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Götschi T, Hodel S, Kühne N, Bachmann E, Li X, Zimmermann SM, Snedeker JG, Fucentese SF. Osteoconductive Scaffold Placed at the Femoral Tunnel Aperture in Hamstring Tendon ACL Reconstruction: A Randomized Controlled Trial. Orthop J Sports Med 2023; 11:23259671231174478. [PMID: 37347015 PMCID: PMC10280525 DOI: 10.1177/23259671231174478] [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: 01/13/2023] [Accepted: 02/22/2023] [Indexed: 06/23/2023] Open
Abstract
Background Bone tunnel enlargement after single-bundle anterior cruciate ligament reconstruction remains an unsolved problem that complicates revision surgery. Hypothesis Positioning of an osteoconductive scaffold at the femoral tunnel aperture improves graft-to-bone incorporation and thereby decreases bone tunnel widening. Study Design Randomized controlled trial; Level of evidence, 1. Methods In a 1:1 ratio, 56 patients undergoing primary anterior cruciate ligament reconstruction were randomized to receive femoral fixation with cortical suspension fixation and secondary press-fit fixation at the tunnel aperture of the tendon graft only (control) or with augmentation by an osteoconductive scaffold (intervention). Adverse events, patient-reported outcomes, and passive knee stability were recorded over 2 years after the index surgery. Three-dimensional bone tunnel widening was assessed using computed tomography at the time of surgery and 4.5 months and 1 year postoperatively. Results The intervention group exhibited a similar number of adverse events as the control group (8 vs 10; P = .775) including 2 partial reruptures in both groups. The approach was feasible, although 1 case was encountered where the osteoconductive scaffold was malpositioned without adversely affecting the patient's recovery. There was no difference between the intervention and control groups in femoral bone tunnel enlargement, as expressed by the relative change in tunnel volume from surgery to 4.5 months (mean ± SD, 36% ± 25% vs 40% ± 25%; P = .644) and 1 year (19% ± 20% vs 17% ± 25%; P =.698). Conclusion Press-fit graft fixation with an osteoconductive scaffold positioned at the femoral tunnel aperture is safe but does not decrease femoral bone tunnel enlargement at postoperative 1 year. Registration NCT03462823 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Tobias Götschi
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich,
Zurich, Switzerland
| | - Sandro Hodel
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Nathalie Kühne
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Xiang Li
- ZuriMED Technologies AG, Zurich,
Switzerland
| | - Stefan M. Zimmermann
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Jess G. Snedeker
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich,
Zurich, Switzerland
| | - Sandro F. Fucentese
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
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Anterior Screw Insertion Results in Greater Tibial Tunnel Enlargement Rates after Single-Bundle Anterior Cruciate Ligament Reconstruction than Posterior Insertion: A Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020390. [PMID: 36837591 PMCID: PMC9967347 DOI: 10.3390/medicina59020390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/19/2023]
Abstract
Background and Objectives: Tunnel enlargement (TE) is a widely reported phenomenon after anterior cruciate ligament reconstruction (ACLR). Given the paucity of knowledge in the literature, it remains unclear whether screw position in the tunnel affects TE. This retrospective cohort study evaluated differences in postoperative tunnel enlargement rates (TER) and clinical results between anterior and posterior tibial interference screw insertion during single-bundle ACLR using autologous hamstring grafts. Materials and Methods: A group of consecutive patients that underwent primary arthroscopic single-bundle ACLR in our hospital were screened and divided into two groups based on the position of the tibial interference screw (determined by Computer Tomography within 3 days after surgery): anterior screw position group (A) and posterior screw position group (B). The bone tunnel size was measured using magnetic resonance imaging (MRI) performed 1 year after surgery. International Knee Documentation Committee (IKDC) score and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used for clinical results 1 year postoperatively. Results: 87 patients were included. The TER of Group A is higher than that of Group B (43.17% vs. 33.80%, p = 0.024). Group A showed a significant increase (12.1%) in enlargement rates at the joint line level than group B (43.77% vs. 31.67%, p = 0.004). Moreover, KOOS and IKDC scores improved in both groups. There were no significant differences in clinical outcomes between the two groups. Conclusions: One year after ACLR, patients with posterior screw showed significantly lower TE than patients with anterior screw. However, the position of screw did not lead to differences in clinical results over our follow-up period. Posterior screw position in the tibial tunnel maybe a better choice in terms of reducing TE. Whether the different screw positions affect the long-term TE and long-term clinical outcomes needs to be confirmed by further studies.
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Taketomi S, Inui H, Yamagami R, Nakazato K, Kawaguchi K, Kono K, Sameshima S, Kage T, Tanaka S. Lateral posterior tibial slope does not affect femoral but does affect tibial tunnel widening following anatomic anterior cruciate ligament reconstruction using a Bone-Patellar Tendon-Bone graft. Asia Pac J Sports Med Arthrosc Rehabil Technol 2022; 30:25-31. [PMID: 36254269 PMCID: PMC9539629 DOI: 10.1016/j.asmart.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/17/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
Background Tunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction has been a research area of interest in ACL reconstruction. In recent years, it has been noted that posterior tibial slope (PTS) affects several types of outcomes after ACL reconstruction including TW. However, the relationships between femoral and tibial TW and between PTS and TW following anatomical ACL reconstruction using a bone–patellar tendon–bone (BTB) graft are often not understood. Therefore, the purpose of this study was to retrospectively clarify the magnitude of femoral and tibial TW and the effect of PTS on TW following anatomical ACL reconstruction using a BTB graft. Methods A total of 111 patients who underwent isolated ACL reconstructions using BTB grafts were included in this study. Femoral and tibial tunnel aperture areas were measured using three-dimensional computed tomography (3D CT) at 1 week and 1 year postoperatively, and femoral and tibial TW (%) was calculated. Lateral and medial PTS was also measured using 3D CT. Results As compared with 1 week postoperatively, the mean tibial tunnel aperture areas increased by 30.6% ± 28.5%, and the mean femoral tunnel aperture areas increased by 28.3% ± 27.9% when measured at 1 year postoperatively. Although no significant difference was observed between femoral and tibial TW, a significant positive correlation was noted between femoral and tibial TW (r = 0.240, p = 0.011). A significant correlation was observed only between lateral PTS and tibial TW (r = 0.354, p < 0.001). There was no significant correlation between medial PTS and tibial TW, lateral PTS and femoral TW, or medial PTS and femoral TW. Conclusion Significant positive correlation was observed between femoral and tibial TW. Steeper lateral PTS correlated with greater tibial TW; on the other hand, medial PTS did not correlate with tibial TW. Although lateral PTS affected tibial TW, it did not affect femoral TW.
