The effect of intraoperative fluoroscopy on the accuracy of femoral tunnel placement in single-bundle anatomic ACL reconstruction

Inderhaug, Eivind; Larsen, Alf-Inge; Waaler, Per Arne Skarstein; Strand, Torbjørn; Harlem, Thomas; Solheim, Eirik

doi:10.1007/s00167-015-3858-3

Cited by 23 publications

(35 citation statements)

References 38 publications

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“…However, this was not always achieved according to our data. Previous studies have assessed the achieved tunnel positions in analyses of clinical practice 8,31 but have not accounted for variation in intended tunnel position. Inderhaug et al 30 compared analyzed tunnel positions by performing postoperative 3-dimensional computed tomography scans.…”

Section: Discussionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

“…12 The potential tunnel position may be referenced using the grid system described by Bernard et al 9 This method has been stated to be reproducible and independent of different knee morphology. 1,31…”

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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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“…Portanto, apesar da preocupação e grande número de estudos no homem sobre a isometria do enxerto na reconstrução do LCCr, tem-se observado que atualmente este não é o fator primordial na reconstrução do ligamento, mas sim a "isometria" pela colocação do enxerto na inserção anatômica nativa do LCCr. Segundo Hinderhaug et al (33) , na proposta anatômica para a reconstrução do LCCr na articulação do homem, a confecção dos túneis ósseos baseia-se em pontos de referência, os quais podem apresentar variação quanto a presença e visibilidade, tornando a sua identificação por artroscopia desafiante ao cirurgião. Neste estudo, nos baseamos principalmente na localização dos resquícios de ligamento presentes no aspecto caudo-medial do côndilo femoral lateral e na superfície da tíbia, para a confecção dos túneis femoral e tibial, respectivamente.…”

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Estudo Da Técnica Intracapsular Assistida Por Artroscopia Para O Tratamento Da Ruptura Do Ligamento Cruzado Cranial Em Cadáveres De Cães

et al. 2019

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Resumo O objetivo foi estudar e aprimorar a técnica intracapsular de reparação do ligamento cruzado cranial assistida por artroscopia em cadáveres de cães com a confecção dos túneis tibial e femoral e utilização de autoenxerto osso-tendão patelar-osso. Foram utilizados 10 membros pélvicos de cães > 20kg. Os túneis ósseos foram confeccionados de forma independente e na posição anatômica original dos locais de inserção do ligamento cruzado cranial. Foram realizados estudo radiográfico e tomográfico para avaliar a articulação. A coleta das porções ósseas do enxerto foi feita com osteótomo e martelo. Ocorreram fratura em três patelas e em três tuberosidades tibiais. Os enxertos apresentaram comprimento médio 7,56cm. Os túneis tibiais e os túneis femorais foram confeccionados no local de inserção do ligamento cruzado cranial em 80% e 90% das articulações, respectivamente. Os túneis tibiais apresentaram ângulo médio de 62,95º mensurado por tomografia computadorizada. Os túneis femorais foram confeccionados em posição 13hs para o joelho esquerdo (100%) e 11hs para o direito (100%). Ao final do procedimento, obteve-se gaveta negativo em 100% das articulações. Pode-se concluir que a técnica proposta é viável de ser realizada no cão, porém faz-se necessário instrumental específico devido ao pequeno tamanho da articulação canina para obter melhor acurácia.

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“…Using intraoperative fluoroscopy gives instant and important feedback to the surgeon and can effectively be used by the surgeon as an additional guide to locate the exact center of the femoral and tibial tunnel placement. [16][17][18] C-arm is ubiquitously present in an orthopaedic theatre and all orthopaedic surgeons and technicians are familiar with its application. Just using C-arm is …”

Section: Discussionmentioning

confidence: 99%

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

Kumar

2017

Arthroscopy Techniques

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Many factors determine the outcome of the anterior cruciate ligament reconstruction surgery. The single most important factor, also well within the control of a surgeon, is tunnel placement. It is difficult to accurately determine the center of the anterior cruciate ligament foot print, and many a times it is also difficult to accurately define the intercondylar and bifurcate ridge. This makes determination of the accurate entry point of the guidewire difficult. We have printed our indigenously formed grid (equidistant boxes) on an old-fashioned transparency sheet. We use a fluoroscopy (C-arm) shot intraoperatively in the lateral position and superimpose this sheet to determine the position of the guidewire by calculating the percentage of boxes. We aim at 27.7% in proximal to distal and 37.5% in anterior to posterior on the femur side and 45% in front to back and medial to lateral on the tibial side. C-arm is freely available, but the inbuilt grid facility may be available in only the higher version of C-arms. Our indigenously designed grid can be easily used across the globe with ease to achieve accuracy in tunnel placement without violating anatomy and without any extra cost.

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The effect of intraoperative fluoroscopy on the accuracy of femoral tunnel placement in single-bundle anatomic ACL reconstruction

Abstract: III.

Cited by 23 publications

References 38 publications

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

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

Estudo Da Técnica Intracapsular Assistida Por Artroscopia Para O Tratamento Da Ruptura Do Ligamento Cruzado Cranial Em Cadáveres De Cães

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

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