaining 12/34 (35.3%) patients had negative MRI with intact graft. Tunnel mal position was seen in 18/24 (75%) with positive post ACL reconstruction complications. ConclusionAnterior cruciate ligament reconstruction is one of the most commonly performed sports medicine procedures. MRI proved as an accurate method for post arthroscopic reconstruction evaluation that can help predict post ACL reconstruction complication.

Femoral Tunnel Enlargement After Medial Patellofemoral Ligament Reconstruction

Background: In recent years, significantly more attention has been focused on the role of the medial patellofemoral ligament (MPFL) in patellar stability, and MPFL reconstruction has become a mainstay of surgical treatment of episodic patellar dislocations. Although previously described in detail after reconstruction of the anterior cruciate ligament, tunnel enlargement has not been investigated after MPFL reconstruction. Hypotheses: (1) Femoral tunnel enlargement occurs after MPFL reconstruction. (2) Patella alta, trochlear dysplasia, and tunnel malposition are risk factors for tunnel enlargement. (3) The presence of tunnel enlargement is not associated with recurrent dislocations or poorer patient-reported outcome scores after MPFL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: Fifty-five of 59 knees treated for episodic patellar dislocations with MPFL reconstruction between 2005 and 2010 were evaluated at 1 year postoperatively for the presence of tunnel enlargement on lateral radiographs. Tunnel enlargement was defined as a tunnel area greater than 2 times that of the original tunnel. Knees with tunnel enlargement at 1 year were compared with those without tunnel enlargement. Patients were assessed for recurrent subluxations or dislocations at a mean of 3 years postoperatively, and patient-reported outcome scores were assessed in a subset of patients at a mean of 3.7 years postoperatively. Results: Tunnel enlargement was noted in 23 knees (41.8%). No differences in patient age or body mass index were noted between the 2 groups. The mean patellar height was significantly higher in the enlarged tunnel group (P = .03). A higher prevalence of trochlear dysplasia or tunnel malposition was not demonstrated in the enlarged tunnel group. Patient-reported outcome scores and the risk of recurrent patellar instability were equal in the 2 groups. Conclusion: Femoral tunnel enlargement after MPFL reconstruction is common, with patients with patella alta at an increased risk. The influence of tunnel malposition and trochlear dysplasia on this condition requires further research. Recurrent instability and patient-reported outcome scores are not affected by tunnel enlargement.

One-stage Revision Anterior Cruciate Ligament Reconstruction With Impacted Bone Graft After Failed Primary Reconstruction

Revision anterior cruciate ligament reconstruction can be performed in a 1- or 2-stage procedure. Restoration of bone stock using bone grafting is often required for good results. The authors performed 1-stage revision surgery with a more lateral and oblique femoral tunnel and an impacted bone graft to avoid the bone defect caused by the previous screw removal from a malpositioned tunnel. No evidence existed of revision surgery failure or viral transmission in any of 17 cases at 2-year follow-up. The authors' technique is also useful for a slightly misplaced femoral tunnel.

Femoral marrow cavity bone harvesting used for arthroscopic refilling of misplaced or enlarged bone tunnels in revision ACL surgery