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Affiliation(s)
- Shuji Taketomi
- Corresponding author. 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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4
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Chiba D, Yamamoto Y, Kimura Y, Sasaki S, Sasaki E, Yamauchi S, Tsuda E, Ishibashi Y. Laterally shifted tibial tunnel can be the risk of residual knee laxity for double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:319-327. [PMID: 33938969 DOI: 10.1007/s00167-021-06546-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/19/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To elucidate the relationship between graft tunnel position and knee laxity in the cases of double-bundle ACL reconstruction. METHODS Total of 132 cases were included. Femoral and tibial tunnels were evaluated by quadrant method on 3D-CT. As additional reference of tibia, the distances from medial tibial spine to the tunnel center (DMS) and from Parsons' knob to the tunnel center (DPK) were evaluated; %DMS/ML and %DPK/AP were calculated (ML and AP: mediolateral and anteroposterior width of tibial plateau). Preoperative and postoperative (1 year from surgery) stabilities were evaluated by Lachman and pivot-shift procedures. If there was ≥ 2 mm side-to-side difference, the subject was defined as having anterior knee laxity (AKL); if the pivot-shift phenomenon was observed with IKDC grade ≥ 1, there was rotatory knee laxity (RKL). Multiple logistic regression analysis was conducted with the prevalence of AKL or RKL as the dependent variable and with tunnel positions as the independent variables. RESULTS Overall, 21 subjects (15.9%) showed AKL, and 15 subjects (11.4%) showed RKL. Those with postoperative laxity showed higher %DMS/ML and higher femoral position than those without laxity. Regarding posterolateral bundle, logistic regression model estimated that %DMS/ML was associated with the prevalence of AKL (B = 0.608; p < 0.001) and RKL (B = 0.789; p < 0.001); %high-low femoral tunnel position (B = - 0.127; p = 0.023) was associated with that of RKL. CONCLUSION There was the risk of residual knee laxity in ACL-reconstructed knee when tibial tunnel shifted more laterally or higher femoral tunnel was created with regard to posterolateral bundle. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Daisuke Chiba
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Shohei Yamauchi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
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5
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Kim Y, Kubota M, Muramoto K, Kunii T, Sato T, Inui T, Ohno R, Ishijima M. Clinical and radiographic results after ACL reconstruction using an adjustable-loop device. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 26:32-38. [PMID: 34584849 PMCID: PMC8437790 DOI: 10.1016/j.asmart.2021.07.002] [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: 12/10/2020] [Revised: 07/03/2021] [Accepted: 07/26/2021] [Indexed: 11/23/2022]
Abstract
Background The femoral cortical suspension device such as fixed loop devices (FLD) and adjustable-loop device (ALD) are used for ACLR technique in recent days. However, there was few studies of clinical and radiographic results for ACLR using ALD. This study was conducted to clarify the clinical and radiographic results, stability and bone tunnel enlargement after ACLR using a ToggleLoc with a zip loop as ALD. Methods 80 patients who had data available from the most recent follow-up at ≥2 years since ACLR were evaluated both clinical and radiographic results. They were divided into single bundle reconstruction group (SBR) and double bundle reconstruction group (DBR). Clinical scores were included subjective scores and objective scores at pre- and postoperatively 2 years. The subjective scores were the Cincinnati knee rating system, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, Tegner activity score, Visual Analog Scale (VAS) and ACL-Return to Sport after Injury (RSI) scale. The objective scores were the isokinetic muscle strength, side-to-side difference in anterior instability and single hop test. In radiographical assessment, femoral and tibial tunnel enlargement was evaluated by three-dimensional computed tomography. Results In both SBR and DBR group, the postoperative subjective scores were significantly improved compared to the preoperative values, except for the Tegner activity score. Similarly, the side-to-side differences in muscle strength, anterior instability and single hop test were significantly improved after surgery. The changes in the femoral and tibial tunnel maximum cross section areas of SBR were 104.3 % ± 21.2 % and 89.2 % ± 15.2 %, respectively, at 2 years post-operatively. In DBR, in the femoral bone volume change of the antero medial (AM) and postero lateral (PL) bundle were 107.0 ± 3.5 % and 108.1 ± 3.3, and in the tibial bone volume change of AM and PL bundle were 90.6 ± 3.3 % and 87.0 ± 4.2 %. At the femoral site, the rate of tunnel enlargement increased for the first 12 months and then decreased through 24 months postoperatively. At the tibial site, by contrast, the rate of tunnel enlargement decreased consistently over the two-year postoperative follow-up. Conclusion This is the first study to include clinical data on ACLR using a ToggleLoc with a zip loop device. ACLR using these devices as ALDs resulted in good clinical outcomes and provided good stability of the knee with relatively little bone tunnel enlargement in both SBR and DBR group.
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Affiliation(s)
- Youngji Kim
- Department of Orthopaedic Surgery, Koshigaya Municipal Hospital, Saitama, Japan.,Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Mitsuaki Kubota
- Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Keisuke Muramoto
- Department of Radiology, Koshigaya Municipal Hospital, Saitama, Japan
| | - Takuya Kunii
- Department of Radiology, Koshigaya Municipal Hospital, Saitama, Japan
| | - Taisuke Sato
- Department of Orthopaedic Surgery, Koshigaya Municipal Hospital, Saitama, Japan.,Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Tetsuya Inui
- Department of Orthopaedic Surgery, Koshigaya Municipal Hospital, Saitama, Japan.,Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Ryuichi Ohno
- Department of Orthopaedic Surgery, Koshigaya Municipal Hospital, Saitama, Japan.,Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Muneaki Ishijima
- Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
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6
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Lee DK, Kim JH, Lee SS, Lee BH, Kim H, Kim J, Wang JH. Femoral Tunnel Widening After Double-Bundle Anterior Cruciate Ligament Reconstruction With Hamstring Autograft Produces a Small Shift of the Tunnel Position in the Anterior and Distal Direction: Computed Tomography-Based Retrospective Cohort Analysis. Arthroscopy 2021; 37:2554-2563.e1. [PMID: 33745939 DOI: 10.1016/j.arthro.2021.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the femoral tunnel position remains in an anatomical footprint after tunnel widening and shifting. METHODS Patients who underwent unilateral double-bundle anterior cruciate ligament reconstruction with hamstring autograft and performed computed tomography scan evaluation at the time of 5 days and 1 year postoperatively were included in this retrospective cohort study. Three-dimensional models of the femur and femoral tunnels were reconstructed from computed tomography scan data. The location of the tunnel center and tunnel margins in the anatomical coordinate system, and the mean shifting distance of tunnel center and margin were measured with image analysis software during the period. The change of tunnel center location in Bernard quadrant was confirmed if the tunnel center remained within the boundaries of anatomical position after tunnel widening. RESULTS A total of 56 patients satisfied the inclusion criteria. The mean shifting distance of AM and PL tunnel centers were 1.7 ± 0.9 mm and 1.6 ± 0.6 mm. The Tunnel margin of the anteromedial (AM) and posteromedial (PL) tunnels were shifted to 2.5 ± 1.3 mm and 2.6 ± 1.4 mm in the anterior direction, and 1.4 ± 0.9 mm and 1.0 ± 0.7 mm in the distal direction, respectively. Among the anatomical located tunnel, 97% (32/33) and 87.1% (27/31) of AM and PL tunnel centers remained in a range of anatomical footprint. The tunnel center was shifted from the anatomical position into a nonanatomical position in 3% (1/33) of the AM tunnel and 12.9% (4/31) of PL tunnel after tunnel widening. The tunnel location which shifted nonanatomically were relatively anterior and distal position. CONCLUSIONS Tunnel widening shifts the tunnel position to the anterior and distal direction, which could change the initial tunnel position. Nevertheless, the majority of tunnel positions remained in the anatomical position after tunnel widening and shifting. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Korea
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyeonsoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jinwoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Health Science and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea; Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
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7
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Okazaki Y, Abe N, Makiyama K, Furumatsu T, Miyazawa S, Ozaki T. Histologic Evaluation of Tibial Attachment in 11-Year Double-Bundle ACL Reconstruction with Hamstring Tendons: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00010. [PMID: 33826555 DOI: 10.2106/jbjs.cc.20.00509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 49-year-old woman injured her anterior cruciate ligament (ACL) as a high-school student. Double-bundle ACL reconstruction (DBACLR) using hamstring tendon grafts was performed because of recurrent instability. Eleven years after DBACLR, total knee arthroplasty was performed because of osteoarthritis progression. Histologic analysis was completed to observe the osteointegration of the tendon in the obtained proximal tibia. The tibial tunnel showed Sharpey-like fibers anteriorly, connecting the tendon graft and lamellar bone, whereas the intraarticular exit revealed well-aligned chondrocytes posteriorly, indicating chondral metaplasia of the tendon graft. CONCLUSION Tendon-bone healing can regenerate both fibrous insertion and chondral metaplasia in DBACLR.
