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Liu W, Wu Y, Wang X, Kuang S, Su C, Xiong Y, Tang H, Xiao Y, Meng J, Gao S. Reliability of the Tibial Spine Versus ACL Stump in Assisting Tibial Tunnel Positioning During ACL Reconstruction: Analysis Based on 3-Dimensional Computed Tomography Modeling. Orthop J Sports Med 2023; 11:23259671231208678. [PMID: 37954861 PMCID: PMC10638886 DOI: 10.1177/23259671231208678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 11/14/2023] Open
Abstract
Background Several techniques have been used by surgeons for anatomic tibial tunnel placement in anterior cruciate ligament (ACL) reconstruction, including the ACL stump positioning (ASP) technique and the tibial spine positioning (TSP) technique. Purpose/Hypothesis The purpose of this study was to evaluate whether bony landmarks (medial and lateral tibial spine [MLTS]) can be a reliable reference for improving the accuracy of tibial tunnel placement in anatomic single-bundle ACL reconstruction compared with the ACL stump. It was hypothesized that the MLTS would not be a reliable bony landmark for tibial tunnel placement. Study Design Cohort study; Level of evidence, 3. Methods The 3-dimensional computed tomography images of 111 patients who underwent ACL reconstruction between 2020 and 2021 were included in this study. For tibial tunnel placement, the ASP technique was used in 49 patients, and the TSP technique was used in 62 patients. The 3-dimensional computed tomography images were reconstructed to enable measurements of the locations of the MLTS and tunnel center based on a grid method. Statistical analysis was conducted to compare the MLTS location and tibial tunnel position as well as the accuracy (mean distance of each actual location from the anatomic center) and precision (standard deviation of the accuracy, indicating the reproducibility of the tunnel position) of the tunnel position between the ASP and TSP groups. Results Significant differences were observed between the ASP and TSP groups in terms of the tibial tunnel position on the mediolateral axis (46.7% ± 2.0% vs 45.9% ± 2.2%, respectively; P = .034), while no significant differences were found in terms of the accuracy (4.1% vs 4.6%, respectively; P = .259) or precision (2.1% vs 2.1%, respectively; P = .259) of tibial tunnel positioning between the 2 groups. Conclusion In anatomic single-bundle ACL reconstruction, the use of the MLTS for tibial tunnel placement achieved comparable accuracy and precision compared with the use of ACL remnants, supporting its role as a reliable bony landmark in tibial tunnel positioning.
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Affiliation(s)
- Weijie Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yumei Wu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaopeng Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Shida Kuang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Su
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yiling Xiong
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
- Hunan Engineering Research Center of Osteoarthritis, Changsha, China
| | - Hang Tang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yifan Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jiahao Meng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Shuguang Gao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
- Hunan Engineering Research Center of Osteoarthritis, Changsha, China
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Iwaasa T, Tensho K, Takahashi T, Koyama S, Shimodaira H, Horiuchi H, Takahashi J. Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction With Suture Augmentation. Arthrosc Tech 2023; 12:e931-e936. [PMID: 37424654 PMCID: PMC10323829 DOI: 10.1016/j.eats.2023.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/12/2023] [Indexed: 07/11/2023] Open
Abstract
Ultra-high molecular weight polyethylene sutures are used for repair and reconstruction of extra-articular ligaments in the knee, elbow, and ankle joints. In recent years, the use of these sutures has become popular in a suture augmentation technique and has been applied for use in the reconstruction of the anterior cruciate ligament, which is an intra-articular ligament. Although several surgical techniques have been described in Technical Notes, all reports have been for single-bundle reconstruction, and none have applied the technique to double-bundle reconstruction. This Technical Note provides a detailed description of an anatomical double-bundle anterior cruciate ligament reconstruction combined with the suture augmentation technique.
