The use of intra-operative fluoroscopy for tibial tunnel placement in anterior cruciate ligament reconstruction

Abstract

ObjectivesOur aim was to assess the use of intra-operative fluoroscopy in the assessment of the position of the tibial tunnel during reconstruction of the anterior cruciate ligament (ACL).MethodsBetween January and June 2009 a total of 31 arthroscopic hamstring ACL reconstructions were performed. Intra-operative fluoroscopy was introduced (when available) to verify the position of the guidewire before tunnel reaming. It was only available for use in 20 cases, due to other demands on the radiology department. The tourniquet times were compared between the two groups and all cases where radiological images lead to re-positioning of the guide wire were recorded. The secondary outcome involved assessing the tibial interference screw position measured on post-operative radiographs and comparing with the known tunnel position as shown on intra-operative fluoroscopic images.ResultsOf the 20 patients treated with fluoroscopy, the imaging led to repositioning of the tibial guide wire before reaming in three (15%). The mean tourniquet time with intra-operative fluoroscopy was 56 minutes (44 to 70) compared with 51 minutes (42 to 67) for the operations performed without. Six patients (30%) had post-operative screw positions that were > 5% more posterior than the known position of the tibial tunnel.ConclusionIntra-operative fluoroscopy can be effectively used to improve the accuracy of tibial tunnel positions with minimal increase in tourniquet time. This study also demonstrates the potential inaccuracy associated with plain radiological assessment of tunnel position.

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

“…Although the technique is reliant on obtaining a true lateral image of the knee (with condyles overlapping), 9 radiation exposure to surgeon and patient is low, 17,39 and there is a minimal increase in operative time. 29,38 Its routine clinical use has been shown to improve accuracy in tunnel placement, 31 yet it was the least frequently used tunnel localization strategy in our study. The use of fluoroscopy may be particularly useful in revision cases, where arthroscopic landmarks may be distorted, and for surgeons adopting a new ACL reconstruction technique.…”

Femoral and Tibial Graft Tunnel Parameters After Transtibial, Anteromedial Portal, and Outside-In Single-Bundle Anterior Cruciate Ligament Reconstruction

“…The anteroposterior femoral and tibial tunnel position was reported to be the most variable measure between orthopaedic surgeons, 40 and graft orientation in the coronal and sagittal plane was nonanatomic and too vertical in 88% of revision surgeries after primary ACL reconstruction with subsequent failure. 24 Intraoperative fluoroscopy and postoperative CT scans have therefore been recommended to improve the accuracy of tunnel placement 11,35 and to allow for positive feedback loops and a process of individual improvement. 12 In contrast to the measurement grid system used by Gadikota et al 10 and Shin et al, 30 our reference system is based on more direct and easily accessible landmarks in 2-dimensional imaging, which might facilitate a transfer of our in vivo results of ACL tunnel placement to intraoperative quality validation via fluoroscopy.…”

“…| | Intraoperative fluoroscopy has been favored by some authors as a practical real-time method to verify correct ACL tunnel positions. 11,12,35 Most investigators have used measurement grid methods and reference values applied to plain radiographs and 3-dimensional computed tomography (3D CT) scans to document ACL tunnel placement. In vivo and in vitro comparisons of the TT and AMP techniques have found differences in insertion site coverage, 28 tunnel axis, 25,33 and tunnel length, 38 as well as a more anatomic tunnel position 2,17 and a higher incidence of a posterior femoral tunnel exit 10 with AMP reconstruction.…”

Radiological evaluation of tunnel position in single bundle anterior cruciate ligament reconstruction in the Indian population and their clinical correlation

“…15 One way of making guidewire placement less subjective is by using intraoperative fluoroscopy to cross-check the guidewire's position. 16,17 The standard radiographic position of tunnels described in the literature is mostly based on western population. 2,6,11,18,19 To customize this concept to the Indian population there is insufficient information available in the literature.…”