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Affiliation(s)
- Yuki Okazaki
- Department of Orthopaedic Surgery and Sport Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan.,Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Nobuhiro Abe
- Department of Orthopaedic Surgery and Sport Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Kimihiko Makiyama
- Department of Orthopaedic Surgery and Sport Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Shinichi Miyazawa
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
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8
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Tachibana Y, Tanaka Y, Kinugasa K, Mae T, Horibe S. Tunnel Enlargement Correlates With Postoperative Posterior Laxity After Double-Bundle Posterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:2325967120977834. [PMID: 33614798 PMCID: PMC7869171 DOI: 10.1177/2325967120977834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 11/24/2022] Open
Abstract
Background: There exists little information in the relevant literature regarding tunnel
enlargement after posterior cruciate ligament (PCL) reconstruction
(PCLR). Purpose: To sequentially evaluate tunnel enlargement and radiographic posterior laxity
through double-bundle PCLR using autologous hamstring tendon grafts. Study Design: Case series; Level of evidence, 4. Methods: We prospectively analyzed 13 patients who underwent double-bundle PCLR for an
isolated PCL injury. Three-dimensional computed tomography images were
obtained at 3 weeks, 6 months, and 1 year postoperatively, and the tunnel
enlargement was calculated by sequentially comparing the cross-sectional
areas of the bone tunnels. We also sequentially measured radiographic
posterior laxity. The correlation between the tunnel enlargement ratio and
the postoperative increase in posterior laxity was evaluated. Results: The cross-sectional area at the aperture in each tunnel significantly
increased from 3 weeks to 6 months (P < .003), but it
did not continue doing so thereafter. The 6-month tunnel enlargement ratios
of the femoral anterolateral tunnel, the femoral posteromedial tunnel, the
tibial anterolateral tunnel, and the tibial posteromedial tunnel were 31.6%
± 23.5%, 90.3% ± 54.7%, 30.5% ± 26.8%, and 49.6% ± 37.0%, respectively,
while the corresponding ratios at 1 year were 28.1% ± 19.8%, 83.1% ± 56.9%,
26.8% ± 32.8%, and 47.6% ± 39.0%, respectively. The posterior laxity was 9.0
± 4.0 mm, −1.5 ± 2.3 mm, 3.4 ± 2.0 mm, and 3.9 ± 1.9 mm, preoperatively,
immediately after surgery, 6 months and 1 year postoperatively,
respectively. From the immediate postoperative period, the posterior laxity
significantly increased at 6 months postoperatively (P <
.001), but it did not thereafter. The postoperative increase in posterior
laxity had a significant positive correlation with the anterolateral tunnel
enlargement ratio in both femoral and tibial tunnels at 6 months (ρ =
0.571-0.699; P = .011-.041) and 1 year (ρ = 0.582-0.615;
P = .033-.037). Conclusion: Tunnel enlargement after PCLR mainly occurred within 6 months, with no
progression thereafter. The anterolateral tunnel enlargement positively
correlated with postoperative increase in posterior laxity.
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Affiliation(s)
- Yuta Tachibana
- Department of Sports Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | - Yoshinari Tanaka
- Department of Sports Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | - Kazutaka Kinugasa
- Department of Sports Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shuji Horibe
- Faculty of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Japan
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9
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Wang HD, Wang TR, Sui Y, Wang J, Chen W, Zhang YZ. An Autograft for Anterior Cruciate Ligament Reconstruction Results in Better Biomechanical Performance and Tendon-Bone Incorporation Than Does a Hybrid Graft in a Rat Model. Am J Sports Med 2020; 48:3515-3524. [PMID: 33141598 DOI: 10.1177/0363546520967668] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The biomechanical and tendon-bone incorporation properties of allograft-augmented hybrid grafts for anterior cruciate ligament (ACL) reconstruction compared with traditional autografts are unknown. HYPOTHESIS Using an autograft for ACL reconstruction yields better results on biomechanical testing, radiographic analysis, and histological evaluation versus using a hybrid graft. STUDY DESIGN Controlled laboratory study. METHODS A total of 66 adult male Sprague Dawley rats underwent unilateral ACL reconstruction with an autograft (AT group; n = 33) or a hybrid graft (HB group; n = 33). The grafts used in both groups were harvested from the peroneus longus tendon and were fixed by suturing to the surrounding periosteum. Samples were harvested for biomechanical testing, micro-computed tomography (CT), and histological evaluation at 4, 8, and 12 weeks postoperatively. Bone tunnels on the femoral and tibial sides were divided into 3 subregions: intra-articular (IA), midtunnel (MT), and extra-articular (EA). A cylinder-like volume of interest in the bone tunnel and a tubular-like volume of interest around the bone tunnel were used to evaluate new bone formation and bone remodeling, respectively, via micro-CT. RESULTS In the AT group, there were significantly higher failure loads and stiffness at 8 weeks (failure load: 3.04 ± 0.40 vs 2.09 ± 0.54 N, respectively; P = .006) (stiffness: 3.43 ± 0.56 vs 1.75 ± 0.52 N/mm, respectively; P < .001) and 12 weeks (failure load: 9.10 ± 1.13 vs 7.14 ± 0.94 N, respectively; P = .008) (stiffness: 4.45 ± 0.75 vs 3.36 ± 0.29 N/mm, respectively; P = .008) than in the HB group. With regard to new bone formation in the bone tunnel, in the AT group, the bone volume/total volume (BV/TV) was significantly higher than in the HB group on the tibial side at 8 weeks (IA: 22.21 ± 4.98 vs 5.16 ± 3.98, respectively; P < .001) (EA: 19.66 ± 7.19 vs 10.85 ± 2.16, respectively; P = .030) and 12 weeks (IA: 30.50 ± 5.04 vs 17.11 ± 7.31, respectively; P = .010) (MT: 21.15 ± 2.58 vs 15.55 ± 4.48, respectively; P = .041) (EA: 20.75 ± 3.87 vs 10.64 ± 3.94, respectively; P = .003). With regard to bone remodeling around the tunnel, the BV/TV was also significantly higher on the tibial side at 8 weeks (MT: 33.17 ± 8.05 vs 15.21 ± 7.60, respectively; P = .007) (EA: 25.19 ± 6.38 vs 13.94 ± 7.10, respectively; P = .030) and 12 weeks (IA: 69.46 ± 4.45 vs 47.80 ± 6.16, respectively; P < .001) (MT: 33.15 ± 3.88 vs 13.76 ± 4.07, respectively; P < .001) in the AT group than in the HB group. Sharpey-like fibers had formed at 8 weeks in the AT group. A large number of fibroblasts withdrew at 12 weeks. In the AT group, the width of the interface was significantly narrower at 4 weeks (85.86 ± 17.49 vs 182.97 ± 14.35 μm, respectively; P < .001), 8 weeks (58.86 ± 10.99 vs 90.15 ± 11.53 μm, respectively; P = .002), and 12 weeks (42.70 ± 7.96 vs 67.29 ± 6.55 μm, respectively; P = .001) than in the HB group. CONCLUSION Using an autograft for ACL reconstruction may result in improved biomechanical properties and tendon-bone incorporation compared with a hybrid graft. CLINICAL RELEVANCE Augmenting small autografts with allograft tissue may result in decreased biomechanical performance and worse tendon-bone incorporation, increasing the risk of graft failure.
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Affiliation(s)
- Hong-De Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Biochemistry and Molecular Biology, Hebei Medical University, Shijiazhuang, China
| | - Tian-Rui Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Biochemistry and Molecular Biology, Hebei Medical University, Shijiazhuang, China.,Department of Orthopaedic Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yao Sui
- Department of Biochemistry and Molecular Biology, Hebei Medical University, Shijiazhuang, China.,Department of Ophthalmology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Juan Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Chen
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ying-Ze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Chinese Academy of Engineering, Beijing, China
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10
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Rugg CM, Pitcher AA, Allen C, Pandya NK. Revision ACL Reconstruction in Adolescent Patients. Orthop J Sports Med 2020; 8:2325967120953337. [PMID: 33062768 PMCID: PMC7534089 DOI: 10.1177/2325967120953337] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 12/14/2022] Open
Abstract
Background: High failure rates have been documented after anterior cruciate ligament reconstruction (ACLR) in pediatric patients, and revision surgery is indicated due to high activity levels of children and adolescents. Purpose: To define trends in revision ACLR in patients who underwent initial ACLR at younger than 18 years. Study Design: Case series; Level of evidence, 4. Methods: An electronic medical record was used to retrospectively identify revision ACLR procedures performed by 2 surgeons between the years 2010 and 2016 in patients younger than 18 years at initial reconstruction. Descriptive information, intraoperative findings, surgical techniques, and rehabilitation data were recorded from initial and revision surgeries. Descriptive statistics were used. Results: A total of 32 patients (17 girls, 15 boys) met the inclusion criteria, with a mean age of 15.8 years at initial reconstruction. For initial reconstructions, 15 patients underwent transphyseal procedures, 3 patients underwent adult-type procedures using an anatomic reconstruction technique that did not take into account the physis, and 2 patients underwent partial intraepiphyseal procedures. Graft types included hamstring autograft (n = 17), allograft (n = 5), hybrid (n = 4), and bone–patellar tendon–bone autograft (BTB; n = 3). Average primary reconstruction graft diameter was 8.0 mm (girls, 7.72 mm; boys, 8.36 mm; P = .045). After initial reconstruction, 10 patients had postoperative protocol noncompliance, and 8 patients reported delayed recovery. Mean time to retear was 565 days (range, 25-1539 days). At revision, BTB autograft was used in 50% (n = 16), followed by hamstring autograph (31.3%; n = 10) and allograft (12.5%; n = 4); mean graft diameter was 9.05 mm. Chondral surgery was more common during revision (25% for revision vs 0% for index; P = .031). There were 4 patients who required staged reconstruction with bone grafting. At mean final follow-up of 29.5 months (SD, 22.2 months), there were 3 graft failures (9.4%) and 5 contralateral ACL ruptures (15.6%). Conclusion: Most patients with ACL graft failure were adequately treated with a single revision. Conversion from a soft tissue graft to a BTB autograft was the most common procedure. Infrequently, patients required staged reconstructions. Providers should have a high index of suspicion for associated intra-articular injuries resulting from graft failure in adolescent patients.
