An audit of tunnel position in anterior cruciate ligament reconstruction

doi:10.1016/S0968-0160(01)00067-9

The Knee

Volume 8, Issue 1, March 2001, Pages 59-63

https://doi.org/10.1016/S0968-0160(01)00067-9 Get rights and content

Abstract

We audited 114 primary anterior cruciate ligament (ACL) reconstructions. Notes were reviewed and tunnel positions assessed on lateral and AP radiographs. A literature review established optimal tunnel position. Sixteen surgeons performed 57 arthroscopic and 57 open reconstructions, using 24 hamstring and 90 bone–tendon–bone autografts. Eighty five sets of radiographs were available for review. Sixty five percent of femoral tunnels and 59% of the tibial tunnels were malpositioned in the sagittal plane. Guidelines for best practice are required for key procedures in each speciality. Tunnel position in ACL reconstruction can be easily measured and should be correct in at least 90% of cases.

Introduction

Tunnel placement is probably the single most important variable that surgeons can influence in achieving a successful outcome in anterior cruciate ligament (ACL) reconstruction. Tunnel misplacement is the most common technical error, which leads to graft failure [1], femoral tunnels placed too anterior, appearing to be the most critical of these errors [2].

In the present healthcare environment in the UK, audit has become an essential part of our working practice. To facilitate audit, standards need to be agreed nationally. Continuous assessment of each individual practice can then be compared with these nationally set standards. This process will promote best practice and attainment of quality outcomes. British standards have not presently been agreed. In the search for the ‘best practice’, the British Association for Surgery to the Knee (BASK) have been asked to devise guidelines for total knee replacement (TKR) and ACL reconstruction.

A literature review established acceptable positions for tunnel placement in ACL reconstruction and we then audited the results obtained in a Regional Centre of Orthopaedics.

Section snippets

Methods

With consent from the consultant surgeons involved, theatre records were searched for primary ACL reconstructions performed between August 1998 and July 1999 (inclusive). The case notes and radiographs of the identified patients were reviewed retrospectively. Patient details, side of injury, type of reconstruction and grade of surgeon were documented. It was noted whether post-operative radiographs were performed. From the available radiographs, femoral tunnel position was measured in the

Results

One hundred and fourteen consecutive cases of primary ACL reconstruction were identified. Of these patients 103 were male and 11 female. There were 59 right knees and 55 left. The median age of the group was 29 years (range 14–57).

Sixteen surgeons (8 consultants and 8 registrars) performed the 114 reconstructions. Fifty seven were arthroscopic and 57 open. Ninety used bone–tendon–bone autografts and 24 hamstring autographs. Femoral tunnel drilling was through the tibial tunnel in 90 and through

Discussion

Tunnel malplacement during an ACL reconstruction is the commonest technical error in a review of revision ACL surgery [1]. Measurement of tunnel placement, on post-operative radiographs, should be routine. It is simple to perform and gives an indication that the ACL graft has been placed correctly. Whilst we accept that this is only one factor in determining the functional outcome after ACL reconstruction it is an important one as the surgeon has control of its accuracy. Functional outcome

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Improperly placed anterior cruciate ligament grafts. correlation between radiological parameters and clinical results
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Cited by (58)