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Affiliation(s)
- Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Tsuneari Takahashi
- Department of Orthopedic Surgery, Ishibashi General Hospital, Shimotsuke, Tochigi, Japan
| | - Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Hiroshi Horiuchi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Nakanishi Y, Nagai K, Kay J, Zakharia A, Nukuto K, Hoshino Y, Matsushita T, Kuroda R, de Sa D. The incidence of tibial tunnel coalition is higher than femoral tunnel coalition in double-bundle anterior cruciate ligament reconstruction using hamstring autografts: A systematic review. Orthop Traumatol Surg Res 2022; 108:103407. [PMID: 36122878 DOI: 10.1016/j.otsr.2022.103407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 01/30/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Intra-operative and postoperative coalition of tunnels may occur in double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). However, the incidence and effect on clinical outcomes of tunnel coalition following primary DB ACLR using a hamstring autograft has yet be analyzed, and thus remains unknown. The objective of this systematic review was to identify the incidence of tunnel coalition upon DB ACLR using hamstring autografts and to elucidate any clinical outcomes and/or complications that tunnel coalition may have postoperatively. HYPOTHESIS The incidence of tunnel coalition would increase in respect to time from the index surgery, and that tunnel coalition would be related to poorer clinical outcomes compared to non-coalition cases. METHODS Three databases (PubMed, EMBASE, Cochrane Library) were searched in accordance with PRISMA and R-AMSTAR guidelines on June 15, 2020. Relevant studies were screened in duplicate and data regarding patient demographics, incidence of femoral and tibial tunnel coalition, and outcomes were extracted. Coalition rate was also compared between follow up at 1 month or less defined as "shorter-term", and 6 months or greater as "longer-term". Coalition is defined as the missing of a bony bridge between the two tunnels. RESULTS Thirty-six studies examining 1,574 patients, mean age 29.1 years, were included in this study. 29 studies (1,110 knees) reported the incidence of femoral coalition with a pooled rate of coalition of 8% (95% CI=4-12%). 28 studies (1,129 knees) reported an incidence of tibial coalition with a pooled rate of coalition of 21% (95% CI=13-30%). The incidence of tibial coalition was significantly higher than the incidence of femoral coalition across 21 comparative studies (OR=3.37, 95% CI=1.41-8.09, p=0.0065). Only two studies (111 knees) compared tunnel coalition and non-coalition groups for clinical outcome and no significant differences were observed with regards to Lysholm score, Tegner activity scale, and knee laxity measured with a KT-1000 arthrometer. DISCUSSION The rate of tibial tunnel coalition in DB ACLR is higher than femoral tunnel coalition, particularly at longer-term follow-up. Despite the higher radiographic evidence of coalition, the clinical effects of such remain to be ascertained, and further comparative studies are required to facilitate this understanding. LEVEL OF EVIDENCE IV, systematic review.
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Affiliation(s)
- Yuta Nakanishi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | | | - Koji Nukuto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
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Shimodaira H, Tensho K, Koyama S, Iwaasa T, Kumaki D, Yoshida K, Horiuchi H, Takahashi J. Effect of a new remnant-preserving technique with anatomical double-bundle anterior cruciate ligament reconstruction on MRI-based graft maturity: a comparison cohort study. Knee Surg Sports Traumatol Arthrosc 2022; 31:2394-2405. [PMID: 36181522 DOI: 10.1007/s00167-022-07180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To investigate the effects of a new remnant-preserving double-bundle anterior cruciate ligament reconstruction (ACLR) technique, focused on avoiding remnant damage and preserving continuity of remnants, on graft maturity using magnetic resonance imaging (MRI). METHODS A total of 169 patients were divided into three groups: 41 in the preservation group, 70 in the resection group, and 58 in the absent group. In the preservation group, rather than passing the graft through the remnant tissue, the graft was reconstructed such that the anteromedial and posterolateral bundles sandwiched the remnant to avoid damage to the