Reliability of Tunnel Measurements and the Quadrant Method Using Fluoroscopic Radiographs After Anterior Cruciate Ligament Reconstruction

Sullivan, Jaron P.; Matava, Matthew J.; Flanigan, David C.; Gao, Yubo; Britton, Carla; Amendola, Annunziato; Wolf, Brian R.

doi:10.1177/0363546512458086

Cited by 26 publications

(25 citation statements)

References 18 publications

(38 reference statements)

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“…In the present study, the femoral condyle overlap method was shown to be highly reliable. Although not yet validated against other quantitative measurement methods, a similar strategy using 90% condyle-to-condyle overlap has previously been used [30]. Further, since the femoral condyle overlap method is used to specify which radiographs can be used to assess the position of the femoral tunnel in the sagittal plane, potential varus or valgus deviation would not affect the interpretation of the outcome.…”

Section: Discussionmentioning

confidence: 99%

No correlation between femoral tunnel orientation and clinical outcome at long-term follow-up after non-anatomic anterior cruciate ligament reconstruction

Sundemo

Mårtensson

Senorski

et al. 2019

Knee Surg Sports Traumatol Arthrosc

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PurposeThis study aimed to determine the influence of femoral tunnel orientation on long-term clinical outcome and osteoarthritis in patients undergoing ACL reconstruction and to test the reliability of the implemented radiographic measurement methods. It was hypothesized that a more horizontal femoral tunnel would correlate with superior clinical outcome.MethodsA cohort of 193 patients who underwent non-anatomic ACL reconstruction was examined. In this specific study, non-anatomic is defined by the surgeons’ pursuit of optimal isometry, not to emulate the native ACL anatomy. At follow-up, the Lachman test, the KT-1000, the pivot-shift test, the one-leg-hop test and the IKDC-2000 were evaluated. Osteoarthritis was evaluated radiographically. Posteroanterior and lateral radiographs were used to determine the position of the femoral tunnel in the coronal and sagittal planes and the angle of the tunnel in the coronal plane. A method for determining femoral rotation on the lateral radiographs was developed and its reliability was evaluated. The femoral tunnel orientation was analyzed to examine its influence on clinical outcome and osteoarthritis.ResultsA total of 101 patients were analyzed at a mean of 16.4 (± 1.3) years postoperatively. The reliability of the measurement methods was regarded as good to excellent (ICC 0.57–0.97). The mean coronal femoral tunnel angle was 9.6° (± 9.4°). The coronal femoral tunnel was positioned at a mean of 43% (± 3.5%) of the distance measured from lateral to medial. The mean sagittal femoral tunnel position, measured using the quadrant method, was 40% (± 6.4%) from posterior to anterior. No significant associations were found between tunnel orientation and the clinical outcome variables.ConclusionsThe orientation of the femoral tunnel did not predict the long-term subjective outcome, functional outcome or the development of osteoarthritis in patients undergoing non-anatomic ACL reconstruction. The method for determining femoral rotation on lateral radiographs was found to be reliable.Level of evidenceRetrospective cohort study, level of evidence IV.

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Section: Discussionmentioning

confidence: 99%

No correlation between femoral tunnel orientation and clinical outcome at long-term follow-up after non-anatomic anterior cruciate ligament reconstruction

Sundemo

Mårtensson

Senorski

et al. 2019

Knee Surg Sports Traumatol Arthrosc

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“…The tibial tunnel was placed 7 mm anterior to the posterior cruciate ligament (PCL) and slightly medial and posterior to the inner edge of lateral meniscus. Studies have investigated the relationship between arthroscopic anatomic landmarks and postoperative radiological and functional outcomes 78…”

Section: Discussionmentioning

confidence: 99%

Radiologic assessment of femoral and tibial tunnel placement based on anatomic landmarks in arthroscopic single bundle anterior cruciate ligament reconstruction

Nema

Balaji

Akkilagunta

et al. 2017

IJOO

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Background:Accurate tibial and femoral tunnel placement has a significant effect on outcomes after anterior cruciate ligament reconstruction (ACLR). Postoperative radiographs provide a reliable and valid way for the assessment of anatomical tunnel placement after ACLR. The aim of this study was to examine the radiographic location of tibial and femoral tunnels in patients who underwent arthroscopic ACLR using anatomic landmarks. Patients who underwent arthroscopic ACLR from January 2014 to March 2016 were included in this retrospective cohort study.Materials and Methods:45 patients who underwent arthroscopic ACLR, postoperative radiographs were studied. Femoral and tibial tunnel positions on sagittal and coronal radiographic views, graft impingement, and femoral roof angle were measured. Radiological parameters were summarized as mean ± standard deviation and proportions as applicable. Interobserver agreement was measured using intraclass correlation coefficient.Results:The position of the tibial tunnel was found to be at an average of 35.1% ± 7.4% posterior from the anterior edge of the tibia. The femoral tunnel was found at an average of 30% ± 1% anterior to the posterior femoral cortex along the Blumensaat's line. Radiographic impingement was found in 34% of the patients. The roof angle averaged 34.3° ± 4.3°. The position of the tibial tunnel was found at an average of 44.16% ± 3.98% from the medial edge of the tibial plateau. The coronal tibial tunnel angle averaged 67.5° ± 8.9°. The coronal angle of the femoral tunnel averaged 41.9° ± 8.5°.Conclusions:The femoral and tibial tunnel placements correlated well with anatomic landmarks except for radiographic impingement which was present in 34% of the patients.

