Principles for placing the tibial tunnel and avoiding roof impingement during reconstruction of a torn anterior cruciate ligament

Abstract

Reconstruction of a form anterior cruciate ligament (ACL) cannot be successful without a properly placed tibial tunnel. Preventable complications such as anterior knee pain, effusions, extension loss, and recurrent instability can occur when the tibial tunnel is improperly placed and the roof and notchplasty are insufficient. This article reviews the principles for anatomic placement of the tibial tunnel so that complications associated with impingement of the ACL graft on the intercondylar roof can be prevented. Five factors that contribute to roof impingement are discussed, including differences in the size and shape of the ACL and the graft, variability in knee extension and roof angle between patients, inability to view the contact between the intercondylar roof and the graft, accentuation of roof impingement from anterior tibial translation caused by quadriceps contraction, and the use of tibial guides that rely on soft-tissue landmarks. A surgical technique is presented which consistently places the tibial tunnel in the pathway of the normal ACL (i.e., anatomic placement) and avoids roof impingement. The indications and need for roof- and wallplasty are discussed.

The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament

“…The PL 6 mm tunnel centre was 9 ± 0.5 mm (8)(9)(10), and the AM 6 mm tunnel was 16 ± 2 mm (12-18) anterior to the "over-the-back" ridge. These had stronger correlations with the overall dimensions of the tibial plateau (Table 1).…”

Validation of the 65° Howell Guide for Anterior Cruciate Ligament Reconstruction

“…The medial and lateral limits of the attachment were at -3±1[-5-(-2)] mm and +6±2 (3)(4)(5)(6)(7)(8)(9) mm respectively lateral to the medial tibial spine. The tibial attachment was on average 17±2(12-19) mm long and 9±2(7-16) mm wide.…”

“…Despite the range of grafts and fixation devices employed, correct tunnel placement remains the main determinant of the final outcome 6,7 and a malpositioned tunnel is likely to result in instability or in lack of recovery of the range of motion 8,9,10,11 . An anatomic position of the graft is desirable but identifying the correct tunnel exit point within the whole attachment area of the ACL may be a challenge.…”

“…Furthermore, usually at arthroscopy and especially in chronic lesions, no ACL remnants may be identified. Many authors have studied the correct intraarticular position of the tunnels and several methods to achieve it have been developed 7,8,10,12,13 . Most of the existing methods either need intraoperative X-rays to confirm the location or rely on "point and shoot" guides aiming at intraarticular landmarks.…”

Surgery of anterior cruciate ligament in knee joint. Comparative analysis of plastic reconstruction methods regarding anterior cruciate ligament in knee joint (BTB and STGT)

“…Артроско-пическая реконструкция ПКС коленного сустава -широко распространенная операция в мировой практике общей травматологии-ортопедии и спор-тивной травматологии. Однако хороших результа-тов хирургическое восстановление ПКС достигает лишь в 75-90% случаев [3][4][5]. Существует много подходов к определению показаний к оперативно-му лечению ПКС коленного сустава и выбору хи-рургической тактики.…”