remnant and maintain its continuity. Based on 1-year postoperative MRI, the grafts were divided into three regions: distal, middle, and proximal. The signal/noise quotient (SNQ) of each region of interest was calculated to evaluate the signal intensity of the graft and was compared among the three groups. Additionally, to identify factors influencing graft maturity, a multiple regression analysis was performed with SNQ as the dependent variable and patient demographics, bone morphology, and surgical factors as independent variables. RESULTS In a three-group comparison of mean SNQs, the distal region was 3.3 ± 3.4, 8.9 ± 8.3, and 9.0 ± 8.6 (p < 0.001), the middle region was 5.3 ± 3.7, 10.9 ± 11.1, and 11.3 ± 10.2 (p < 0.001), and the proximal region was 6.8 ± 4.5, 11.1 ± 8.8, and 11.7 ± 10.8 (p = 0.017), in order of the preservation, resection, and absent groups, respectively. That indicated that the remnant-preserving ACLR was more hypointense than ACLR with remnant resection or absent in all three regions. Multiple regression analysis showed that remnant preservation remained the relevant factor affecting SNQ of the graft at the distal and middle levels. CONCLUSION The new remnant-preserving anatomic double-bundle ACLR had significantly better graft maturity, measured by SNQ on MRI, than the remnant resection and absent groups. The remnant procedure was the relevant factor affecting graft maturity. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Daiki Kumaki
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kazushige Yoshida
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroshi Horiuchi
- Department of Rehabilitation, Shinshu University Hospital, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
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Koyama S, Tensho K, Shimodaira H, Iwaasa T, Kumaki D, Horiuchi H, Saito N, Takahashi J. A new remnant preservation technique reduces bone tunnel enlargement after anatomic double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:2020-2028. [PMID: 35122109 DOI: 10.1007/s00167-022-06882-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the effect of a new remnant preservation technique with a focus on remnant continuity on postoperative femoral and tibial tunnel enlargement after anatomical double-bundle anterior cruciate ligament reconstruction (ACLR). METHODS A total of 150 knees were divided into three groups: Preservation Group (Group P: 49 knees), wherein the remnant continuity remained after tunnel creation; Resection Group (Group R: 47 knees), wherein the remaining remnant was resected, and Absent Group (Group A: 54 knees), wherein the remnant had no femoral attachment before tunnel creation. In Group P, the remnant maintained continuity, and the anteromedial (AM) and posterolateral (PL) bundles were positioned anterior and posterior to the remnant, respectively. Computed tomographic scans were performed at 1 week and 1 year after surgery, and the cross-sectional area of each tunnel aperture was measured. Tunnel enlargement was compared among the three groups by one-way analysis of variance (ANOVA) and the Bonferroni test. Univariate and multivariate logistic analyses were performed to identify the risk factors for tunnel enlargement in demographic and radiographic data. RESULT For femoral AM tunnels, the tunnel enlargement of Group P was significantly smaller than Groups R and A (p < 0.001), femoral PL (p < 0.001 vs. R and A), tibial AM (p < 0.001 vs. R, 0.002 vs. A), and tibial PL (p < 0.001 vs. R, 0.002 vs. A). There was no significant difference between Groups R and A. Multivariate logistic analysis showed that remnant preservation was a significant factor in reducing tunnel enlargement in the femoral AM, femoral PL, tibial AM, and tibial PL. CONCLUSION The new remnant-preserving anatomical double-bundle ACLR, which preserves the continuity of the remnant, prevented all bone tunnel enlargement at 1 year postoperatively. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Daiki Kumaki
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroshi Horiuchi
- Department of Rehabilitation, Shinshu University Hospital, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Naoto Saito
- Institute for Biomedical Sciences, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
