Anatomic Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction

Tompkins, Marc; Milewski, Matthew D.; Brockmeier, Stephen F.; Gaskin, Cree M.; Hart, Joseph M.; Miller, Mark D.

doi:10.1177/0363546512443047

Cited by 101 publications

(37 citation statements)

References 66 publications

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“…Conversely, the IF technique more accurately places the femoral tunnel in the anatomic footprint 14 and does so irrespective of the tibial tunnel. In our study, the IF technique was associated with a more horizontal sagittal graft angle, which diminished the risk for roof impingement.…”

Section: Discussionmentioning

confidence: 99%

ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels?

Tanksley

Werner

Conte

et al. 2017

Orthopaedic Journal of Sports Medicine

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Background:Anatomic femoral tunnel placement for single-bundle anterior cruciate ligament (ACL) reconstruction is now well accepted. The ideal location for the tibial tunnel has not been studied extensively, although some biomechanical and clinical studies suggest that placement of the tibial tunnel in the anterior part of the ACL tibial attachment site may be desirable. However, the concern for intercondylar roof impingement has tempered enthusiasm for anterior tibial tunnel placement.Purpose:To compare the potential for intercondylar roof impingement of ACL grafts with anteriorly positioned tibial tunnels after either transtibial (TT) or independent femoral (IF) tunnel drilling.Study Design:Controlled laboratory study.Methods:Twelve fresh-frozen cadaver knees were randomized to either a TT or IF drilling technique. Tibial guide pins were drilled in the anterior third of the native ACL tibial attachment site after debridement. All efforts were made to drill the femoral tunnel anatomically in the center of the attachment site, and the surrogate ACL graft was visualized using 3-dimensional computed tomography. Reformatting was used to evaluate for roof impingement. Tunnel dimensions, knee flexion angles, and intra-articular sagittal graft angles were also measured. The Impingement Review Index (IRI) was used to evaluate for graft impingement.Results:Two grafts (2/6, 33.3%) in the TT group impinged upon the intercondylar roof and demonstrated angular deformity (IRI type 1). No grafts in the IF group impinged, although 2 of 6 (66.7%) IF grafts touched the roof without deformation (IRI type 2). The presence or absence of impingement was not statistically significant. The mean sagittal tibial tunnel guide pin position prior to drilling was 27.6% of the sagittal diameter of the tibia (range, 22%-33.9%). However, computed tomography performed postdrilling detected substantial posterior enlargement in 2 TT specimens. A significant difference in the sagittal graft angle was noted between the 2 groups. TT grafts were more vertical, leading to angular convergence with the roof, whereas IF grafts were more horizontal and universally diverged from the roof.Conclusion:The IF technique had no specimens with roof impingement despite an anterior tibial tunnel position, likely due to a more horizontal graft trajectory and anatomic placement of the ACL femoral tunnel. Roof impingement remains a concern after TT ACL reconstruction in the setting of anterior tibial tunnel placement, although statistical significance was not found. Future clinical studies are planned to develop better recommendations for ACL tibial tunnel placement.Clinical Relevance:Graft impingement due to excessively anterior tibial tunnel placement using a TT drilling technique has been previously demonstrated; however, this may not be a concern when using an IF tunnel drilling technique. There may also be biomechanical advantages to a more anterior tibial tunnel in IF tunnel ACL reconstruction.

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Section: Discussionmentioning

confidence: 99%

ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels?

Tanksley

Werner

Conte

et al. 2017

Orthopaedic Journal of Sports Medicine

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“…Similar to other literature (4), the AMP and the OI techniques are collectively referred to as the independent drilling (ID) techniques in this report. Plenty of studies showed that femoral tunnels could not be precisely placed in the natural ACL anatomic insertion by using the standard transtibial (sTT) technique (5,6), which, as a result, caused abnormal rotation of knee joints (7,8) and failed to reduce the occurrence of knee osteoarthritis (KOA). At present, the sTT technique has been basically abandoned by surgeons.…”

Section: Introductionmentioning

confidence: 99%

A meta‑analysis on anterior cruciate ligament reconstruction: Is modified transtibial technique inferior to independent drilling techniques?