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Affiliation(s)
- Caitlin M Rugg
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Austin A Pitcher
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Christina Allen
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Nirav K Pandya
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
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11
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Yue L, DeFroda SF, Sullivan K, Garcia D, Owens BD. Mechanisms of Bone Tunnel Enlargement Following Anterior Cruciate Ligament Reconstruction. JBJS Rev 2020; 8:e0120. [DOI: 10.2106/jbjs.rvw.19.00120] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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12
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Zhang S, Liu S, Yang L, Chen S, Chen S, Chen J. Morphological Changes of the Femoral Tunnel and Their Correlation With Hamstring Tendon Autograft Maturation up to 2 Years After Anterior Cruciate Ligament Reconstruction Using Femoral Cortical Suspension. Am J Sports Med 2020; 48:554-564. [PMID: 31967861 DOI: 10.1177/0363546519898136] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Graft healing within the femoral tunnel after anterior cruciate ligament reconstruction (ACLR) using suspensory fixation could be reflected in graft maturation and tunnel morphological changes. However, the correlation between graft maturation and femoral tunnel changes remains unclear. PURPOSE To quantitatively evaluate femoral tunnel morphological changes and graft maturation and to analyze their correlation after ACLR using femoral cortical suspension. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent single-bundle ACLR with a hamstring tendon autograft using femoral cortical suspension were included. Preoperative and postoperative (at 6, 12, and 24 months) knee function were evaluated using KT-1000 arthrometer testing, the Lysholm knee scoring scale, and the International Knee Documentation Committee (IKDC) questionnaire. At 1 day, 6 months, 12 months, and 24 months after ACLR, 3-dimensional magnetic resonance imaging was performed to observe the morphology of the femoral tunnel and to evaluate graft maturation using the graft signal/noise quotient (SNQ). The Pearson product moment correlation coefficients (r) of femoral tunnel radii versus clinical outcomes and graft SNQs at last follow-up were analyzed. RESULTS A total of 22 patients completed full follow-up. KT-1000 arthrometer, Lysholm, and IKDC scores improved over time postoperatively, but no significant improvement was seen after 12 months (P < .05). The radius of the tunnel containing the graft and the SNQs of the femoral intraosseous graft and intra-articular graft were the highest at 6 months, and they decreased by 24 months but remained higher than their 1-day postoperative values (P < .05). Expansion mainly occurred at the anteroinferior wall of the femoral tunnel. The tunnel aperture radius was positively correlated with SNQs of the intraosseous graft (r = 0.591; P < .05) and intra-articular graft (r = 0.359; P < .05) but not with clinical outcomes. CONCLUSION After ACLR using suspensory fixation, morphological changes of the femoral tunnel were mainly observed in the part of the tunnel containing the graft, which expanded at 6 months and reduced by 24 months. Expansion mainly occurred at the anteroinferior wall of the femoral tunnel. Femoral tunnel expansion was correlated with inferior graft maturation but not with clinical outcomes.
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Affiliation(s)
- Shurong Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
| | - Shaohua Liu
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
| | - Liqin Yang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Shuang Chen
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
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Is Remnant Preservation in Anterior Cruciate Ligament Reconstruction Superior to the Standard Technique? A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1652901. [PMID: 31886174 PMCID: PMC6927015 DOI: 10.1155/2019/1652901] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 10/09/2019] [Accepted: 11/06/2019] [Indexed: 01/08/2023]
Abstract
Purpose This is a systematic review and meta-analysis of current evidence that aims at comparing the clinical outcomes of remnant-preserving anterior cruciate ligament reconstruction (ACLR) and standard ACLR. Methods A systematic review of randomized controlled studies and cohort studies comparing remnant-preserving ACLR with standard ACLR with a minimum level of evidence of II was performed. Studies were included by strict inclusion and exclusion criteria. Extracted data were summarized as preoperative conditions, postoperative clinical outcomes, and postoperative complications. When feasible, meta-analysis was performed with RevMan5.3 software. Study methodological quality was evaluated with the modified Coleman methodology score (CMS). Results Eleven studies (n = 466 remnant-preserving and n = 536 standard) met the inclusion criteria. The mean modified CMS for all included studies was 85.8 (range: 77–92 on a 100-point scale). In total, 466 patients underwent remnant-preserving ACLR by 3 different procedures: standard ACLR plus tibial remnant tensioning (n = 283), selective-bundle augmentation (n = 49), and standard ACLR plus tibial remnant sparing (n = 134). Remnant-preserving ACLR provided a superior outcome of postoperative knee anterior stability (WMD = −0.42, 95% CI, −0.66, −0.17; P < 0.01) and Lysholm score (WMD = 2.01, 95% CI, 0.53 to 3.50; P < 0.01). There was no significant difference between the two groups with respect to second-look arthroscopy (OR = 1.38, 95% CI, 0.53, 3.62; P=0.51), complications (OR = 1.24 95% CI, 0.76, 2.02; P=0.39), International Knee Documentation Committee (IKDC) subject scores, IKDC grades, Lachman test, and pivot-shift test. Summary/conclusion Remnant-preserving ACLR promotes similar graft synovial coverage and revascularization to standard ACLR. Equivalent or superior postoperative knee stability and clinical scores were observed for remnant-preserving ACLR compared with standard ACLR. No significant difference in the total complication rate between the groups was evident.
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14
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Shumborski S, Heath E, Salmon LJ, Roe JP, Linklater JP, Facek M, Pinczewski LA. A Randomized Controlled Trial of PEEK Versus Titanium Interference Screws for Anterior Cruciate Ligament Reconstruction With 2-Year Follow-up. Am J Sports Med 2019; 47:2386-2393. [PMID: 31306589 DOI: 10.1177/0363546519861530] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Graft fixation with interference screws for anterior cruciate ligament (ACL) reconstruction is a highly successful technique. Polyether ether ketone (PEEK) is a novel thermoplastic polymer with high biocompatibility and mechanical properties that mimic native bone, and it can be imaged on computed tomography or magnetic resonance imaging (MRI) without signal flare. PURPOSE To compare the clinical performance of ACL reconstruction with PEEK and titanium interference screws at 2 years and to evaluate a novel method of measuring tunnel volume. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 133 patients underwent arthroscopic ACL reconstruction with 4-strand hamstring autografts and were randomized to have titanium or PEEK interference screws for femoral and tibial tunnel fixation. At 2 years, subjective Lysholm and International Knee Documentation Committee scores were assessed and clinical examination performed. At 12 months, MRI was performed to assess graft incorporation and cyst formation, and a novel technique was employed to measure tunnel volumes. RESULTS There were no significant differences in graft rerupture rate, contralateral ACL rupture rate, subjective outcomes, or objective outcomes. In the titanium and PEEK groups, MRI demonstrated high overall rates of graft integration (96%-100% and 90%-93%, respectively) and ligamentization (89% and 84%) and low rates of synovitis (22% and 10%) and cyst formation (0%-18% and 13%-15%). There was a higher proportion of patients with incomplete graft integration within the femoral tunnel in the PEEK group as compared with the titanium group (10% vs 0%, P = .03); however, the authors suggest that metal artifact precluded proper assessment of the graft in the titanium group by MRI. Tunnel volumes also appeared to be equivalent in the 2 groups and were measured with a novel technique that was highly reproducible in the PEEK group secondary to the absence of flare. CONCLUSION Two-year clinical analysis of PEEK interference screws for femoral and tibial fixation of ACL reconstructions showed equivalent clinical performance to titanium interference screws. Given the excellent mechanical characteristics, biological compatibility, and absence of metal artifact on MRI, PEEK has become our material of choice for interference screw fixation in ACL reconstruction.