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Iwaasa T, Tensho K, Koyama S, Shimodaira H, Horiuchi H, Saito N, Takahashi J. Clinical outcome of a new remnant augmentation technique with anatomical double-bundle anterior cruciate ligament reconstruction: Comparison among remnant preservation, resection, and absent groups. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 25:22-29. [PMID: 34141592 PMCID: PMC8167804 DOI: 10.1016/j.asmart.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 03/21/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022]
Abstract
Purpose The aim of this study was to verify the effects of a new remnant augmentation technique with anatomical double-bundle anterior cruciate ligament (ACL) reconstruction for postoperative clinical scores, anterior stability and frequency of complications compared to remnant removal and cases with remnant defects. Methods The 105 patients who underwent anatomical double-bundle ACL reconstruction were divided into three groups. If the remnant was a Crain I-III type, remnant-preserving bone tunnel creation was attempted. After the creation of the bone tunnel, good continuity was maintained in 34 patients (preserved group). Due to lost continuity, the remnant was resected in 26 patients (resected group). No identifiable remnant continuity remained (Crain IV) in 45 patients (absent group). The Lysholm knee score, Tegner activity scale, International Knee Documentation Committee (IKDC) subjective score, anterior stability measured using the KT-1000 arthrometer at 2 years postoperatively, and frequency of complications were compared among the three groups. Univariate and multiple linear regression analysis were performed to clarify the factors affecting postoperative anterior stability. Results The Lysholm knee score, Tegner activity scale, IKDC subjective score, and frequency of complications were not significantly different among the groups. The mean side-to-side difference of anterior stability was significantly better in the preserved group (0.3 ± 1.6 mm) compared to the resected group (1.6 ± 2.3 mm, p = 0.003) and absent group (1.6 mm ± 1.7, p = 0.009). The multiple linear regression analysis showed remnant preservation significantly related to postoperative anterior stability. Conclusion Although there were no differences in clinical scores, the ACL reconstruction with new preservation technique showed good anterior stability and no difference in the frequency of complications.
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Affiliation(s)
- Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan
| | - Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroshi Horiuchi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan
| | - Naoto Saito
- Institute for Biomedical Sciences, Interdisciplinary Cluster for Cutting Edge Research, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan
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Remnant preservation does not affect accuracy of tibial tunnel positioning in single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:1157-1163. [PMID: 32602038 DOI: 10.1007/s00167-020-06125-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 06/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Remnant preservation, in anterior cruciate ligament (ACL) reconstruction, has potential biological advantages. However, graft positioning remains vital to functional outcome and the prevention of failure. The aim of this study was to investigate the accuracy and precision of tibial tunnel positioning in remnant preservation single-bundle hamstring reconstruction. METHODS Fifty consecutive adult patients, with isolated ACL rupture, were recruited to a prospective study. Remnant preservation was performed in all cases where > 25% of the native ACL was present. Three-dimensional computer tomography was preformed 3-6 months post-operatively to assess tibial tunnel position (using a grid-based measurement). Accuracy and precision of this technique were assessed against published anatomical data in direct comparison with the group where remnant preservation could not be performed. RESULTS Two patients withdrew following surgery. In the remaining groups (31 remnant preservation; 17 non-remnant preservation), no difference was demonstrated in tunnel position (40.4 ± 6.7% (anterior-to-posterior) and 47.4 ± 1.5% (medial-to-lateral) vs. 38.8 ± 4.9% and 46.7 ± 1.5%, respectively; n.s.), accuracy (6.1% vs. 4.8%; n.s.) or precision (3.9% vs. 2.8%; n.s.). CONCLUSIONS Remnant preservation can be safely performed without compromising tunnel position. Therefore, the potential benefits of this technique can be utilised, in clinical practice, without sacrificing the ability to optimize tibial tunnel positioning. LEVEL OF EVIDENCE III.