Anterior cruciate ligament reconstruction learning curve study – Comparison of the first 50 consecutive patients of five orthopaedic surgeons during a 5-year follow-up
2023, Knee
The goal of all surgical and orthopaedic training is to ensure necessary education and surgical skills without compromising the quality of operations or patient safety. Anterior cruciate ligament reconstruction (ACLR) is a common multi-staged orthopaedic surgical procedure with a learning curve. Previous studies focus mainly on learning or the learning curve of one surgeon and tunnel placements. The aims of this study were to define the learning curve in arthroscopic ACLRs, define the number of procedures needed before the surgical “knifetime” plateaus, examine the effect of experience on complications, and identify possible individual differences in the surgical learning curve.
The study included the first 50 consecutive ACLR operations of five orthopaedic surgeons, thus, a total of 250 patients. For comparison and statistical analysis, patients were arranged into five groups, each comprising 50 patients (=order group). Order group 1 comprised the first 10 patients operated on by each of the five surgeons, group 2 patients 11–20, group 3 patients 21–30, group 4 patients 31–40, and group 5 the last 10 patients. The learning curve was defined with a LOESS curve. Surgical time and complications, including graft failure and postoperative knee instability, were analysed between order groups and between surgeons.
Median surgical time was 105 (interquartile range 82–124) min. The learning curve showed the first steep decline in surgical time and started to settle slowly after 20 reconstructions. Surgical time was significantly longer when order group 1 was compared with order group 2 (p = 0.031), and when order group 1 was compared separately with order groups 3, 4, and 5 (p < 0.001). Operation order alone explained only 17.1% of the alteration in surgical time. No significant difference emerged in graft failure rate between the order groups or the surgeons. Objective instability of the knee showed a significant difference when order group 1 was compared separately with order group 3 and with order group 4 (p = 0.004). Surgical time differed between surgeons (p < 0.001), and the shape of the learning curve showed great individual variability.
In the first 10 to 20 ACLR operations, the surgical time was longer and the complication rate higher, but thereafter both started to settle down. We recommend that first 10–20 ACLR operations should be supervised.
Grid and Image Intensifier Improve Arthroscopic ACL Tunnel Position and Patient-Reported Outcomes
2023, Arthroscopy, Sports Medicine, and Rehabilitation
To evaluate the accuracy in the femoral and tibial tunnel placement after the use of fluoroscopy along with an indigenously designed grid method to assist in arthroscopic anterior cruciate ligament reconstruction as compared with the tunnel placement without using them and to validate the findings with computed tomography scan performed postoperatively along with assessing the functional outcome at a minimum of 3 years of follow-up.
This was a prospective study conducted on patients who underwent primary anterior cruciate ligament reconstruction. Patients were included and segregated into a nonfluoroscopy (group B) and a fluoroscopy group (group A), and both had postoperative computed tomography scans so that femoral and tibial tunnel position could be evaluated. Scheduled follow-up occurred 3, 6, 12, 24, and 36 months’ postoperatively. Patients were evaluated objectively with the Lachman test, measurement of range of motion, and functional outcome using patient-reported outcome measures, i.e., Tegner Lysholm Knee score, Knee injury and Osteoarthritis Outcome Score, and International Knee Documentation Committee subjective knee score.
A total of 113 subjects were included. There were 53 in group A and 60 in group B. The average location of femoral tunnel showed significant differences between the 2 groups. However, the variability in femoral tunnel location was significantly lower in group A as compared with group B for proximal–distal planes only. The average location of the tibial tunnel as per the grid of Bernard et al. showed significant differences in both the planes. The variability in tibial tunnel was greater in the medial–lateral plane as compared with the anterior–posterior plane. There was a statistically significant difference in mean value of the 3 scores among the 2 groups. The variability of the scores was greater in group B as compared with group A. None of the patient was reported as a failure.
The results of our study suggests that fluoroscopy-guided positioning using a grid technique increases the accuracy of anterior cruciate ligament tunnel positioning with decreased variability and is associated with better patient-reported outcomes 3 years after surgery compared with tunnel positioning using landmarks.
Level II, prospective, comparative therapeutic trial.
Freehand Anatomic Transtibial Single-Bundle Anterior Cruciate Ligament Reconstruction
2022, Arthroscopy Techniques
