An in Vivo 3D Computed Tomographic Analysis of Femoral Tunnel Geometry and Aperture Morphology Between Rigid and Flexible Systems in Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal Technique

Kim, Jae Gyoon; Chang, Min-Sun; Lim, Hong Chul; Bae, Ji Hoon; Lee, Seung Yup; Ahn, Jin Hwan; Wang, Joon Ho

doi:10.1016/j.arthro.2015.01.021

Cited by 20 publications

(35 citation statements)

References 34 publications

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“…The combination of steep GBA and high graft tension may have increased the interference between the bone and the reconstructed graft. Previous studies have also reported steep GBA of about 70° after ACL reconstruction using trans-portal technique with rigid drills 31,33,39-41 . Although these studies assessed GBA statically with knees in a fixed position, their postoperative CT examinations were performed at near extension, thus they led to similarly high GBA.…”

Section: Discussionmentioning

confidence: 83%

“…A study using computer simulation also concluded that more proximal location of femoral exits could reduce graft bending angles without changing the anatomic femoral and tibial aperture position 64 . Another previous study, however, reported apparently contradictory results, with lower GBA with flexible (as opposed to rigid) drills 39 . A different flexible drill system was used (Clancy Anatomic Cruciate Guide System; Smith & Nephew), suggesting that the effect of flexible vs. rigid drilling may be dependent on the type of flexible drill system used (as well as the specific surgical technique).…”

Section: Discussionmentioning

confidence: 88%

“…However, the issue of steep graft bending angle is a specific phenomenon seen only in the reconstructed graft, but not in the native ACL, because the graft-tunnel construct cannot recreate the native insertion site anatomy at its tunnel aperture. If the graft changes direction at the femoral tunnel aperture, redirecting forces or abrasive forces may be created and they could cause a localized area of increased graft stress at the sharp aperture edge, potentially contributing to graft damage, widening of the bone tunnel aperture 39-43 , and/or increased knee laxity over time.…”

Section: Introductionmentioning

confidence: 99%

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In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

Tashiro

Sundaram

Thorhauer

et al. 2017

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Purpose To determine in vivo dynamic graft bending angle (GBA) in anterior cruciate ligament (ACL) reconstructed knees, correlate the angle to tunnel positions and tunnel widening, and evaluate the effects of two femoral tunnel drilling techniques on GBA. Methods Patients with an isolated ACL injury undergoing reconstruction were included from 2011 to 2012. Trans-portal techniques were used to create femoral tunnels. Tunnel locations were determined using 3D-CT. Tibio-femoral kinematics during treadmill walking and running were assessed using dynamic stereo X-ray analysis 6 months and 2 years postoperatively. The GBA was calculated from the 3D angle between the graft and femoral tunnel vectors at each motion frame. Cross-sectional area of femoral tunnels were measured at 6 months and compared to initial size to assess tunnel widening. Results A total of 54 patients were included. Use of flexible drills resulted in significantly higher GBA during walking (80.6° ± 7.8°; p<0.001) and running (80.5° ± 9.0°; p=0.025) than rigid drills (walking: 67.5° ± 9.3°, running: 74.1° ± 9.6°). It led to greater tunnel widening of 113.9±17.6 %, compared with rigid drills of 97.7±17.5 % (p=0.003). Femoral and tibial apertures were located in similar anatomic positions in both groups, but femoral tunnel exits were located more anteriorly (p<0.001) in the flexible drill group. Higher GBA was highly correlated with anterior location of femoral exits (r=0.63, p<0.001) and moderately correlated with greater tunnel widening (r=0.48, p<0.001). Conclusions High GBA was identified during dynamic activities after anatomic ACL reconstruction using a trans-portal femoral tunnel drilling technique. The GBA was greater when flexible drills were used. The high bending angle resulted from more anterior location of femoral tunnel exits, and correlated with early bone tunnel widening at 6 months. These results suggest that high GBA may increase stress on the bone-graft interface and contribute to greater tunnel widening after anatomic ACL reconstruction, although clinical impact should be further investigated. Level of Evidence Level III, retrospective comparative study

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Section: Discussionmentioning

confidence: 83%

Section: Discussionmentioning

confidence: 88%

Section: Introductionmentioning

confidence: 99%

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In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

