Original articles
Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts

https://doi.org/10.1016/j.arthro.2004.08.010Get rights and content

Purpose: To develop and evaluate an anatomic reconstruction procedure of the posterolateral and anteromedial bundles of the anterior cruciate ligament (ACL). Type of study: Anatomic study and case series. Methods: The femoral attachment of the anteromedial and posterolateral bundles of the ACL was anatomically analyzed with 5 cadaveric knees. Using another 3 cadaveric knees, anatomic reconstruction of the posterolateral and anteromedial bundles was performed with the transtibial technique, and tunnel positioning and graft function in a range of knee motion was observed. Based on this anatomic study, an anatomic reconstruction procedure of the anteromedial and posterolateral bundles was developed using hamstring tendon autografts. This procedure was carried out in 57 consecutive patients with an ACL-deficient knee. The patients were followed-up for a minimum of 24 months. Results: We developed the arthroscopically assisted anatomic reconstruction procedure of the posterolateral and anteromedial bundles, involving a new method of creating the tibial and femoral tunnels for the posterolateral bundle. To visualize the femoral attachment of the posterolateral bundle, the medial infrapatellar portal was more useful than the lateral portal. In clinical results, the side-to-side difference of anterior laxity averaged 1.0 mm with a standard deviation of 0.9. Conclusions: The anatomic reconstruction of the anteromedial and posterolateral bundles using hamstring tendon autografts is clinically practical in the treatment for the ACL-deficient knee. Level of evidence: Level IV.

Section snippets

Anatomic study

An anatomic study was performed with a total of 8 cadaveric knees. In 5 of the 8 knees, the muscles and the tendons around the joint as well as the capsular ligaments were removed. In the primary observation, the shape and function of the ACL were noted in the various positions of the knee. Then the femur was split in the sagittal plane with an oscillating saw, and the posterior cruciate ligament with the medial half of the femur was resected from the tibial insertion. This exposure allowed us

Anatomic observations

On the medial surface of the lateral femoral condyle, a footprint of the ACL attachment was in the form of an egg with its long axis inclined toward the posterior direction by 30° to the long axis of the femur (Fig 5A). When we drew a vertical line (defined as V-line) through the contact point between the femoral condyle and the tibial plateau on a digital image taken at 90° of flexion, the V-line and the long axis of the ACL attachment were crossed at the point on the vertical line 5 to 8 mm

Discussion

This study demonstrated a new procedure to anatomically reconstruct the anteromedial and posterolateral bundles of the ACL. Concerning tunnel positioning on the femur, the first important point was that we found the following anatomic facts: The footprint on the femur is egg-like in shape, and its long axis inclines toward the posterior direction by 30° to the long axis of the femur. Specifically, the center of the attachment (the PL point) of the posterolateral bundle is located approximately

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    Supported in part by a Grant-in-Aid for Scientific Research (No. 10558124), from the Ministry of Education, Science and Culture of Japan.

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