Posterior Wall Blowout in Anterior Cruciate Ligament Reconstruction

Mitchell, Justin J.; Dean, Chase S.; Chahla, Jorge; Menge, Travis J.; Cram, Tyler R.; LaPrade, Robert F.

doi:10.1177/2325967116652122

Cited by 24 publications

(41 citation statements)

References 44 publications

(120 reference statements)

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“… 1 , 2 , 3 , 4 , 19 Although during ACL reconstruction the anatomic positioning is objectified, the maintenance of the bone integrity of the tunnels created is not always guaranteed. 18 The advantages of the described test are that it is technically straightforward to learn and the surgeon is quickly able to obtain a superior view of patient anatomy to facilitate accurate tunnel integrity evaluation, despite this is not a common complication. 18 , 20 , 21 Although in this study it was done for integrity evaluation using an in-out technique, the test can be extrapolated to other techniques (e.g., out-in), other tunnels (e.g., tibial), and in other reconstructions (e.g., posterior cruciate ligament).…”

Section: Discussionmentioning

confidence: 99%

“… 18 The advantages of the described test are that it is technically straightforward to learn and the surgeon is quickly able to obtain a superior view of patient anatomy to facilitate accurate tunnel integrity evaluation, despite this is not a common complication. 18 , 20 , 21 Although in this study it was done for integrity evaluation using an in-out technique, the test can be extrapolated to other techniques (e.g., out-in), other tunnels (e.g., tibial), and in other reconstructions (e.g., posterior cruciate ligament). The potential disadvantage of this technique is the necessity to modify the portal for direct visualization, although this does not significantly increase the time of the procedure.…”

Section: Discussionmentioning

confidence: 99%

“…Although femoral tunnel misposition in an anterior location can result in rotational laxity or graft impingement, a posteriorly placed femoral tunnel may result in deleterious consequences such as a breach of the posterior femoral cortex and consequent lack of femoral graft fixation. 11 , 18 , 19 The compromising of the walls of the femoral tunnel can lead to a loss of graft containment and subsequent difficulty with fixation. 18 , 20 If this intraoperative error is not promptly recognized and appropriately treated, the graft is at an increased risk of premature failure.…”

mentioning

confidence: 99%

“… 11 , 18 , 19 The compromising of the walls of the femoral tunnel can lead to a loss of graft containment and subsequent difficulty with fixation. 18 , 20 If this intraoperative error is not promptly recognized and appropriately treated, the graft is at an increased risk of premature failure. 5 , 13 Thus, in these situations, recognizing the complication and knowing strategies for alternative or salvage fixation are of paramount importance.…”

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confidence: 99%

“… 3 The true incidence of posterior wall blowout in ACL reconstruction is difficult to determine because it is unclear how often such blowouts are recognized intraoperation and treated appropriately versus how many go unrecognized. 18 , 20 , 21 …”

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confidence: 99%

See 4 more Smart Citations

A Femoral Tunnel View Test During ACL Reconstruction

Temponi

Soares

Júnior

2017

Arthroscopy Techniques

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Despite technologic advances in the surgical techniques for anterior cruciate ligament (ACL) reconstruction, some patients continue to have violation of the femoral cortex, commonly referred to as wall blowout. These posterior or lateral cortical breaches lead to loss of graft containment and subsequent difficulty with graft fixation. If this intraoperative error is not promptly recognized and treated, the graft is at an increased risk of premature failure. Thus, in these situations, recognizing the complication and knowing strategies for alternative or salvage fixation are of importance. This article details a simple tunnel view test realized during ACL reconstruction that would enable determining the integrity and depth of the femoral tunnel. The femoral tunnel view test is a technically straightforward and quick test able to obtain a superior view of patient anatomy to facilitate accurate tunnel integrity evaluation during ACL reconstruction.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 3 more Smart Citations

A Femoral Tunnel View Test During ACL Reconstruction

Temponi

Soares

Júnior

2017

Arthroscopy Techniques

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Posteriorly positioned femoral grafts decrease long-term failure in anterior cruciate ligament reconstruction, femoral and tibial graft positions did not affect long-term reported outcome