Creation of the femoral tunnel for single-bundle anterior cruciate ligament (ACL) reconstruction has a high rate of nonanatomic placement with the transtibial (TT) technique but yields better restoration with the anteromedial portal technique and close restoration of the anatomic femoral footprint with the outside-in technique. Modifications of the traditional (TT) technique have been described to restore the native femoral ACL footprint and to simulate double-bundle reconstruction. Modified TT techniques try to capture the anatomic femoral footprint through an anatomic tibial tunnel. In the technique described in this article, the anatomic femoral footprint is drilled first by the use of a 2.5-mm Kirschner wire through the parapatellar anteromedial portal, making an angle 30° to the sagittal plane and 20° to the horizontal plane. The wire is drilled while the knee is hyperflexed and then withdrawn from outside until its distal end reaches the intercondylar notch. The wire is then advanced in an antegrade manner while the knee is flexed 90° until it reaches the center of the marked tibial footprint. The angle of knee flexion may be slightly increased or decreased around 90° with or without slight internal rotation to capture the anatomic tibial footprint. The procedure is completed as a TT single-bundle ACL reconstruction.
A Systematic Review of Anterior Cruciate Ligament Femoral Footprint Location Evaluated by Quadrant Method for Single-Bundle and Double-Bundle Anatomic Reconstruction
2016, Arthroscopy - Journal of Arthroscopic and Related Surgery
To unravel the standard position of anterior cruciate ligament (ACL) femoral origin and deduce practical arthroscopic localization and postsurgical evaluation method.
Two independent reviewers searched PubMed using the terms ACL, footprint, femur, etc. We included studies published since January 1, 2000, in which the results were measured by Bernard's quadrant method. This method consists of 4 distances, including total diameter of lateral condyle along Blumensaat's line (distance t), maximum intercondylar notch height (distance h), distance from center of footprint to proximal border (distance x), and distance from center of footprint to Blumensaat's line (distance y). The data of included studies were combined to calculate theoretical centers and standard area for both ACL as a whole bundle and as anteromedial (AM) and posterolateral (PL) bundles individually. Finally, we translated the combined data to arthroscopic localization and postsurgical evaluation.
A total of 13 studies were included. The theoretical centers of ACL as a whole bundle is 28.4% ± 5.1% (x) of distance t and 35.7% ± 6.9% (y) of distance h, whereas AM bundle is 24.2% ± 4%, 21.6% ± 5.2% (x, y) and PL bundle is 32.8% ± 4.7%, 46.7% ± 4.9% (x, y), respectively. The standard area of ACL footprint is a circle with a center of 27.53%, 35.85% (x, y), and a radius of 4.58%, 9.2% (x, y), respectively. Translation of combined data shows that under arthroscopy, for single-bundle ACL reconstruction, the midpoint of distance from border of proximal to distal articular cartilage is the center of anatomic femoral socket.
Combined data unravel the standard position of ACL femoral origin. It can be used by clinicians to localize anatomic tunnel both in surgery and postsurgical evaluation. For single-bundle ACL reconstruction, the midpoint of lateral femoral condyle corresponds to anatomic socket.
Level V, systematic review of anatomic studies.
Transtibial vs anatomical single bundle technique for anterior cruciate ligament reconstruction: A Retrospective Cohort Study
2016, International Journal of Surgery
Citation Excerpt :
The present study demonstrated that the anatomical single-bundle ACL reconstruction provides better initial stability when compared to the non-anatomical single-bundle ACL reconstruction with the combined anterior and internal rotatory forces. Several studies have extensively examined tunnel position in ACL reconstruction and found that inappropriate graft placement had significant adverse effect on graft incorporation and knee function [11,14–17]. According to the radiographic analysis, the femoral insertion of the anteromedial bundle is located at 66.5% of the intercondylar depth and at 27.6% of the intercondylar height.
Most of the ACL reconstruction is done with isometric single-bundle technique. Traditionally, surgeons were trained to use the transtibial technique (TT) for drilling the femoral tunnel. Our study compared the early postoperative period functional and clinical outcomes of patients who had ACL reconstruction with TT and patients who had ACL reconstruction with anatomical single-bundle technique (AT).
Fifty-five patients who had ACL reconstruction and adequate follow-up between January 2010–December 2013 were included the study. Patients were grouped by their surgery technique. 28 patients included into anatomical single-bundle ACL reconstruction surgery group (group 1) and 27 patients were included into transtibial AC reconstruction group (group 2). Average age of patients in group 1 and group 2 was 28.3 ± 6, and 27.9 ± 6.4, respectively. Lachman and Pivot-shift tests were performed to patients. Laxity was measured by KT-1000 arthrometer test with 15, 20 and 30 pound power. All patients' muscle strength between both extremities were evaluated with Cybex II (Humac) at 60°/sec, 240°/sec frequencies with flexion and extension peak torque. The maximum force values of non-operated knee and the operated knee were compared to each other. Groups were evaluated by using International Knee Documentation Committee (IKDC) knee ligament healing Standard form, IKDC activity scale, modified Lysholm and Cincinnati evaluation forms. Return to work and exercise time of patients were compared. Functional and clinical outcomes of two groups were compared. NCSS 2007 and PASS 2008 Statistical Software programs were used for statistical analysis.