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Affiliation(s)
- Sarah Shumborski
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, Australia
| | - Emma Heath
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, Australia
| | - Lucy J Salmon
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, Australia
| | - Justin P Roe
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, Australia
| | | | - Michael Facek
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, Australia
| | - Leo A Pinczewski
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, Australia.,University of Notre Dame, Sydney, Australia
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15
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Relationship between bone plug position and morphological changes of tunnel aperture in anatomic rectangular tunnel ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:2417-2425. [PMID: 30465097 DOI: 10.1007/s00167-018-5224-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/17/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE In animal studies after ACL reconstruction (ACL-R) using the bone-patellar tendon-bone (BTB), the graft-healing pattern was found to depend on the relationship between bone plug and the tunnel wall. This difference of graft-healing pattern could influence the postoperative morphological changes of the tunnel. However, no study has assessed the relationship between bone plug position and the change of tunnel morphology. Therefore, the main purpose of this study was to investigate the relationship between the bone plug position within femoral or tibial tunnel and morphological changes of each tunnel aperture in ACL-R using computed tomography. METHODS Subjects were 30 consecutive patients (six females and 24 males; mean age, 20.4 ± 5.4 years) who underwent primary ACL-R using BTB. The distance from the tunnel aperture to the tendon-bone junction (TBJ) at 2 weeks postoperatively, and tunnel aperture enlargement and tunnel wall migration from 2 weeks to 6 months postoperatively, were evaluated. RESULTS The distance from the femoral tunnel aperture to the TBJ in most cases was less than 2 mm, whereas the TBJ was located within the tibial tunnel. Femoral tunnel aperture was significantly enlarged (17.0 ± 11.7%) distally, and the tibial tunnel aperture was significantly enlarged (19.6 ± 12.5%) posterolaterally. Only the position at distal portion of femoral bone plug was correlated with femoral tunnel aperture enlargement (r = 0.454, p = 0.0015). CONCLUSION Both femoral and tibial tunnel aperture were significantly enlarged distally and posterolaterally 6 months postoperatively. Only correlation between the position at distal portion of femoral bone plug and femoral tunnel enlargement were found, suggesting the deep plug position in the tunnel is a risk factor for femoral tunnel enlargement, highlighting the importance of accurately locating the TBJ just at the femoral tunnel aperture. Another option is to deviate the harvest site in the patellar tendon to match the shape of the TBJ and the tunnel aperture. LEVEL OF EVIDENCE 4 (case series).
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16
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Egloff C, Huber L, Wurm M, Pagenstert G. No added value using SPECT/CT to analyze persistent symptoms after anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2019; 139:807-816. [PMID: 30637504 DOI: 10.1007/s00402-019-03117-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the diagnostic and clinical value of SPECT/CT compared to the standard algorithm for patients with persistent symptoms after anterior cruciate ligament reconstructions. The standard algorithm uses clinical information, conventional radiographs, MRI and CT scan, while the trial algorithm uses the same information but SPECT/CT in addition. METHODS In a diagnostic comparative trial three experienced surgeons evaluated 23 consecutive patients with persistent symptoms after ACL reconstruction using first standard and second the trial algorithm with a time interval. Each rater had to establish a diagnosis and therapeutic decision with each algorithm. On MRI, graft continuity, bone marrow edema, chondral and meniscal lesions, femoral notch osteophytes were evaluated. Bone tracer uptake in SPECT/CT was anatomically analyzed and compared with MRI findings. MRI findings and SPECT/CT tracer uptake were correlated using Spearman's rho test. RESULTS Additional SPECT/CT analysis did not change diagnosis in any case and did not correlate with clinical graft integrity. Treatment decisions remained unchanged as well. Chondral lesions, arthritic changes, meniscal lesions, graft impingement are best visualized in MRI and showed correspondent tracer uptake in SPECT/CT. Tunnel position was well classified with standard CT scan and showed no correlation with SPECT/CT tracer uptake. CONCLUSION Information derived by SPECT/CT in addition to the standard algorithm using clinical information, X-rays, MRI, and CT scan did not change the diagnosis or treatment plan. There is currently no justification to implement SPECT/CT for patients with persistent symptoms after anterior cruciate ligament reconstructions. LEVEL OF EVIDENCE Level II: diagnostic comparative study.
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Affiliation(s)
- Christian Egloff
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | | | - Markus Wurm
- Department of Orthopaedic Sports Medicine, Technische Universität München (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Geert Pagenstert
- Department of Clinical Research, University of Basel, Schanzenstr. 55, 4056, Basel, Switzerland
- Clarahof Clinic of Orthopaedic Surgery, Merian-Iselin-Hospital Swiss Olympic Medical Center, Foehrenstr. 2, 4054, Basel, Switzerland
- Knee Institute Basel, Mittlere Str. 129, 4056, Basel, Switzerland
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17
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Mutsuzaki H, Kinugasa T, Ikeda K, Sakane M. Morphological changes in the femoral and tibial bone tunnels after anatomic single-bundle anterior cruciate ligament reconstruction using a calcium phosphate-hybridized tendon graft in 2years of follow-up. Orthop Traumatol Surg Res 2019; 105:653-660. [PMID: 30853458 DOI: 10.1016/j.otsr.2019.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/21/2018] [Accepted: 01/09/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A calcium phosphate (CaP)-hybridized tendon graft improves tendon-to-bone healing. The purpose of the study was to evaluate the progression of morphological changes in the femoral and tibial bone tunnels after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction using the CaP-hybridized tendon graft versus an untreated tendon graft during 2 years of follow-up. HYPOTHESIS We hypothesized that the CaP-hybridized tendon graft would prevent the progression of bone tunnel enlargement compared with the untreated tendon graft. PATIENTS AND METHODS The CaP group comprised 19 patients, while the conventional group comprised 18. Computed tomography was performed at postoperative 1 week, 1 year, and 2 years. The bone tunnel enlargement and tunnel translation at the aperture of the femoral and tibial tunnels were analyzed. RESULTS In the CaP group, the femoral bone tunnel did not expand during 2 years of follow-up. In the conventional group, the femoral bone tunnel diameters at postoperative 1 year and 2 years were enlarged compared with postoperative 1 week, and the proximal and distal walls of the femoral bone tunnel shifted proximally and distally, respectively. The femoral bone tunnel in the CaP group was smaller than that in the conventional group at 1 year postoperatively. Although the tibial bone tunnels expanded for up to 1 year postoperatively in both groups, the expanded bone tunnel reduced during 2 years of follow-up only in the CaP group. DISCUSSION In anatomic single-bundle ACL reconstruction, the femoral bone tunnel in the CaP group did not expand or progress with time compared with the conventional group, while the tibial bone tunnel in the CaP group expanded for up to 1 year postoperatively and then reduced for up to 2 years postoperatively. The CaP-hybridized tendon can prevent the progression of bone tunnel enlargement. LEVEL OF EVIDENCE Level II, Low-powered prospective randomized trial.
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Affiliation(s)
- Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami Ami-machi, 300-0394 Inashiki-gun, Ibaraki, Japan.
| | - Tomonori Kinugasa
- Department of Orthopaedic Surgery, Ichihara Hospital, 3681 Oozone, 300-3295 Tsukuba, Ibaraki, Japan
| | - Kotaro Ikeda
- Department of Orthopaedic Surgery, Ichihara Hospital, 3681 Oozone, 300-3295 Tsukuba, Ibaraki, Japan
| | - Masataka Sakane
- Department of Orthopaedic Surgery, Tsukuba Gakuen Hospital, 2573-1 Kamiyokoba, 305-0854 Tsukuba, Ibaraki, Japan
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Teuschl AH, Tangl S, Heimel P, Schwarze UY, Monforte X, Redl H, Nau T. Osteointegration of a Novel Silk Fiber-Based ACL Scaffold by Formation of a Ligament-Bone Interface. Am J Sports Med 2019; 47:620-627. [PMID: 30653344 DOI: 10.1177/0363546518818792] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Given the unsatisfactory results and reported drawbacks of anterior cruciate ligament (ACL) reconstruction, such as donor site morbidity and the limited choice of grafts in revision surgery, new regenerative approaches based on tissue-engineering strategies are currently under investigation. PURPOSES To determine (1) if a novel silk fiber-based ACL scaffold is able to initiate osteointegration in the femoral and tibial bone tunnels under in vivo conditions and (2) if the osteointegration process will be improved by intraoperatively seeding the scaffolds with the autologous stromal vascular fraction, an adipose-derived, stem cell-rich isolate from knee fat pads. STUDY DESIGN Controlled laboratory study. METHODS A total of 33 sheep underwent ACL resection and were then randomly assigned to 2 experimental groups: ACL reconstruction with a scaffold alone and ACL reconstruction with a cell-seeded scaffold. Half of the sheep in each group were randomly chosen and euthanized 6 months after surgery and the other half at 12 months. To analyze the integration of the silk-based scaffold in the femoral and tibial bone tunnels, hard tissue histology and micro-computed tomography measurements were performed. RESULTS Hard tissue histological workup showed that in all treatment groups, with or without the application of the autologous stromal vascular fraction, an interzone of collagen fibers had formed between bone and silk-based graft. This collagen-fiber continuity partly consisted of Sharpey fibers, comparable with tendon-bone healing known for autografts and allografts. Insertion sites were more broad based at 6 months and more concentrated on the slightly protruding, bony knoblike structures at 12 months. Histologically, no differences between the treatment groups were detectable. Analysis of micro-computed tomography measurements revealed a significantly higher tissue density for the cell-seeded scaffold group as compared with the scaffold-alone group in the tibial but not femoral bone tunnel after 12 months of implantation. CONCLUSION The novel silk fiber-based scaffold for ACL regeneration demonstrated integration into the bone tunnels via the formation of a fibrous interzone similar to allografts and autografts. Histologically, additional cell seeding did not enhance osteointegration. No significant differences between 6 and 12 months could be detected. After 12 months, there was still a considerable amount of silk present, and a longer observation period is necessary to see if a true ligament-bone enthesis will be formed. CLINICAL RELEVANCE ACL regeneration with a silk fiber-based scaffold with and without additional cell seeding may provide an alternative treatment option to current techniques of surgical reconstruction.
