Relationship between femoral tunnel location and graft bending angle in outside-in and transportal technique for ACL double bundle reconstruction in 3D-CT study

Tomihara, Tomohiro; Hashimoto, Yusuke; Taniuchi, Masatoshi; Shimada, Naoki

doi:10.1007/s00402-015-2226-6

Cited by 23 publications

(35 citation statements)

References 27 publications

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“…The significant correlation between anterior location of femoral exits and increased GBA support the conclusion that the more anterior exit points resulting from use of the flexible drill are the primary cause of the increased GBA. These results are consistent with a previous study that reported higher GBA and more anterior location of femoral exits with an outside-in drilling technique, compared to lower GBA with trans-portal drilling (which resulted in femoral exits at approximately the level of the lateral epicondyle) 40 . A study using computer simulation also concluded that more proximal location of femoral exits could reduce graft bending angles without changing the anatomic femoral and tibial aperture position 64 .…”

Section: Discussionsupporting

confidence: 93%

“…A comparison study of trans-portal and trans-tibial ACL reconstruction reported that antero-medial and postero-lateral graft bending angles with trans-portal technique were significantly more acute (steep) than with single-bundle trans-tibial technique 33 . Recent studies comparing GBA between trans-portal and outside-in ACL reconstruction by postoperative CT have reported that outside-in technique resulted in even steeper graft bending than in trans-portal technique, with about 80° GBA 31,40,41 .…”

Section: Discussionmentioning

confidence: 99%

“…Most of the previous studies on GBA assessed the knee at only one static phase by CT 31,33,40-42 . A previous cadaver study demonstrated that GBA changes significantly with knee motion 32 , and this effect may be even larger when the knee is under dynamic, high-magnitude loads that alter knee kinematics.…”

Section: Discussionmentioning

confidence: 99%

“…The repetitive bending or the abrasive force at the sharp femoral tunnel aperture may cause excessive stress on the graft, which can be a possible cause of graft damage or poor healing after ACL reconstruction 40,44,45 . Graft deformation at the femoral aperture corner has been reported after anatomic ACL reconstruction when applying cyclic load to cadavers 46 .…”

Section: Introductionmentioning

confidence: 99%

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In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

Tashiro

Sundaram

Thorhauer

et al. 2017

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Purpose To determine in vivo dynamic graft bending angle (GBA) in anterior cruciate ligament (ACL) reconstructed knees, correlate the angle to tunnel positions and tunnel widening, and evaluate the effects of two femoral tunnel drilling techniques on GBA. Methods Patients with an isolated ACL injury undergoing reconstruction were included from 2011 to 2012. Trans-portal techniques were used to create femoral tunnels. Tunnel locations were determined using 3D-CT. Tibio-femoral kinematics during treadmill walking and running were assessed using dynamic stereo X-ray analysis 6 months and 2 years postoperatively. The GBA was calculated from the 3D angle between the graft and femoral tunnel vectors at each motion frame. Cross-sectional area of femoral tunnels were measured at 6 months and compared to initial size to assess tunnel widening. Results A total of 54 patients were included. Use of flexible drills resulted in significantly higher GBA during walking (80.6° ± 7.8°; p<0.001) and running (80.5° ± 9.0°; p=0.025) than rigid drills (walking: 67.5° ± 9.3°, running: 74.1° ± 9.6°). It led to greater tunnel widening of 113.9±17.6 %, compared with rigid drills of 97.7±17.5 % (p=0.003). Femoral and tibial apertures were located in similar anatomic positions in both groups, but femoral tunnel exits were located more anteriorly (p<0.001) in the flexible drill group. Higher GBA was highly correlated with anterior location of femoral exits (r=0.63, p<0.001) and moderately correlated with greater tunnel widening (r=0.48, p<0.001). Conclusions High GBA was identified during dynamic activities after anatomic ACL reconstruction using a trans-portal femoral tunnel drilling technique. The GBA was greater when flexible drills were used. The high bending angle resulted from more anterior location of femoral tunnel exits, and correlated with early bone tunnel widening at 6 months. These results suggest that high GBA may increase stress on the bone-graft interface and contribute to greater tunnel widening after anatomic ACL reconstruction, although clinical impact should be further investigated. Level of Evidence Level III, retrospective comparative study

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

Tashiro

Sundaram

Thorhauer

et al. 2017

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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“…26 Furthermore, Tomihara et al reported that the creation of a femoral aperture with a sharp edge due to a steep GBA of the PLB results in abrasive force and repetitive bending, which causes excessive mechanical stress on the bone-graft interface and may result in tunnel enlargement of the femoral PLB. 27 Shin et al reported that the tunnel length in patients with a mild GBA is increased compared with the tunnel length in those with a steep GBA. 28 The creation of a fixation point that is a long distance from the joint line leads to tunnel enlargement due to the "bungee cord effect."…”

Section: Discussionmentioning

confidence: 99%

A steep coronal graft bending angle is associated with bone tunnel enlargement of the posterolateral bundle after anterior cruciate ligament reconstruction

Kimura¹,

Hagiwara²,

Ogoshi³

et al. 2019

J Orthop Surg (Hong Kong)

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Purpose: The correlation between the graft bending angle (GBA) of the anteromedial bundle and posterolateral bundle after anterior cruciate ligament reconstruction (ACLR) and postoperative tunnel enlargement was evaluated. Methods: Two hundred fifty-eight patients (137 males, 121 females; mean age 27.3 years) who had undergone doublebundle ACLR were included. Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months postoperatively. The area of the tunnel aperture for femoral anteromedial tunnel (FAMT) and femoral posterolateral tunnel (FPLT) was measured; the area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The femoral tunnel angles were obtained with Cobb angle measurements. The femoral tunnel angle in the coronal plane was measured relative to the tibial plateau (coronal GBA). On the median value, the patients were divided into two groups in each of FAMT and FPLT; those with a coronal GBA of FAMT of !27 were classified as group A, while those with a coronal GBA of <27 were classified as group B, those with a coronal GBA of FPLT of !23 were classified as group C, while those with a coronal GBA of<23 were classified as group D. Results: Group A included 129 knees, while group B included 129 knees. Groups A and B did not significantly differ regarding FAMT enlargement. Group C included 133 knees, while group D included 125 knees. The percentage of FPLT enlargement in group C was significantly smaller than that in group D (p ¼ 0.001). Conclusions: A steep coronal GBA of the FPLT after ACLR results in greater FPLT enlargement. The present findings suggest that surgeons should avoid creating a steep GBA of the FPLT in the outside-in technique.

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Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction

Tashiro

Irarrázaval

Osaki

et al. 2016

Knee Surg Sports Traumatol Arthrosc

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Relationship between femoral tunnel location and graft bending angle in outside-in and transportal technique for ACL double bundle reconstruction in 3D-CT study

Cited by 23 publications

References 27 publications

In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique

A steep coronal graft bending angle is associated with bone tunnel enlargement of the posterolateral bundle after anterior cruciate ligament reconstruction

Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction

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