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“…To eliminate the effect of different-sized femurs on our investigation, the distance between the intended and achieved femoral ACL tunnels was modeled in 2 dimensions. The grid method of Bernard et al, 9,55 as applied to the fluoroscopic true lateral images, allowed each intended and achieved tunnel position to be defined as a percentage ratio of the sagittal diameter of the whole lateral condyle measured along the Blumensaat line ( X axis) and as a percentage of the maximum width of the femoral condyle perpendicular to the Blumensaat line ( Y axis) (Figure 5). The achieved and intended tunnel positions were measured by an independent observer (J.R.) who was blinded to the names of the surgeons, their tunnel localization strategy, and their viewing portal used.…”

Section: Methodsmentioning

confidence: 99%

Anterior Cruciate Ligament Femoral Tunnel Placement: An Analysis of the Intended Versus Achieved Position for 221 International High-Volume ACL Surgeons

et al. 2020

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Background: Femoral tunnels that are not anatomically placed within the native anterior cruciate ligament (ACL) footprint during ACL reconstruction are associated with residual instability, graft rupture, and poor clinical outcomes. Although surgeons may intend to place their femoral tunnels within the native ACL attachment, this is not always achieved. This study assesses the variation between intended and achieved femoral tunnel positions in a large cohort of experienced ACL surgeons. Hypothesis: The accuracy with which experienced ACL surgeons achieve their intended femoral tunnel position is dependent on viewing portal, localization strategy, and drilling technique. Study Design: Controlled laboratory study. Methods: A total of 221 surgeons indicated their intended femoral tunnel location on a true lateral radiograph of a cadaveric knee specimen and a scaled photograph. Each surgeon then arthroscopically demonstrated the femoral tunnel on the specimen. The position was captured using fluoroscopy. The Euclidean distance (the straight-line distance between 2 points) between the intended and achieved tunnel positions, referenced to a grid applied to the lateral femoral condyle, was compared. Data were analyzed according to surgeons’ viewing portal (anteromedial [AM] or anterolateral [AL]), tunnel localization strategy (offset aimer, estimation from landmarks, ACL ruler, or C-arm fluoroscopy), and stated drilling technique (transtibial, AM portal, or outside-in). Results: Surgeons who viewed the lateral intercondylar notch wall through the AM portal were closer (mean distance, 9.5) to their intended position than those who viewed through the AL portal (mean distance, 15.1; P < .0001). By localization strategy, the mean distance between achieved and intended tunnel positions was greater for surgeons who used an offset aimer (14.5) and estimated the femoral tunnel position (12.9) than for those using a malleable ACL ruler (8.1; P < .0001) and fluoroscopy (4.3; P < .0001). Surgeons’ preferred drilling technique (AM portal, transtibial, or outside-in) had no effect on distance between intended and achieved positions. However, the mean achieved position was higher in the intercondylar notch for those using transtibial drilling ( P < .042). Conclusion: Surgeons using the AM portal to view the femoral attachment site were closer to their intended tunnel position than those who viewed it with the arthroscope in the AL portal. Surgeons who used fluoroscopy to localize femoral tunnel position were the closest to their intended position. Those who used estimation or an offset aimer had the farthest distance between achieved and intended tunnel positions. Clinical Relevance: Although accurate tunnel placement can be achieved using any method, given the disparity between intended and achieved tunnel positions, it may be advisable, even for high-volume surgeons, to verify the placement of their tunnels using either fluoroscopy or a malleable ACL ruler to ensure that they achieve their intended position. Fluoroscopy may be particularly useful for cases where the native femoral stump is no longer visible and for revisions. Viewing through the AM portal is recommended to aid accuracy of tunnel placement.

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Reliability of Tunnel Measurements and the Quadrant Method Using Fluoroscopic Radiographs After Anterior Cruciate Ligament Reconstruction

Abstract: Measurements with good to excellent reliability can be used to evaluate ACL tunnel placement when ideal radiographic views are obtained.

Cited by 26 publications

References 18 publications

No correlation between femoral tunnel orientation and clinical outcome at long-term follow-up after non-anatomic anterior cruciate ligament reconstruction

No correlation between femoral tunnel orientation and clinical outcome at long-term follow-up after non-anatomic anterior cruciate ligament reconstruction

Radiologic assessment of femoral and tibial tunnel placement based on anatomic landmarks in arthroscopic single bundle anterior cruciate ligament reconstruction

Anterior Cruciate Ligament Femoral Tunnel Placement: An Analysis of the Intended Versus Achieved Position for 221 International High-Volume ACL Surgeons

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