2018

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This report respectively compared the standard transtibial (sTT) technique to the independent drilling (ID) techniques applied to anterior cruciate ligament (ACL) reconstruction. It also made a comparison between the clinical results of the modified transtibial (mTT) technique and of the ID techniques. Prospective studies on transtibial (TT) and ID techniques for ACL reconstruction were retrieved from several databases and a subgroup analysis was performed to compare the sTT technique with the ID techniques and the mTT with the ID techniques. Furthermore, comparison of the Lachman test, pivot-shift test, International Knee Documentation Committee (IKDC) subjective and objective evaluations, Lysholm score and Tegner activity scale were conducted. This report included 12 clinical studies that involved 681 patients having received ACL reconstruction. The study results indicated that in comparison between the sTT and ID techniques, the ID techniques outperformed the sTT technique in the IKDC subjective score (P=0.01) and laxity (P=0.0004). However, there was no significant difference in the IKDC objective score (P=0.34), pivot-shift test (P=0.24), Lachman test (P=0.21), Lysholm score (P=0.14) and Tegner activity scale (P=0.66). The comparison between the new mTT technique and the ID techniques suggested no significant difference in the IKDC objective and subjective scores (P=0.86), laxity (P=0.38), pivot-shift test (P=0.66), Lachman test (P=0.10), Lysholm score (P=0.10) and Tegner activity scale (P=0.55). Compared to the sTT technique, the mTT and ID techniques are more suitable for ACL reconstruction because they can present better subjective feelings. Moreover, considering that the TT technique is familiar to surgeons and the mTT technique can bring favorable subjective feelings and objective clinical outcomes, the mTT technique shows greater utilization potential.

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“…Femoral tunnel placement has been considered to be the most critical step in ACLR. It has been postulated that traditional single-bundle transtibial (TT) reconstructions have placed grafts in an isometric location relative to the true ACL insertion sites 23. Recent studies advocate the use of an accessory medial portal for more accurate placement of the femoral tunnel 3.…”

Section: Introductionmentioning

confidence: 99%

“…reported that accessory medial portal technique placed the femoral tunnel close to the native femoral footprint, as compared to the TT technique. Anatomic placement of the graft closer to the femoral footprint has been shown to enhance the rotational stability of the knee 23…”

Section: Introductionmentioning

confidence: 99%

Functional and computed tomography correlation of femoral and tibial tunnels in single-bundle anterior cruciate ligament reconstruction

Mathai¹,

Amaravathi

Pavan

et al. 2016

IJOO

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Background:An accessory anteromedial portal (AAMP) has been shown to be effective in placing an anatomically ideal femoral tunnel. It is well known that this is due to the independent femoral drilling which is possible with the AAMP. However very little is known regarding the significance of this reconstruction technique in influencing the functional outcomes of anatomic anterior cruciate ligament reconstruction (ACLR). This study documents the influence of tibial and femoral tunnel positions on functional outcomes of anatomic ACLR using the AAMP.Materials and Methods:41 patients who underwent anatomic ACLR between 2011 and 2013 were included in this prospective cohort study. The primary outcome involved the documentation of femoral and tibial tunnel positions with volume rendering imaging using a three-dimensional computed tomography (3D-CT) done at the end of 1 year. The tunnel position evaluations from the CT images were performed by an independent observer specializing in radiodiagnosis. Functional outcome measures included preoperative and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores (subjective) documented by an independent investigator who was not involved with the surgical procedure, at the end of 1 year.Results:The minimum followup was 1 year. All patients achieved good clinical and functional outcomes postoperatively with no reported complications. Tunnel position evaluations with 3D-CT revealed the average tibial tunnel distance to be 15.5 mm (standard deviation [SD] =2.52) from the anterior border of the tibial plateau and the average femoral tunnel distance to be 14.33 mm (SD = 2.6) from the inferior margin of the medial surface of lateral femoral condyle and 13.72 mm (SD = 2.8) from the posterior margin of the medial surface of lateral femoral condyle. The average tunnel diameters were found to be 7.9 mm (SD = 0.72) for the tibial tunnels and 8.6 mm (SD = 1.07) for the femoral tunnels. Statistically significant correlation between the tibial tunnel distance and the IKDC scores with anterior placement of tibial tunnel were found; however, no such statistical relationship were found between the femoral tunnel positions and the functional outcome measures.Conclusion:AAMP gives an ideal approach to drill the femoral tunnel independently. However, the influence of this tunnel placement on long term functional outcomes of ACLR needs to be assessed on larger cohort of patients.

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Anatomic Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction

Abstract: More accurate placement of the femoral tunnel in the native ACL femoral footprint should improve the ability to achieve more anatomic positioning of the ACL graft.

Cited by 101 publications

References 66 publications

ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels?

ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels?

A meta‑analysis on anterior cruciate ligament reconstruction: Is modified transtibial technique inferior to independent drilling techniques?

Functional and computed tomography correlation of femoral and tibial tunnels in single-bundle anterior cruciate ligament reconstruction

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