Prevalence of Nonanatomical Graft Placement in a Series of Failed Anterior Cruciate Ligament Reconstructions

Abstract

The occurrence of nonanatomical graft placement in primary and revision knees may represent an inadequacy of transtibial tunnel drilling techniques to obtain graft placement within the native femoral and tibial footprints. In revision cases, the prior graft location requires close scrutiny so the new graft tunnels are placed at the native anterior cruciate ligament attachments. Independent drilling of tibial and femoral tunnels is recommended using either 2-incision or anteromedial portal techniques.

Medial portal technique for single-bundle anatomical Anterior Cruciate Ligament (ACL) reconstruction

“…Anatomical ACL graft placement is defined as positioning the ACL femoral and tibial bone tunnels at the centre of the native ACL femoral and tibial attachment sites. Clinical studies have demonstrated that non-anatomical ACL graft placement is the most common technical error leading to recurrent instability following ACL reconstruction [1,2]. ACL reconstruction has been commonly performed using a transtibial technique in which the ACL femoral tunnel is drilled through a tibial tunnel positioned in the posterior half of the native ACL tibial attachment site.…”

“…Other potential problems that can result from drilling the ACL femoral tunnel in hyperflexion include: (1) difficulty passing the endoscopic reamer over the guide pin due to the medial portal tightening in hyperflexion, (2) difficulty visualising the endoscopic reamer due to the reamer dragging the fat pad into the notch and (3) difficulty advancing the endoscopic reamer over the guide wire due to a bend or kink in the guide pin. Drilling the ACL femoral tunnel through a medial portal which is placed too close to the medial femoral condyle can result in iatrogenic injury to the articular cartilage of the medial femoral condyle.…”

Accurate Positioning of Femoral and Tibial Tunnels in Single Bundle Anterior Cruciate Ligament Reconstruction Using the Indigenously Made Bernard and Hurtle Grid on a Transparency Sheet and C-arm

“…1,2 In this regard, it is important to either use an anatomical landmark or go by the remnant of the remaining ACL foot print. Study has shown that determining the correct entry point on the basis of anatomical landmarks is not always accurate.…”

“…The literature is unanimous on one point that the incorrect tunnel position is the single most common cause of failure. 1,2 The concept of the anatomical attachment, orientation, and function of the ACL has been a matter of debate for long. Some recent studies have shown that the ACL is attached as a single footprint on the femoral side (the ribbon concept).…”

Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator

“…Due to the unsatisfactory outcomes of conservative treatments for ACL injuries, ACL reconstruction remains the treatment of choice in most young patients who wish to maintain an active lifestyle. However, clinical studies indicate that non-anatomical ACL graft placement is the most common technical error that subsequently leads to recurrent instability after reconstruction [2,3] . Therefore, the anatomical placement of an ACL graft is generally considered critical to the successful clinical outcome of ACL reconstruction [4] , although this topic remains controversial.…”