Mees

Reijman

Waarsing

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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Purpose To investigate the effect that femoral and tibial tunnel positions have on long-term reported and clinical outcome and to identify a safe zone based on favourable outcome. Methods Seventy-eight patients from a previous randomised controlled trial were included and were followed with a mean follow-up of 11.4 years. All patients had primary trans-tibial anterior cruciate ligament reconstruction performed. The femoral and tibial tunnel positions were visualised and translated in percentages with three-dimensional computed tomography post-operatively. There were 3 separate outcome variables: patient-reported outcome measured with the IKDC Subjective Knee Form, overall failure, and radiographic osteoarthritis. The correlation between tunnel aperture positions and outcome was determined with multivariate regression. The area with best outcome was defined as the safe zone and was determined with Youden’s index in conjunction with receiver operating characteristics. Results No significant relationship was found between tunnel aperture positions and IKDC Subjective Knee Form at 10-year follow-up. The posterior-to-anterior femoral tunnel aperture position parallel to Blumensaat line showed a significant relationship (p = 0.03) to overall failure at 10-year follow-up. The mean posterior-to-anterior tunnel position of the group that did not fail was 37.7% compared to 44.1% in the overall failure group. Femoral tunnel apertures placed further anteriorly had more overall failures at long-term. The cut-off point lies at 35.0% from posterior-to-anterior parallel to Blumensaat. Of the 16 overall failures, 15 (93.8%) were placed further anteriorly than the cut-off point. No significant relationship was found between tunnel aperture positions and radiographic osteoarthritis. Conclusion Femoral and tibial tunnel positions were not associated with long-term patient-reported outcome and radiographic osteoarthritis. Long-term overall failure was more frequently seen in patients with a more anteriorly placed femoral tunnel. This study identified a safe zone located at the most posterior 35% of the femoral condyle parallel to Blumensaat. This knowledge offers guidance to surgeons to operate more precisely and accurately and reconstruct a long-lasting graft. Level of evidence Level III.

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Smaller diameter femoral tunnel biocomposite interference screws provide adequate fixation strength in anterior cruciate ligament reconstruction

Ina

Megerian

Knapik

et al. 2023

Knee Surg Sports Traumatol Arthrosc

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Purpose The purpose of this study was to evaluate the efect of bioabsorbable interference screw diameter on the pullout strength and failure mode for femoral tunnel ixation in primary anterior cruciate ligament reconstruction (ACLR) at time zero ixation using bone-patellar tendon-bone (BTB) autograft in a cadaveric model. Methods Twenty-four fresh-frozen cadaveric knees were obtained from 17 diferent donors. Specimens were allocated to three diferent treatment groups (n = 8 per group) based on interference screw diameter: 6 mm, 7 mm, or 8 mm biocomposite interference screw. All specimens underwent dual energy X-ray absorptiometry (DEXA) scanning prior to allocation to ensure no diference in bone mineral density among groups (n.s.). All specimens underwent femoral-sided ACLR with BTB autograft. Specimens subsequently underwent mechanical testing under monotonic loading conditions to failure. The load to failure and failure mechanism were recorded. ResultsThe mean pullout force (N) at time zero for each group was 309 ± 213 N, 518 ± 313 N, and 541 ± 267 N for 6 mm, 7 mm, and 8 mm biocomposite interference screw diameter, respectively (n.s.). One specimen in the 6 mm group, two specimens in the 7 mm group, and one specimen in the 8 mm group failed by screw pullout. The remainder in each group failed by graft failure (n.s.). Conclusion Biocomposite interference screw diameter did not have a signiicant inluence on ixation pullout strength or failure mode following femoral tunnel ixation using BTB autograft at time zero. A 6 mm interference screw can improve preservation of native bone stock, increase potential for biologic healing, and decrease the risk of damage to the graft during insertion without signiicantly compromising ixation strength. This study supports the use of smaller 6 mm interference screw diameter options for femoral tunnel ixation in ACLR.

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Posterior Wall Blowout in Anterior Cruciate Ligament Reconstruction

Cited by 24 publications

References 44 publications

A Femoral Tunnel View Test During ACL Reconstruction

A Femoral Tunnel View Test During ACL Reconstruction

Posteriorly positioned femoral grafts decrease long-term failure in anterior cruciate ligament reconstruction, femoral and tibial graft positions did not affect long-term reported outcome

Smaller diameter femoral tunnel biocomposite interference screws provide adequate fixation strength in anterior cruciate ligament reconstruction

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