In anterior cruciate ligament (ACL) revision surgery, refilling of misplaced or enlarged tunnels frequently requires bone harvesting from the iliac crest. Unfortunately, donor-site pain displays a relevant complication. In order to optimize patients' comfort, we developed a procedure combining minimally invasive intramedullary bone harvesting from the femur with arthroscopic tunnel refilling. Patients with ACL reconstruction failure that were not eligible for one-step revision surgery but required tunnel refilling prior to the next ACL reconstruction were enrolled prospectively. Cancellous bone was harvested intramedullarily from the ipsilateral femur using the reamer-irrigator-aspirator system in a minimally invasive manner. Afterwards, the femoral and tibial tunnels were arthroscopically refilled using cones and push rods. Computer tomography (CT) analyses were carried out before and after the filling procedure. Pain levels were assessed during the entire follow-up. Patients undergoing iliac crest bone harvesting for other reasons served as a control group. Finally, the quality of the newly formed bone stock was evaluated in the subsequent ACL reconstruction procedure. Five patients were included during a 6-month period. Prior to refilling, tunnel analysis revealed a mean tunnel volume of 7.9 cm(3) at the femur [SD ± 5.3 cm(3)] and of 6.7 cm(3) [SD ± 5.1 cm(3)] at the tibia. The CT analyses further revealed that graft failure was predominantly caused by tunnel misplacement. Post-operatively, pain levels due to intramedullary bone harvesting were significantly lower compared to iliac crest bone harvesting at every analysed time point. Three to five months after tunnel filling, CT analyses showed sufficiently incorporated bone stocks with filling rates of 75 % femoral and 94 % tibial. ACL revision surgery was performed 4-5 months after tunnel filling without any complication. Intramedullary bone harvesting from the ipsilateral femur combined with arthroscopic refilling of the bone tunnels ensures a high-quality bone stock for further ACL reconstruction. The clinical relevance is shown by the feasibility of this technique and the significantly reduced pain levels during post-operative recovery.

Anticipating Problems Unique to Revision ACL Surgery

Anterior cruciate ligament (ACL) injuries are common in the athletic population. In fact, ACL reconstruction has become one of the most common orthopedic procedures. With the increasing number of primary ACL reconstructions being performed combined with the continued expectations of high-level athletes, revision ACL reconstruction is likely to become more frequent. Revision ACL reconstruction poses several diagnostic and technical challenges compared to primary reconstructions. The purpose of this article is to highlight problems that are unique to revision ACL reconstruction such as tunnel malposition, tunnel widening, preexisting hardware, and injuries to concomitant structures in the knee. Recognizing and avoiding these pitfalls are crucial to obtaining a successful result after revision ACL reconstruction.

Biomechanical Analysis of Stacked Bioabsorbable Screws in Revision ACL Reconstruction (SS-02)

Revision anterior cruciate ligament (ACL) surgery is often complicated by tunnel malposition and widening. Several authors report using bioabsorbable interference screws to fill defects. Subsequently, new tunnels are drilled in the anatomic position through both the native bone and the filler screw. Despite their common use, there is no biomechanical analysis available to support the use of such a construct. We used 30 porcine legs divided into 3 groups. Group I had native ACL fixation with 8-mm composite interference screws made from ß–TCP (beta-TriCalcium Phosphate) and PLGA (poly [L-lactide, co-glycolide]). Groups II and III had bone defects created and subsequently filled with 12mm ß-TCP/PLGA screws. Bone tunnels were subsequently drilled through the filler screw and surrounding bone, and the patellar plug was inserted. Group II had 8-mm fixation screws on the side opposite the filler screw, while Group III had the fixation screw between. The construct was loaded at 0.2 mm/s, with the vector in line with the tunnel. Force to failure, stiffness, and mode of failure were recorded. Average pullout strength for groups I, II, and III was 626, 652, and 719 N respectively (p=0.328). Average stiffness of the construct in groups I, II, and III was 71.4, 84.1, and 82.0 N/mm respectively. Groups II and III were significantly stiffer than group I (p=0.026). Mode of failure was predominantly by screw-plug pullout in groups I (7/10) and II (7/10). No bone plugs broke in either groups I or II. Group III failed by plug breakage (4/10), plug pullout (3/10), or screw-plug pullout (3/10). Drilling through ß-TCP/PLGA screws and fixing bone plugs with another screw provides adequate fixation strength in ACL revision surgery. This may allow for single stage revision for tunnel malposition and widening, thus avoiding 2-stage revisions.