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Affiliation(s)
- Andreas Herbert Teuschl
- Department of Life Science Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Stefan Tangl
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Core Facility Hard Tissue and Biomaterial Research, Karl Donath Laboratory, School of Dentistry, Medical University of Vienna, Vienna, Austria
| | - Patrick Heimel
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Uwe Yacine Schwarze
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Core Facility Hard Tissue and Biomaterial Research, Karl Donath Laboratory, School of Dentistry, Medical University of Vienna, Vienna, Austria
| | - Xavier Monforte
- Department of Life Science Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Heinz Redl
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Thomas Nau
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
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Masuda T, Kondo E, Onodera J, Kitamura N, Inoue M, Nakamura E, Yagi T, Iwasaki N, Yasuda K. Effects of Remnant Tissue Preservation on Tunnel Enlargement After Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Hamstring Tendon. Orthop J Sports Med 2018; 6:2325967118811293. [PMID: 30547042 PMCID: PMC6287319 DOI: 10.1177/2325967118811293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background The effects of remnant tissue preservation on tunnel enlargement after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction have not yet been established. Hypothesis The preservation of ACL remnant tissue may significantly reduce the degree and incidence of tunnel enlargement after anatomic double-bundle ACL reconstruction, while the remnant-preserving procedure may not significantly increase the incidence of tunnel coalition after surgery. Study Design Cohort study; Level of evidence, 2. Methods A total of 79 patients underwent anatomic double-bundle ACL reconstruction. Based on the Crain classification of ACL remnant tissue, 40 patients underwent the remnant-preserving procedure (group P), and the remaining 39 patients underwent the remnant-resecting procedure (group R). There were no differences between the 2 groups concerning all background factors, including preoperative knee instability and intraoperative tunnel positions. All patients were examined using computed tomography and a standard physical examination at 2 weeks and 1 year after surgery. Results During surgery, the femoral and tibial anteromedial (AM) tunnel sizes in both groups averaged 6.6 and 6.5 mm, respectively. The femoral and tibial posterolateral (PL) tunnel sizes in both groups averaged 6 and 6 mm, respectively. There were no differences in the intraoperative tunnel positions and tunnel sizes between groups. Concerning the femoral AM tunnel, the degree of tunnel enlargement in the oblique coronal and oblique axial views in group P was significantly less than that in group R (P = .0068 and .0323, respectively). Regarding the femoral AM tunnel cross-sectional area, the degree and incidence of tunnel enlargement in group P were significantly less than those in group R (P = .0086 and .0278, respectively). There were no significant differences in tunnel coalition between groups. In each group, there were no significant relationships between tunnel enlargement and each clinical outcome. Conclusion Remnant preservation in anatomic double-bundle ACL reconstruction reduced enlargement of the femoral AM tunnel and did not increase the incidence of tunnel coalition. This is one of the advantages of remnant-preserving ACL reconstruction.
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Affiliation(s)
- Tetsuro Masuda
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Eiji Kondo
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Advanced Therapeutic Research for Sports Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Jun Onodera
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Nobuto Kitamura
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masayuki Inoue
- Department of Orthopaedic Surgery, NTT East Sapporo Hospital, Sapporo, Japan
| | - Eiichi Nakamura
- Department of Orthopaedic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tomonori Yagi
- Department of Orthopaedic Surgery, Yagi Orthopaedic Hospital, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazunori Yasuda
- Sports Medicine and Arthroscopy Center, Yagi Orthopaedic Hospital, Sapporo, Japan
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Takata Y, Nakase J, Oshima T, Shimozaki K, Asai K, Tsuchiya H. No difference in the graft shift between a round and a rounded rectangular femoral tunnel for anterior cruciate ligament reconstruction: an experimental study. Arch Orthop Trauma Surg 2018; 138:1249-1255. [PMID: 29770879 DOI: 10.1007/s00402-018-2958-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We developed a novel technique of creating a rounded rectangular femoral bone tunnel for anatomical, single-bundle, autologous hamstring tendon anterior cruciate ligament (ACL) reconstruction. Although this tunnel has many advantages, its non-circular shape has raised concerns regarding excessive graft shift within the bone tunnel. This study aimed to compare the graft shift between round and rounded rectangular tunnels using a graft diameter tester for simulating the femoral bone tunnel. MATERIALS AND METHODS Seven semitendinosus tendon grafts harvested from fresh-frozen cadavers were prepared by removing all excess soft tissue. The two ends of a double-fold hamstring tendon were sutured using a baseball stitch and then looped over a TightRope (Arthrex Co., Ltd., Naples, Florida, USA) to make a fourfold graft. The diameter of the graft was standardized to 8 mm using a round graft diameter tester. A round and an original rounded rectangular graft diameter tester were used for simulating the respective femoral bone tunnels. The graft was inserted into the tunnel, with the TightRope positioned on the outside of the tunnel. The distal end of the graft was tensioned to 40 N at an angle of 75° to reproduce the most severe graft bending angle. Digital photographs of the tunnel aperture taken at each simulated tunnel and the range of graft shift in the simulated tunnel were analyzed by ImageJ software. Statistical analyses were performed using the Tukey test. P < 0.05 was considered to be significant. RESULTS There were no significant differences between the round and the rounded rectangular tunnel groups (P > 0.05) in terms of graft shift, gap area, and graft shift ratio. CONCLUSION In a simulated ACL reconstruction, there is no difference in the graft shift between a round and a rounded rectangular bone tunnel.
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Affiliation(s)
- Yasushi Takata
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Takeshi Oshima
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kengo Shimozaki
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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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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Richter DJ, Lyon R, Van Valin S, Liu XC. Current Strategies and Future Directions to Optimize ACL Reconstruction in Adolescent Patients. Front Surg 2018; 5:36. [PMID: 29761106 PMCID: PMC5937439 DOI: 10.3389/fsurg.2018.00036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 04/19/2018] [Indexed: 11/13/2022] Open
Abstract
The incidence of anterior cruciate ligament (ACL) injuries in the pediatric population has risen in recent years. These injuries have historically presented a management dilemma in skeletally immature patients with open physes and significant growth remaining at time of injury. While those nearing skeletal maturity may be treated with traditional, transphyseal adult techniques, these same procedures risk iatrogenic damage to the growth plates and resultant growth disturbances in younger patients with open physes. Moreover, conservative management is non-optimal as significant instabilities of the knee remain. Despite the development of physeal-sparing reconstructive techniques for younger patients, there remains debate over which procedure may be most suitable on a patient to patient basis. Meanwhile, the drivers behind clinical and functional outcomes following ACL reconstruction remain poorly understood. Therefore, current strategies are not yet capable of optimizing surgical ACL reconstruction on an individualized basis with absolute confidence. Instead, aims to improve surgical treatment of ACL tears in skeletally immature patients will rely on additional approaches in the near future. Namely, finite element models have emerged as a tool to model complex knee joint biomechanics. The inclusion of several individualized variables such as bone age, three dimensional geometries around the knee joint, tunnel positioning, and graft tension collectively present a possible means of better understanding and even predicting how to enhance surgical decision-making. Such a tool would serve surgeons in optimizing ACL reconstruction in the skeletally immature individuals, in order to improve clinical outcomes as well as reduce the rate of post-operative complications.
