Tunnel collision during simultaneous anterior cruciate ligament and posterolateral corner reconstruction

Abstract

Drilling PLT and FCL femoral tunnels at 20° axial/20° coronal angulation is a safe positioning for simultaneous ACL and PLC reconstructions. However, in smaller knees, the risk for tunnel collision could be greater. Surgeons should consider the possibility of tunnel collision when performing simultaneous ACL and PLC anatomical reconstruction, especially in knees with a small LFC width where the risk for tunnel collision could be greater.

Multiple Ligament Reconstruction Femoral Tunnels: Intertunnel Relationships and Guidelines to Avoid Convergence

“…Posterolateral corner injuries rarely occur in isolation, and persistent posterolateral corner instability increases the risk of cruciate reconstruction graft failure. 24,25 Our results are supported by previous studies that reported a high risk of tunnel convergence during concomitant ACL and posterolateral corner reconstructions when the FCL tunnels were drilled in a neutral orientation (0°in the axial and coronal planes) 3,13,33,37 ; previous studies reported that aiming the FCL tunnels anteriorly reduced the risk of tunnel convergence, while the additional proximal orientation of the FCL tunnels 20°was reported to further increase the risk of convergence with the ACL tunnel. The anterior angulation was heterogeneous between studies; however, our results suggest that angles from 35°to 40°are safe to avoid tunnel convergence, obtain the desired tunnel length, and avoid violation of the intercondylar notch and trochlea.…”

“…32 Different angles have been suggested in the literature for both medial-sided 4,16 and lateral-sided reconstructions. 3,13,15,20,37 However, to our knowledge, there is no available literature concerning the optimal tunnel orientation for multiple knee ligament reconstructions of all 4 primary ligamentous structures: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and posteromedial and posterolateral corners. The aim of our study was to determine the optimal tunnel orientation in the femur when performing multiple ligament knee reconstructions to achieve the desired tunnel length while avoiding tunnel convergence.…”

Surgical Management of the Multiple-Ligament Knee Injury

“… 45 Moreover, individual factors such as small lateral femoral condylar width may increase the risk of tunnel convergance and even femoral condyle fractures. 11 , 46 …”

“…However, with evolving surgical techniques, additional problems developed, including tunnel convergence, either on the lateral or medial side of the knee, involving cruciate and collateral ligament reconstructions. 10 , 11 Furthermore, with revision rates of multiligament injured knees nearing 9%, the importance of bone stock preservation for potential future surgeries cannot be overstated. 3 , 12 …”

Biomechanical study of strength and stiffness of the knee anterolateral ligament

“…However, according to biomechanical studies, fixation with interference screws is more resistant [ 38 ]. The use of anchors for fixation would avoid creating one more bone tunnel in addition to the ACL tunnel, which would avoid the convergence problem that exists, for example, in combined reconstructions of the ACL and the posterolateral corner structures [ 39 , 40 ]. Furthermore, because of the anatomical proximity between the ALL and the LCL, a lateral tunnel at the anatomical point of the ALL could cause an iatrogenic injury of the femoral insertion site of the LCL [ 1 – 6 , 41 ].…”