Clavicular Bone Tunnel Malposition Leads to Early Failures in CC Ligament Reconstructions (SS-06)

Clavicular Bone Tunnel Malposition Leads to Early Failures in CC Ligament Reconstructions (SS-06)

Failed anterior cruciate ligament reconstruction: analysis of factors leading to instability after primary surgery

Background Revision anterior cruciate ligament (ACL) surgery can be expected to become more common as the number of primary reconstruction keeps increasing. This study aims to investigate the factors causing instability after primary ACL reconstruction, which may provide an essential scientific base to prevent surgical failure. Methods One hundred and ten revision ACL surgeries were performed at our institute between November 2001 and July 2012. There were 74 men and 36 women, and the mean age at the time of revision was 27.6 years (range 16-56 years). The factors leading to instability after primary ACL reconstruction were retrospectively reviewed. Results Fifty-one knees failed because of bone tunnel malposition, with too anterior femoral tunnels (20 knees), posterior wall blowout (1 knee), vertical femoral tunnels (7 knees), too posterior tibial tunnels (12 knees), and too anterior tibial tunnels (10 knees). There was another knee performed with open surgery, where the femoral tunnel was drilled through the medial condyle and the tibial tunnel was too anterior. Five knees were found with malposition of the fixation. One knee with allograft was suspected of rejection and a second surgery had been made to take out the graft. Three knees met recurrent instability after postoperative infection. The other factors included traumatic (48 knees) and unidentified (12 knees). Conclusion Technical errors were the main factors leading to instability after primary ACL reconstructions, while attention should also be paid to the risk factors of re-injury and failure of graft incorporation.

Clavicular Bone Tunnel Malposition Leads to Early Failures in Coracoclavicular Ligament Reconstructions

Background: Modern techniques for the treatment of acromioclavicular (AC) joint dislocations have largely centered on free tendon graft reconstructions. Recent biomechanical studies have demonstrated that an anatomic reconstruction with 2 clavicular bone tunnels more closely matches the properties of native coracoclavicular (CC) ligaments than more traditional techniques. No study has analyzed tunnel position in regard to risk of early failure. Purpose: To evaluate the effect of clavicular tunnel position in CC ligament reconstruction as a risk of early failure. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was performed of a consecutive series of CC ligament reconstructions performed with 2 clavicular bone tunnels and a free tendon graft. The population was largely a young, active-duty military group of patients. Radiographs were analyzed for the maintenance of reduction and location of clavicular bone tunnels using a picture archiving and communication system. The distance from the lateral border of the clavicle to the center of each bone tunnel was divided by the total clavicular length to establish a ratio. Medical records were reviewed for operative details and functional outcome. Failure was defined as loss of intraoperative reduction. Results: The overall failure rate was 28.6% (8/28) at an average of 7.4 weeks postoperatively. Comparison of bone tunnel position showed that medialized bone tunnels were a significant predictor for early loss of reduction for the conoid (a ratio of 0.292 vs 0.248; P = .012) and trapezoid bone tunnels (a ratio of 0.171 vs 0.128; P = .004); this correlated to an average of 7 to 9 mm more medial in the reconstructions that failed. Reconstructions performed with a conoid ratio of ≥0.30 were significantly more likely to fail (5/5, 100%) than were those performed lateral to a ratio of 0.30 (3/23, 13.0%) (P < .01). There were no failures when the conoid ratio was <0.25 (0/10, 0%). Conoid tunnel placement was also statistically significant for predicting return to duty in our active-duty population. Conclusion: Medial tunnel placement is a significant factor in risk for early failures when performing anatomic CC ligament reconstructions. Preoperative templating is recommended to evaluate optimal placement of the clavicular bone tunnels. Placement of the conoid tunnel at 25% of the clavicular length from the lateral border of the clavicle is associated with a lower rate of lost reduction and a higher rate of return to military duty.

Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction (SS-76)

Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction (SS-76)