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Montreuil J, Saleh J, Cresson T, De Guise JA, Lavoie F. Tibial Tunnel Placement in ACL Reconstruction Using a Novel Grid and Biplanar Stereoradiographic Imaging. Orthop J Sports Med 2021; 9:2325967121989369. [PMID: 34250158 PMCID: PMC8239338 DOI: 10.1177/2325967121989369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Nonanatomic graft placement is a frequent cause of anterior cruciate ligament
reconstruction (ACLR) failure, and it can be attributed to either tibial or
femoral tunnel malposition. To describe tibial tunnel placement in ACLR, we
used EOS, a low-dose biplanar stereoradiographic imaging modality, to create
a comprehensive grid that combines anteroposterior (AP) and mediolateral
(ML) coordinates. Purpose: To (1) validate the automated grid generated from EOS imaging and (2) compare
the results with optimal tibial tunnel placement. Study Design: Descriptive laboratory study. Methods: Using EOS, 3-dimensional models were created of the knees of 37 patients who
had undergone ACLR. From the most medial, lateral, anterior, and posterior
points on the tibial plateau of the EOS 3-dimensional model for each
patient, an automated and personalized grid was generated from 2 independent
observers’ series of reconstructions. To validate this grid, each observer
also manually measured the ML and AP distances, the medial proximal tibial
angle (MPTA), and the tibial slope for each patient. The ideal tibial tunnel
placement, as described in the literature, was compared with the actual
tibial tunnel grid coordinates of each patient. Results: The automated grid metrics for observer 1 gave a mean (95% CI) AP depth of
54.7 mm (53.4-55.9), ML width of 75.0 mm (73.3-76.6), MPTA of 84.9°
(83.7-86.0), and slope of 7.2° (5.4-9.0). The differences with corresponding
manual measurements were means (95% CIs) of 2.4 mm (1.4-3.4 mm), 0.5 mm
(–1.3 to 2.2 mm), 1.2° (–0.4° to 2.9°), and –0.4° (–2.1° to 1.2°),
respectively. The correlation between automated and manual measurements was
r = 0.78 for the AP depth, r = 0.68
for the ML width, r = 0.18 for the MPTA, and
r = 0.44 for the slope. The center of the actual tibial
aperture on the plateau was a mean of 5.5 mm (95% CI, 4.8-6.1 mm) away from
the referenced anatomic position, with a tendency toward more medial
placement. Conclusion: The automated grid created using biplanar stereoradiographic imaging provided
a novel, precise, and reproducible description of the tibial tunnel
placement in ACLR. Clinical Relevance: This technique can be used during preoperative planning, intraoperative
guidance, and postoperative evaluation of tibial tunnel placement in
ACLR.
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Affiliation(s)
- Julien Montreuil
- Laboratoire de recherche en Imagerie et Orthopédie de l'ETS, Montréal, Québec, Canada.,McGill Division of Orthopaedic Surgery, Montreal General Hospital, Montréal, Québec, Canada
| | - Joseph Saleh
- Faculté de Médecine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Thierry Cresson
- Laboratoire de recherche en Imagerie et Orthopédie de l'ETS, Montréal, Québec, Canada
| | - Jacques A De Guise
- Laboratoire de recherche en Imagerie et Orthopédie de l'ETS, Montréal, Québec, Canada
| | - Frédéric Lavoie
- Service de chirurgie orthopédique, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Cremer P, Peltier A, Maubisson L, Neyret P, Lustig S, Servien E. Positioning of the Tibial Tunnel After Single-Bundle ACL Primary Reconstruction on 3D CT scans: A New Method. Arthrosc Sports Med Rehabil 2020; 2:e615-e622. [PMID: 33135002 PMCID: PMC7588642 DOI: 10.1016/j.asmr.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 07/16/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To assess intra-articular tunnel aperture positioning after primary anterior cruciate ligament (ACL) reconstruction with either the reference standard method or the intercondylar area method in a single center using 3-dimensional (3D) computed tomography (CT) scans and to evaluate the intra-articular position of the tibial tunnel relative to the ACL footprint. Methods 3D CT scans were performed after 120 single-bundle primary ACL reconstruction cases. The center of the tibial tunnel aperture and the center of the ACL footprint were referenced on axial views of the tibial plateau in the anteroposterior (AP) and mediolateral (ML) planes according to a centimetric grid system including the whole plateau (reference standard). This was compared with a grid system based on intercondylar area bony anatomy. The posterior aspect of intertubercular fossa, anterior aspect of the tibial plateau, medial intercondylar ridge, and crossing point between lateral intercondylar ridge and posterior margin were used as landmarks to define the grid. Results According to the reference standard method, the center of the tibial tunnel aperture was positioned 0.57 ± 2.62 mm more posterior and 0.67 ± 1.55 mm more medial than the center of the footprint. According to the intercondylar area method, the center of the tibial tunnel aperture was positioned 1.32 ± 2.74 mm more posterior and 0.66 ± 1.56 mm more medial than the center of the footprint. The position difference between the center of the tunnel aperture and the center of the footprint were statistically correlated for both grids, with r = –0.887, P < .001 for AP positioning and r = 0.615, P < .001 for ML positioning. Conclusion This intercondylar area method using arthroscopic landmarks can be used to assess tunnel placement on 3D CT scans after ACL reconstruction. Level of Evidence III, retrospective comparative study.