Tashiro

Sundaram

Thorhauer

et al. 2017

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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“…12,31,38 Preservation of the ACL remnant during reconstruction is considered important, as it may confer improved knee stability. 2,4,25,26,27,35 It is postulated that a greater intrinsic potential for healing, 28 better graft vascularization, 26,28 and preservation of proprioceptive nerve fibers 21 can result in reduced rates of graft rupture 1,3,12,16–18,33,34,40 and improved proprioceptive function. 20,27 In addition, it is reported that the presence of the ACL remnant can serve as an important and reliable intraoperative landmark for tunnel positioning, but in contrast, it may also make overall visualization more difficult.…”

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confidence: 99%

Three-Dimensional CT Evaluation of Tunnel Positioning in ACL Reconstruction Using the Single Anteromedial Bundle Biological Augmentation (SAMBBA) Technique

Buscayret

Temponi

Saithna

et al. 2017

Orthopaedic Journal of Sports Medicine

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Background:Remnant preservation may confer important advantages in the anterior cruciate ligament (ACL)–reconstructed knee. However, the presence of a large remnant may obscure visualization and impair the ability to correctly place tunnels during surgery.Purpose:To determine whether tunnel placement during anatomic ACL reconstruction using the single anteromedial bundle biological augmentation (SAMBBA) technique is consistent and precise when a large native remnant is preserved.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were 99 patients undergoing an ACL reconstruction during which at least 50% of the native ACL was preserved. The femoral tunnel was created using an outside-in specific guide. The tibial tunnel was positioned in the anteromedial region of the ACL footprint, and the remnant was carefully preserved while drilling and passing the semitendinosus graft through it. Postoperatively, 3-dimensional computed tomography (3D CT) was used to evaluate tunnel placement. The mean tunnel locations were calculated and the standard deviation was used to evaluate precision of positioning. Inter- and intrareader agreement were determined to assess reliability of evaluation of tunnel position.Results:The center of the femoral tunnel was positioned at a mean 19.4% (SD, 2%) of the depth of the notch and a mean 23.1% (SD, 3.5%) of the lateral wall height. The center of the tibial tunnel was positioned at a mean 36.3% (SD, 3.8%) of the anteroposterior length of the tibial plateau and at a mean 47.0% (SD, 2.7%) of the mediolateral width. The small standard deviations demonstrate that this technique allows precise tunnel placement. The tunnel positions achieved were consistent with previous anatomic studies of femoral and tibial anteromedial bundle insertion. Intra- and interobserver reliability were high.Conclusion:Three-dimensional CT evaluation demonstrated that despite the presence of a large remnant, placement of femoral and tibial tunnels for anatomic ACL reconstruction using the SAMBBA technique is consistent and precise.

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“…T he article "In vivo analysis of graft bending angle in anterior cruciate ligament reconstructed knees during downward running and level walking: Comparison of flexible and rigid drills for trans-portal technique" 1 by Tashiro, Sundaram, Thorhauer, Gale, Anderst, Irrgang, Fu, and Tashman attempts to add to the understanding of this concept and shed light on the potential clinical impact. Many other publications [2][3][4][5][6][7][8][9] have evaluated graft bending angle (GBA) and the effect that drilling technique has. These reviews include the effects of variations within anatomic anterior cruciate ligament drilling such as type of drill, where we are drilling from, and where the drill exits.…”

mentioning

confidence: 99%

Editorial Commentary: Angle Versus Anatomy: Sacrificing Graft Bending Angle for Anatomic Anterior Cruciate Ligament Reconstruction

Pula¹

2017

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Graft bending angle (GBA) is the angle created by the intra-articular anterior cruciate ligament (ACL) graft and the femoral tunnel. By definition then, it is affected by the angle at which the surgeon drills the femoral tunnel. In an attempt to create a more anatomic ACL, different techniques have been described to put the femoral tunnel in the anatomic footprint. If you can get past each author's unique description of GBA, whether they are referring to the graft, the tunnel angle, or using adjectives such as acute or higher GBA, you see that attempting to create more anatomic ACL reconstructions has resulted in a sharper turn for our grafts. The million-dollar question is: what does that mean? For now, the answer is unknown.

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An in Vivo 3D Computed Tomographic Analysis of Femoral Tunnel Geometry and Aperture Morphology Between Rigid and Flexible Systems in Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal Technique

Cited by 20 publications

References 34 publications

In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

Three-Dimensional CT Evaluation of Tunnel Positioning in ACL Reconstruction Using the Single Anteromedial Bundle Biological Augmentation (SAMBBA) Technique

Editorial Commentary: Angle Versus Anatomy: Sacrificing Graft Bending Angle for Anatomic Anterior Cruciate Ligament Reconstruction

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