Tunnel Convergence Rate in Combined Anteromedial Portal Anterior Cruciate Ligament and Anterolateral Structure Reconstructions Is Influenced by Anterior Cruciate Ligament Knee Flexion Angle, Tunnel Position, and Direction

Editorial Commentary: Lateral Extra-Articular Tenodesis Reduces Anterior Cruciate Ligament Graft Rerupture Rates: Proper Anterior Cruciate Ligament and Lateral Extra-Articular Tenodesis Technique Is Vital to Prevent Complications

“…Kittl et al focus on potential conflict of tunnels for ACL reconstruction and supplemental LETda topic of particular importance and interest. 3 To avoid any confusion, I believe in ilio-tibial band (ITB)related restraint of ALRI, and hence, ITB-based surgery, and not in the "anterolateral ligament" or related surgical techniques. 4 London, United Kingdom The author reports no conflicts of interest in the authorship and publication of this article.…”

“…When longer implants or tunnels are used, the orientation should be directed at least 30 anteriorly in the axial plane to minimize the risk of tunnel conflict. 8 Kittl et al 3 studied the effect of the drilling angle for the LET femoral tunnel on conflict with the ACL femoral tunnel, drilled via the AM portal, placed in the central femoral footprint ("anatomic") position. Despite the different position of the femoral tunnel, their advice is similar to ours in the cadaveric study above.…”

“…Despite the different position of the femoral tunnel, their advice is similar to ours in the cadaveric study above. 8 As well as this variable, Kittl et al 3 also studied the effects of varying knee flexion angle at which the ACL femoral tunnel was drilled and conclude that deeper angles of knee flexion (130-140 ) make tunnel conflict more likely. The corollary is that when LET is being used, a lower flexion angle should be employed for drilling the femoral ACL tunnel.…”

“…Finally, Kittl et al 3 consider the impact of varying the LET attachment site on the femur. Because of the pulley-like effect of the LCL attachment to the femur, an attachment site for an LET taken anteriorly will maintain the biomechanical efficacy of the LET.…”

The Biomechanical Stability of Bone Staples in Cortical Fixation of Tendon Grafts for Medial Collateral Ligament Reconstruction Depends on the Implant Design

“…3,5 However, the creation of the required bony socket may lead to converging tunnels, especially in multiligament knee reconstruction or in combination with osteotomy around the knee. 12,16,17,29 The use of bone staples (BSs) as an extracortical fixation device offers the advantage of a simplified operative procedure, as BSs do not require a large tunnel for peripheral ligament reconstruction. Other possible advantages of BS fixation are the lower costs per implant in comparison…”