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Affiliation(s)
| | | | | | - Philippe Neyret
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
| | | | - Elvire Servien
- Centre Albert Trillat, Hôpital de la Croix Rousse, Lyon, France
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10
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Tensho K, Iwaasa T, Shimodaira H, Koyama S, Horiuchi H, Takahashi J, Saito N. Anatomical Remnant-Preserving Double-Bundle ACL Reconstruction With a New Remnant Augmentation Technique. Arthrosc Tech 2020; 9:e283-e290. [PMID: 32099783 PMCID: PMC7029215 DOI: 10.1016/j.eats.2019.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/13/2019] [Indexed: 02/03/2023] Open
Abstract
Anterior cruciate ligament (ACL) remnant preservation techniques have been recently introduced for covering the graft with remnant to improve the clinical results of ACL reconstruction. Several theoretical advantages exist for this technique; however, clinical results remain inconsistent and controversial. We have focused on the biomechanical function of the remnant and have been performing a new remnant-preserving reconstruction procedure that augments the graft with residual remnant. Preserving the structure and continuity of good-quality remnants may help maintain the early postoperative stress on the tendon graft, thereby providing a positive effect on remodeling. Although our concept is significantly different from previously reported remnant preservation techniques and has several pitfalls, the surgical technique that we outline in this report is simple and does not require specialized equipment. The procedure will also work more advantageously in preserving the residual mechanoreceptors in the remnant. We believe that this method can be a procedure with better results for patients with remnants that are in good condition.
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Affiliation(s)
- Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan,Address correspondence to Keiji Tensho, Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan.
| | - Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Horiuchi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoto Saito
- Institute for Biomedical Sciences, Interdisciplinary Cluster for Cutting Edge Research, Shinshu University School of Medicine, Matsumoto, Japan
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11
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Tensho K, Iwaasa T, Koyama S, Yoshida K, Shimodaira H, Horiuchi H, Kato H, Saito N, Fukushima N. The interrelationship between anterior cruciate ligament tibial footprint and anterolateral meniscal root insertions: Quantitative, morphological and positional analyses using three-dimensional computed tomography images. Knee 2019; 26:969-977. [PMID: 31375445 DOI: 10.1016/j.knee.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 06/18/2019] [Accepted: 07/03/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate quantitative, morphological and positional differences between the anterior cruciate ligament (ACL) tibial footprint and anterolateral meniscal root (ALMR) insertion and investigate an intraoperative landmark to estimate their boundaries. METHODS Thirty-three fixed human cadaveric knees were evaluated. After resecting the components, the anterior fiber (AF) and posterior fiber (PF) of ALMR, the tibial center of ACL bundles (anteromedial (AM) and posterolateral (PL) bundles) and ACL were marked. Insertion morphology was classified into three categories, and the distance and relative positional relationship between AF/PF insertions and the center of each attachment were measured on three-dimensional computed tomography images. RESULTS There was no significant difference between the AF of AM and ACL (P = 0.16), but both were significantly shorter than the AF of PL (both P < 0.001). There was no significant difference between the PF of ACL and PL (P = 0.99), which were significantly shorter than PF of AM (both P < 0.001). Morphology of the ACL tibial insertion was classified as follows: triangular, 15 knees (45.5%); oval, 18 knees (54.5%); none, C-shape. Quantitative and positional analyses showed that the AF insertion was significantly closer to AM and ACL centers in the oval type than in the triangular type. Excluding two cases, the AF/PF insertion was located laterally to the ML center of the medial and lateral intercondylar tubercles. CONCLUSION Proximity of ACL tibial footprint and ALMR varies by their footprint morphology. The medial and lateral intercondylar tubercles were useful landmarks for ALMR injury prevention.