Femoral Tunnel Malposition in ACL Revision Reconstruction

The Multicenter Anterior Cruciate Ligament (ACL) Revision Study (MARS) group was formed to study a large cohort of revision ACL reconstruction patients. The purpose of this subset analysis study of the MARS database is to describe specific details of femoral tunnel malposition and subsequent management strategies that surgeons chose in the revision setting. The design of this study is a case series. The multicenter MARS database is compiled from a questionnaire regarding 460 ACL reconstruction revision cases returned by 87 surgeons. This subset analysis described technical aspects and operative findings in specifically those cases in which femoral tunnel malposition was cited as the cause of primary ACL reconstruction failure. Of the 460 revisions included for study, 276 (60%) cases cited a specific "technical cause of failure." Femoral tunnel malposition was cited in 219 (47.6%) of 460 cases. Femoral tunnel malposition was cited as the only cause of failure in 117 cases (25.4%). Surgeons judged the femoral tunnel too vertical in 42 cases (35.9%), too anterior in 35 cases (29.9%), and too vertical and anterior in 31 cases (26.5%). Revision reconstruction involved the drilling of an entirely new femoral tunnel in 91 cases (82.1%). For primary reconstruction, autograft tissue was used in 82 cases (70.1%). For revision reconstruction, autograft tissue was used in 61 cases (52.1%) and allograft tissue in 56 cases (47.9%). Femoral tunnel malposition in primary ACL reconstruction was the most commonly cited reason for graft failure in this cohort. Graft selection is widely variable among surgeons.

Third time’s a charm?: improving re-revision ACL reconstruction by addressing reasons for prior failures

The purpose of this study was to determine whether re-revision anterior cruciate ligament (ACL) reconstruction including careful assessment and treatment of reason for prior failures decreases knee laxity and improves International Knee Documentation Committee (IKDC) scores. Re-revision ACL reconstructions were performed in eight patients at a mean age of 29.6 ± 6.9 years. All reported subjective knee instability preoperatively and demonstrated objectively increased laxity on physical examination and Lachman stress radiographs. Reasons for failure of the prior revision reconstructions were classified as tunnel malposition (two), associated posteromedial (one) or posterolateral (one) laxity, excessive tibial slope (one), and recurrent trauma (three). Specific steps were taken to address reasons for prior failure, including correcting malpositioned tunnels (two cases), posteromedial reefing (one case), posterolateral corner reconstruction (one case), or tibial deflexion osteotomy (one case). Follow-up evaluation included physical examination, radiographic evaluation including Lachman stress views, and a subjective IKDC evaluation. Seven patients were available for follow-up at 4.4 ± 2.3 years postoperative. Lachman examination improved with surgery in five patients and was unchanged in two patients (p = 0.013). The pivot shift examination, improved in five patients, was unchanged in one patient and worsened in one patient (p = 0.33). Two graft failures were diagnosed based on physical examination findings. Anterior tibial translation on stress radiographs decreased in all patients. The mean value decreased from 8.3 ± 2.9 to 3.0 ± 2.6 mm (p = 0.0025). The postoperative subjective IKDC score was 56.9 ± 16.9. Overall IKDC score improved in all patients. Re-revision ACL reconstruction including identification and treatment of reasons for prior failure results in improved knee laxity and IKDC scores.

Complications In Brief: Anterior Cruciate Ligament Reconstruction

When performing reconstruction of the ACL, the major complications that can arise include missed concomitant injuries, tunnel malposition, patellar fracture, knee stiffness, and infection. We review the complications that can occur as a result of errors made before, during, and after surgery.

Paper # 20: The Incidence of Failed ACL Reconstruction by Tunnel Malposition

Paper # 20: The Incidence of Failed ACL Reconstruction by Tunnel Malposition

Technical Failure of Medial Patellofemoral Ligament Reconstruction

In patients with chronic patellofemoral instability who have normal alignment and deficient proximal medial restraints, medial patellofemoral ligament (MPFL) reconstruction is a good option to treat patellar instability. However, medial subluxation, medial patellofemoral articular overload, and recurrent lateral instability are possible when the graft is positioned non-anatomically. The clinical presentation of MPFL femoral tunnel malpositioning has not been highlighted in the literature. We have had 5 patients referred to us after a malpositioned femoral MPFL graft led to disabling symptoms and a need for revision surgery. This report highlights the effects of a malpositioned graft and describes strategies to identify the anatomic MPFL insertion during surgery.

Techniques to Avoid Tibial Tunnel Influence on Femoral Tunnel Malposition in ACL Reconstruction

Techniques to Avoid Tibial Tunnel Influence on Femoral Tunnel Malposition in ACL Reconstruction