Avoiding Posterior Cruciate Ligament and Roof Impingement With Transtibial Anterior Cruciate Ligament Reconstruction: Keys to Correct Tunnel Placement

Abstract

Avoiding posterior cruciate ligament (PCL) impingement, avoiding roof impingement, and replicating the tension pattern of the intact anterior cruciate ligament (ACL) are the keys to successful ACL reconstruction. To avoid PCL impingement, the tibial tunnel should be placed in the coronal plane at an angle between 60°and 65°with the medial joint line, and the lateral edge of the tibial tunnel should pass through the apex of the lateral tibial spine. Placement of the tibial tunnel with these 2 criteria usually requires removal of the medial wall of lateral femoral condyle (ie, wallplasty) until the space between the PCL and lateral femoral condyle exceeds the diameter of the graft by 1 mm. The guidewire should be drilled through the lateral hole in the bullet of the guide and enter the notch midway between the PCL and lateral femoral condyle. To avoid roof impingement without a roofplasty, the tibial tunnel should be customized in the sagittal plane 5 to 6 mm posterior and parallel to the intercondylar roof with the knee in maximum hyperextension, which accounts for variability in roof angle and knee extension. We prefer to use the Howell 65 Degree Tibial Guide to place the tibial tunnel with these criteria in the coronal and the sagittal planes. When the femoral tunnel is drilled through and in line with the correctly placed tibial tunnel, and when the back wall of the femoral tunnel is 1 mm thick, the tension pattern in the graft replicates that of the intact ACL.

The WasherLoc and Bone Dowel: A Rigid, Slippage-Resistant Tibial Fixation Device for a Soft Tissue Anterior Cruciate Ligament Graft

“…20 Remove the cortex at the distal end of the tibial tunnel with a reamer. Insert the cannulated plunger over the K-wire.…”

The EZLoc: A Simple, Rigid Femoral Fixation Device for a Soft Tissue Anterior Cruciate Ligament Graft

“…12 Briefly, correct placement of the tibial tunnel is easy and reproducible with use of the Howell 65 Degree Tibial Guide (Arthrotek, Inc.), which is designed to place the ACL graft without posterior cruciate ligament (PCL) and roof impingement. Angle the tibial tunnel 60°to 65°with the medial joint line and position the lateral edge of the tibial tunnel so that it passes through the apex of the lateral tibial spine in the coronal plane to avoid PCL impingement.…”