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Affiliation(s)
- Dustin Jon Richter
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Roger Lyon
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Orthopaedic Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - Scott Van Valin
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Orthopaedic Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - Xue-Cheng Liu
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Orthopaedic Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, United States
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23
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Stress distribution is deviated around the aperture of the femoral tunnel in the anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:1145-1151. [PMID: 28401277 DOI: 10.1007/s00167-017-4543-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/04/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Final tunnel location in the anterior cruciate ligament (ACL) reconstruction is unpredictable due to tunnel widening and/or transposition. The mechanical stress around the tunnel aperture seems to be a major factor but is not fully investigated. The purpose of this study was to measure the stress from the ACL graft around the tunnel aperture when the ACL graft tension reaches its peak. METHODS Six cadaveric knees were used. Single-bundle ACL reconstruction was performed using a hamstrings graft. Both femoral and tibial tunnels were created at the centre of the original ACL footprint. A 7-mm-internal-diameter aluminium cylinder with pressure sensors was placed in the femoral tunnel. Hamstrings graft with a microtension sensor was inserted. After fixation, passive extension-flexion was performed while monitoring the tunnel aperture pressure and the graft tension simultaneously. The pressure on the femoral tunnel aperture when the ACL graft tension reach its peak was compared between four directions. RESULTS The ACL graft tension peaked (67 ± 49 N) at full extension (-5.8 ± 4.1°). Pressure at the femoral tunnel aperture was different between different directions (p < 0.01). Distal part had significantly larger pressure (1.7 ± 1.3 MPa) than the other directions (p < 0.01). Second largest pressure was carried in the anterior part (0.6 ± 0.5 MPa), followed by proximal and posterior parts (0.4 ± 0.3, 0.2 ± 0.2 MPa respectively). CONCLUSION The stress distribution at the femoral tunnel aperture is not equal in different directions, while the distal part dominantly bears the stress from the ACL graft. Surgeons should pay close attention to the distal edge of the femoral tunnel which should be inside the anatomic ACL footprint eventually.
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Calcium phosphate-hybridized tendon grafts reduce femoral bone tunnel enlargement in anatomic single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:500-507. [PMID: 28748492 DOI: 10.1007/s00167-017-4657-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aimed to clarify the effect of calcium phosphate (CaP)-hybridized tendon grafting versus unhybridized tendon grafting on the morphological changes to the bone tunnels at the aperture 1 year after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS Seventy-three patients were randomized to undergo the CaP (n = 37) or the conventional method (n = 36). All patients underwent computed tomography (CT) evaluation 1 week and 1 year post-operatively. The femoral and tibial tunnels at the aperture were evaluated on reconstructed 3D CT images. Changes in the cross-sectional area (CSA) and diameters of the femur and the tibia, and the translation rate of the tunnel walls and the morphological changes of both tunnels were assessed. RESULTS There was a significant reduction in the increase in the CSA and the anterior-posterior and proximal-distal tunnel diameters on the femoral side in the CaP group as compared with the conventional group. On the femoral side, the translation rate of the posterior wall was significantly larger in the CaP group than in the conventional group, whereas the translation rate of the distal wall was significantly smaller in the CaP group than in the conventional group. CONCLUSIONS As compared with the conventional method, the CaP-hybridized tendon graft reduced bone tunnel enlargement on the femoral side 1 year after anatomic single-bundle ACL reconstruction due to an anterior shift of the posterior wall and reduced distal shift in the femoral bone tunnel. Clinically, the CaP-hybridized tendon grafts can prevent femoral bone tunnel enlargement in anatomic single-bundle ACL reconstruction. LEVEL OF EVIDENCE I.
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25
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Furumatsu T, Ozaki T. Iatrogenic injury of the lateral meniscus anterior insertion following anterior cruciate ligament reconstruction: A case report. J Orthop Sci 2018; 23:197-201. [PMID: 27251565 DOI: 10.1016/j.jos.2016.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 04/21/2016] [Accepted: 04/26/2016] [Indexed: 02/09/2023]
Affiliation(s)
- Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan.
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
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26
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Mayr R, Smekal V, Koidl C, Coppola C, Fritz J, Rudisch A, Kranewitter C, Attal R. Tunnel widening after ACL reconstruction with aperture screw fixation or all-inside reconstruction with suspensory cortical button fixation: Volumetric measurements on CT and MRI scans. Knee 2017; 24:1047-1054. [PMID: 28705571 DOI: 10.1016/j.knee.2017.06.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/17/2017] [Accepted: 06/07/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tunnel widening after anterior cruciate ligament reconstruction (ACLR) is influenced by the surgical and fixation techniques used. Computed tomography (CT) is the most accurate image modality for assessing tunnel widening, but magnetic resonance imaging (MRI) might also be reliable for tunnel volume measurements. In the present study tunnel widening after ACLR using biodegradable interference screw fixation was compared with all-inside ACLR using button fixation, with tunnel volume changes being measured on CT and MRI scans. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS Thirty-three patients were randomly assigned to hamstring ACLR using a biodegradable interference screw or all-inside cortical button fixation. CT and MRI scanning were done at the time of surgery and six months after. Tunnel volume changes were calculated and compared. RESULTS On CT, femoral tunnel volumes changed from the postoperative state (100%) to 119.8% with screw fixation and 143.2% with button fixation (P=0.023). The changes in tibial tunnel volumes were not significant (113.9% vs. 117.7%). The changes in bone tunnel volume measured on MRI were comparable with those on CT only for tunnels with interference screws. Tibial tunnels with button fixation were significantly underestimated on MRI scanning (P=0.018). CONCLUSIONS All-inside ACLR using cortical button fixation results in increased femoral tunnel widening in comparison with ACLR with biodegradable interference screw fixation. MRI represents a reliable imaging modality for future studies investigating tunnel widening with interference screw fixation.
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Affiliation(s)
- Raul Mayr
- Department of Trauma Surgery, Medical University of Innsbruck, Austria
| | | | - Christian Koidl
- Department of Trauma Surgery, Medical University of Innsbruck, Austria
| | - Christian Coppola
- Department of Trauma Surgery, Medical University of Innsbruck, Austria
| | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Austria
| | - Ansgar Rudisch
- Department of Radiology, Medical University of Innsbruck, Austria
| | | | - René Attal
- Department of Trauma Surgery, Medical University of Innsbruck, Austria.
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27
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Shimizu R, Adachi N, Ishifuro M, Nakamae A, Ishikawa M, Deie M, Ochi M. Bone tunnel change develops within two weeks of double-bundle anterior cruciate ligament reconstruction using hamstring autograft: A comparison of different postoperative immobilization periods using computed tomography. Knee 2017; 24:1055-1066. [PMID: 28803035 DOI: 10.1016/j.knee.2017.06.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 05/29/2017] [Accepted: 06/26/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate bone tunnel changes following anterior cruciate ligament (ACL) reconstruction during the early postoperative period using computed tomography (CT), and to understand the impact of postoperative immobilization on these changes. METHODS Twenty patients who underwent double-bundle ACL reconstruction using hamstring tendon autografts were included. We subcategorized patients into two groups: patients who underwent isolated ACL reconstruction and had three days of knee immobilization (Group A, n=10); and patients with concomitant meniscus injuries who underwent ACL reconstruction and meniscus repair simultaneously (Group B, n=10) had their knees immobilized for two weeks after surgery. Bone tunnel enlargement was evaluated using CT imaging at one to three days, two weeks, one month, three months and six months after surgery. The cross-sectional area of the femoral and tibial tunnels was measured, and enlargement rate was calculated. The tunnel center location at two weeks after surgery was also evaluated. RESULTS The mean cross-sectional area adjacent to the joint space of the femoral and tibial tunnels significantly increased immediately after surgery, especially in the first month (P<0.01). However, after one to six months they were not increased (P>0.01). There was no significant difference in tunnel enlargement rate between group A and B. Tunnel center location changed even in the first two weeks. CONCLUSIONS Bone tunnel enlargement following double-bundle ACL reconstruction occurred at an earlier time point after surgery than anticipated. Postoperative immobilization could not prevent bone tunnel enlargement, but might prevent tunnel migration.