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Affiliation(s)
- Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan.
| | - Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Kazushige Yoshida
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroshi Horiuchi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroyuki Kato
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Naoto Saito
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Nanae Fukushima
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
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12
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Tachibana Y, Shino K, Mae T, Iuchi R, Take Y, Nakagawa S. Anatomical rectangular tunnels identified with the arthroscopic landmarks result in excellent outcomes in ACL reconstruction with a BTB graft. Knee Surg Sports Traumatol Arthrosc 2019; 27:2680-2690. [PMID: 30460396 DOI: 10.1007/s00167-018-5300-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 11/13/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE To elucidate tunnel locations and clinical outcomes after anatomic rectangular tunnel (ART) anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) graft. METHODS Sixty-one patients with a primary unilateral ACL injury were included. Tunnels were created inside the ACL attachment areas after carefully removing the ACL remnant and clearly identifying the bony landmarks. Using 3-dimensional computed tomography (3-D CT) images, the proportion of the tunnel apertures to the anatomical attachment areas was evaluated at 3 weeks. The clinical outcomes were evaluated at 2 years postoperatively. RESULTS Geographically, the 3-D CT evaluation showed the entire femoral tunnel aperture; at least 75% of the entire tibial tunnel aperture area was consistently located inside the anatomical attachment areas surrounded by the bony landmarks. In the International Knee Documentation Committee (IKDC) subjective assessment, all patients were classified as 'normal' or 'nearly normal'. The Lachman test and pivot-shift test were negative in 98.4% and 95.1% of patients, respectively. The mean side-to-side difference of the anterior laxity at the maximum manual force with a KT- 1000 Knee Arthrometer was 0.2 ± 0.9 mm, with 95.1% of patients ranging from - 1 to + 2 mm. CONCLUSION By identifying arthroscopic landmarks, the entire femoral tunnel aperture and at least 75% of the entire tibial tunnel aperture area were consistently located inside the anatomical attachment areas. With properly created tunnels inside the anatomical attachment areas, the ART ACLR using a BTB graft could provide satisfactory outcomes both subjectively and objectively in more than 95% of patients. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Yuta Tachibana
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan.
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ryo Iuchi
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Yasuhiro Take
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Shigeto Nakagawa
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
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13
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Kodama Y, Furumatsu T, Hino T, Kamatsuki Y, Ozaki T. Minimal Ablation of the Tibial Stump Using Bony Landmarks Improved Stability and Synovial Coverage Following Double-Bundle Anterior Cruciate Ligament Reconstruction. Knee Surg Relat Res 2018; 30:348-355. [PMID: 30466255 PMCID: PMC6254876 DOI: 10.5792/ksrr.18.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/26/2018] [Accepted: 08/09/2018] [Indexed: 01/16/2023] Open
Abstract
Purpose To evaluate the clinical effects of using anatomical bony landmarks (Parsons’ knob and the medial intercondylar ridge) and minimal ablation of the tibial footprint to improve knee anterior instability and synovial graft coverage after double-bundle anterior cruciate ligament reconstruction. Materials and Methods We performed a retrospective comparison of outcomes between patients who underwent reconstruction with minimal ablation of the tibial footprint, using an anatomical tibial bony landmark technique, and those who underwent reconstruction with wide ablation of the tibial footprint. Differences between the two groups were evaluated using second-look arthroscopy, radiological assessment of the tunnel position, postoperative anterior knee joint laxity, and clinical outcomes. Results Use of the anatomical reference and minimal ablation of the tibial footprint resulted in a more anterior positioning of the tibial tunnel, with greater synovial coverage of the graft postoperatively (p=0.01), and improved anterior stability of the knee on second-look arthroscopy. Both groups had comparable clinical outcomes. Conclusions Use of anatomical tibial bony landmarks that resulted in a more anteromedial tibial tunnel position improved anterior knee laxity, and minimal ablation improved synovial coverage of the graft; however, it did not significantly improve subjective and functional short-term outcomes.