There was no statistically significant difference between Lachman and Pivot-shift results (p > 0.01). Positive value of Pivot-shift test and incidence of anterior translation in Lachman test were higher in the patients who had TT. Lysholm activity level of patients who had TT, 33.3% (n = 9) were excellent, 51.9% (n = 14) were good and 14.8% (n = 4) were moderate; patients who had AT, 57.1% (n = 16) were excellent, 39.3% (n = 11) were good and 3.6% (n = 1) was good level. There was no statistically significant difference between Lysholm Activity level of the patients (p < 0.01). Lysholm Activity level of patients who had AT significantly higher than TT. There was no statistically significant difference between Modified Cincinnati activity level of the patients (p < 0.05). Modified Cincinnati activity level of patients who had AT were significantly higher than those had TT. There was no statistically significant difference between two groups with post treatment IKDC activity level (p < 0.01). Intense activity after treatment rate of patient who had AT was significantly higher than those had TT. There was statistically significant difference between Cybex extension-flexion 60 measurement and extension 240 measurement of the patients (p < 0.01). KT-1000 arthrometer test results with AT was better than the TT in antero-posterior translation of the knee kinematics at 20 and 30 pound of forces. Return to exercise time of patients who had TT was significantly higher than those had AT (p < 0.01). There was no statistically significant difference between return to work time of patients (p > 0.05).
Single-bundle anatomic ACL reconstruction was better than the TT in term of clinical, functional, and laboratory results. We believe that AT ACL reconstruction will increase in use and traditional method which is TT ACL reconstruction surgery will decrease in the long term. Theoretically, anatomic relocation of the ACL can provide better knee kinematics.
A radiological comparative study between transtibial & anteromedial portal drilling of femoral tunnel in single bundle anterior cruciate ligament reconstruction: A comparison of four angles
2016, Journal of Arthroscopy and Joint Surgery
Femoral tunnel drilling for graft insertion is performed by transtibial or transportal technique.
Main objective of this study was to compare the postoperative anteroposterior and lateral radiographs after arthroscopic ACL reconstruction by transtibial and transportal techniques by measuring four angles.
A retrospective study of 60 patients was conducted, who were further subdivided into two groups containing 30 each. The first group had patients who had undergone arthroscopic ACL reconstruction by transtibial technique and the second group had patients who had undergone ACL reconstruction by transportal technique. Post-operative anteroposterior radiographs (AP) and lateral radiographs of the operated knees were compared. Condylar tunnel (CT) and tunnel screw (TS) angles were measured in AP radiographs and compared. In lateral radiographs, shaft tunnel (ST) and TS angles were measured and compared. ‘Student t-test’ was used in calculating the results.
Mean of the angles measured were tabulated and compared. CT angle was noted to be more acute in transportal group (38.4 ± 8.756°) as compared to transtibial group (46.97 ± 12.754°) with a significant ‘p-value’ (0.004). ST angle was noted to be more obtuse in the transportal group (119.57 ± 11.212°) as compared to transtibial group (113.17 ± 12.793°) with a significant ‘p-value’ (0.044).
This infers that transportal technique oriented the graft more horizontal as compared to transtibial technique.
Tunnel screw angles when compared in AP radiographs showed that transportal technique (5.5 ± 4.644°) had more acute angulation as compared to transtibial group (12.57 ± 8.287°) with a significant ‘p-value’ (<0.001). Same results were obtained when the lateral views were compared between transportal (9.27 ± 8.25°) and transtibial technique (23.73 ± 12.174°) with a significant ‘p-value’ (<0.001). This indicated reduced screw tunnel divergence in transportal technique as compared to transtibial technique.
Transportal technique results in a more anatomical femoral tunnel placement as compared to transtibial technique.

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An audit of tunnel position in anterior cruciate ligament reconstruction

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Arthroscopy

Arthroscopy

Arthroscopy

Failed anterior cruciate ligament reconstruction

J Bone Joint Surg [Br]

Improperly placed anterior cruciate ligament grafts. correlation between radiological parameters and clinical results

Knee Surg, Sports Traumatol, Arthrosc