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Affiliation(s)
- Yuya Kodama
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomohito Hino
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yusuke Kamatsuki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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14
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Naraoka T, Kimura Y, Tsuda E, Yamamoto Y, Ishibashi Y. Does Remnant Preservation Influence Tibial Tunnel Enlargement or Graft-to-Bone Integration After Double-Bundle Anterior Cruciate Ligament Reconstruction Using Hamstring Autografts and Suspensory Fixation? A Computed Tomography and Magnetic Resonance Imaging Evaluation. Orthop J Sports Med 2018; 6:2325967118790238. [PMID: 30182026 PMCID: PMC6111403 DOI: 10.1177/2325967118790238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Remnant-preserving anterior cruciate ligament (ACL) reconstruction was
introduced to improve clinical outcomes and biological healing. However, the
influences of remnant preservation on tibial tunnel position and enlargement
are still uncertain. Purpose: To evaluate whether remnant-preserving ACL reconstruction influences tibial
tunnel position or enlargement and to examine the relationship between
tunnel enlargement and graft-to-bone integration in the tibial tunnel. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 91 knees with double-bundle ACL reconstructions were enrolled in
this study. ACL reconstruction was performed without a remnant (<25% of
the intra-articular portion of the graft) in 44 knees (nonremnant [NR]
group) and with remnant preservation in the remaining 47 knees
(remnant-preserving [RP] group). Tibial tunnel position and enlargement were
assessed using computed tomography (CT). Comparisons between groups were
performed. Furthermore, graft-to-bone integration in the tibial tunnel was
evaluated using magnetic resonance imaging, and the relationship between
tunnel enlargement and graft-to-bone integration at 1 year after ACL
reconstruction was assessed. Results: A total of 48 knees (25 in NR group, 23 in RP group) were included; 19 and 24
knees in the NR and RP groups were excluded, respectively, because of graft
reruptures and a lack of CT scans. There were no significant between-group
differences in tibial tunnel position (P > .05). The
degree of posterolateral tunnel enlargement in the axial plane was
significantly higher in the RP group than that in the NR group
(P = .007) 1 year after ACL reconstruction. The degree
of anteromedial tunnel enlargement on axial CT was significantly smaller in
knees with graft-to-bone integration than in those without integration
(P = .002) 1 year after ACL reconstruction. Conclusion: ACL reconstruction with remnant preservation did not influence tibial tunnel
position and did not decrease the degree or incidence of tibial tunnel
enlargement. At 1 year postoperatively, tunnel enlargement did not affect
graft-to-bone integration in the posterolateral tunnel, but graft-to-bone
integration was delayed in the anteromedial tunnel.
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Affiliation(s)
- Takuya Naraoka
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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15
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Shimodaira H, Tensho K, Akaoka Y, Takanashi S, Kato H, Saito N. Tibial Tunnel Positioning Technique Using Bony/Anatomical Landmarks in Anatomical Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2017; 6:e49-e55. [PMID: 28373940 PMCID: PMC5368106 DOI: 10.1016/j.eats.2016.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/01/2016] [Indexed: 02/03/2023] Open
Abstract
Because various biomechanical studies and clinical results have shown the effectiveness of an anatomical approach for anterior cruciate ligament (ACL) reconstruction, this approach has become gradually commonplace to improve postoperative performance. Standard tunnel positioning methods with accuracy, reproducibility, and adaptability to varied concepts are essential for the success of anatomical ACL reconstruction. However, there were no standard tibial tunnel positioning methods to satisfy these conditions. This technical note reports our tibial tunnel positioning technique using bony and/or anatomical landmarks for anatomical ACL reconstruction.
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Affiliation(s)
- Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan,Address correspondence to Keiji Tensho, M.D., Ph.D., Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.Department of Orthopedic SurgeryShinshu University School of MedicineAsahi 3-1-1Matsumoto390-8621Japan
| | - Yusuke Akaoka
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Seiji Takanashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroyuki Kato
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoto Saito
- Institute for Biomedical Sciences, Interdisciplinary Cluster for Cutting Edge Research, Shinshu University School of Medicine, Matsumoto, Japan
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