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Affiliation(s)
- Ryo Shimizu
- Department of Orthopaedic Surgery, Division of Clinical Medical Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Division of Clinical Medical Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Minoru Ishifuro
- Department of Higher Medical Imaging, Hiroshima University Hospital Clinical Support, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Atsuo Nakamae
- Department of Orthopaedic Surgery, Division of Clinical Medical Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Masakazu Ishikawa
- Department of Orthopaedic Surgery, Division of Clinical Medical Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Masataka Deie
- Department of Orthopaedic Surgery, Aichi Medical University Hospital, 1-1 Yasakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Mitsuo Ochi
- Hiroshima University, 1-3-2 Kagamiyama, Higashihiroshima, Hiroshima 739-8511, Japan
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de Beus A, Koch JE, Hirschmann A, Hirschmann MT. How to evaluate bone tunnel widening after ACL reconstruction - a critical review. Muscles Ligaments Tendons J 2017; 7:230-239. [PMID: 29264333 DOI: 10.11138/mltj/2017.7.2.230] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Comparing different imaging modalities and methods for assessment tunnel widening after ACL reconstruction and providing a detailed evidence-based literature overview. Methods PubMed was searched from 1970 to 2016 using the terms "ACL reconstruction" and "tunnel" and "imaging" or "CT" or "computerized tomography" or "MRI" or "magnetic resonance imaging" or "radiographs". 647 studies were found. 575 articles were excluded due to absence of specific radiological measurement methods of tunnel widening and 40 due to repetition of a previously published radiological measurement method. 32 articles were included reporting interand intraobserver reliabilities of tunnel measurement methods after ACL reconstruction. Results A variety of different algorithms and measurement methods using radiographs, magnetic resonance imaging, computed tomography or SPECT/CT evaluating tunnel position and bone tunnel enlargement have been described. Tunnel delination restricts an exact analysis using X-ray. Measurements using CT or MR were mostly obtained perpendicular to the tunnel axis or using specialized software for tunnel volume calculation in 3D.Based on the review the width of the femoral and tibial tunnels should be assessed perpendicular to the tunnel axis at different levels in relation to the joint. At least one measurement should be performed at the tunnel entrance, exit and midpoint of the tunnel. Conclusion CT should be considered the gold standard assessing tunnel widening in patients after ACL reconstruction. If specialized software is available calculating the tunnel volume, measurements should be preferably performed in 3D CT. Level of evidence II.
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Affiliation(s)
- Arjan de Beus
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Jonathan Ej Koch
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Anna Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
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Ohori T, Mae T, Shino K, Tachibana Y, Sugamoto K, Yoshikawa H, Nakata K. Morphological changes in tibial tunnels after anatomic anterior cruciate ligament reconstruction with hamstring tendon graft. J Exp Orthop 2017; 4:30. [PMID: 28916912 PMCID: PMC5602815 DOI: 10.1186/s40634-017-0104-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/04/2017] [Indexed: 02/05/2023] Open
Abstract
Background Three-dimensional (3D) reconstructed computed tomography (CT) is crucial for the reliable and accurate evaluation of tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purposes of this study were to evaluate the tibial tunnel enlargement at the tunnel aperture and inside the tunnel and to clarify the morphological change at the tunnel footprint 1 year after the anatomic triple-bundle (ATB) ACL reconstruction using 3D CT models. Methods Eighteen patients with unilateral ACL rupture were evaluated. The ATB ACL reconstruction with a semitendinosus tendon autograft was performed. 3D computer models of the tibia and the three tibial tunnels were reconstructed from CT data obtained 3 weeks and 1 year after surgery. The cross-sectional areas (CSAs) of the two anterior and the one posterior tunnels were measured at the tunnel aperture and 5 and 10 mm distal from the aperture and compared between the two periods. The locations of the center and the anterior, posterior, medial, and lateral edges of each tunnel footprint were also measured and compared between the two periods. Results The CSA of the posterior tunnel was significantly enlarged at the aperture by 40.4%, whereas that of the anterior tunnels did not change significantly, although the enlargement rate was 6.1%. On the other hand, the CSA was significantly reduced at 10 mm distal from the aperture in the anterior tunnels. The enlargement rate in the posterior tunnel was significantly greater than that in the anterior tunnels at the aperture. The center of the posterior tunnel footprint significantly shifted postero-laterally. The anterior and posterior edges of the posterior tunnel footprint demonstrated a significant posterior shift, while the lateral edge significantly shifted laterally. There was no significant shift of the center or all the edges of the anterior tunnels footprint. Conclusions The posterior tibial tunnel was significantly enlarged at the aperture by 40% with the morphological change in the postero-lateral direction reflected by the ACL fiber orientation 1 year after the ATB ACL reconstruction. The proper tibial tunnel location in the ACL reconstruction should be determined considering the tunnel enlargement in postero-lateral direction after surgery.
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Affiliation(s)
- Tomoki Ohori
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Konsei Shino
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Yuta Tachibana
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Kazuomi Sugamoto
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
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Taketomi S, Inui H, Tahara K, Shirakawa N, Tanaka S, Nakagawa T. Effects of initial graft tension on femoral tunnel widening after anatomic anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft. Arch Orthop Trauma Surg 2017; 137:1285-1291. [PMID: 28616652 DOI: 10.1007/s00402-017-2728-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The effects of initial graft tension upon tunnel widening (TW) following anatomic anterior cruciate ligament (ACL) reconstruction have not been elucidated. The purpose of this study was to retrospectively investigate the effect of two different graft-tensioning protocols upon femoral TW following anatomic ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft and a three-dimensional (3D) computed tomography (CT) model. METHODS Forty-three patients who underwent isolated ACL reconstruction using BPTB grafts were included in this study. In 18 out of the 43 patients, the graft was fixed at full knee extension with manual maximum pull (Group H). These patients were compared with 25 patients in whom the BPTB graft was fixed at full knee extension with 80-N pull (Group L). Tunnel aperture area was measured using 3D CT 1 week and 1 year postoperatively, thus enabling us to calculate the percentage change in the area of femoral tunnel aperture. Clinical assessment was performed 1 year postoperatively, corresponding to the time period of CT assessment, and involved the evaluation of Lysholm score, anterior knee stability using a KneeLax3 arthrometer, and the pivot-shift test. RESULTS When measured at 1 year postoperatively, the mean area of the femoral tunnel aperture had increased by 78.6 ± 36.8% in Group H when compared with at 1 week postoperatively, whereas that of Group L had increased by 27.7 ± 32.3%. Furthermore, TW (%) in Group H was significantly greater than that of Group L (P < 0.001). No significant differences were detected between the two groups with regard to any of the clinical outcomes evaluated. CONCLUSION High levels of initial graft tension resulted in greater TW of the femoral tunnel aperture following anatomical ACL reconstruction using BPTB grafts. However, such levels of graft tension did not affect clinical outcome.
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Affiliation(s)
- Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroshi Inui
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keitaro Tahara
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuyuki Shirakawa
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takumi Nakagawa
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
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Onodera J, Yasuda K, Masuda T, Tanabe Y, Kitamura N, Yagi T, Kondo E. Is the Grafted Tendon Shifted Anteriorly in the Femoral Tunnel at the Postremodeling Phase After Anterior Cruciate Ligament Reconstruction? A Clinical MRI Study. Orthop J Sports Med 2017; 5:2325967117711120. [PMID: 28680891 PMCID: PMC5480636 DOI: 10.1177/2325967117711120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Based on previous in vitro studies, it has been commonly believed that during anterior cruciate ligament (ACL) reconstruction with hamstring tendon, the grafted tendon is shifted anteriorly in the tunnel permanently after the graft is anchored to the tunnel wall. However, this has not been proven by in vivo studies. HYPOTHESIS At 1 year after anatomic double-bundle ACL reconstruction, the grafted tendons may not be shifted anteriorly in the femoral tunnel but anchored to the bony wall at the center of the tunnel. STUDY DESIGN Case series; Level of evidence, 4. METHODS Participants consisted of 40 patients who underwent anatomic double-bundle ACL reconstruction. The grafted tendons located in the femoral tunnel were examined 1 year after surgery using 2 different magnetic resonance imaging (MRI) protocols. In the first substudy, with 20 patients, the grafted tendon location was evaluated on an inclined sagittal multiplanar reconstruction (MPR) image taken using a standard T2-weighted protocol. In the second substudy with the remaining 20 patients, tendon location was evaluated on a pure axial MPR image taken using a VISTA (volume isotropic turbo spin echo acquisition) protocol. RESULTS On the inclined sagittal T2-weighted images of the anteromedial (AM) graft, the anterior width of the newly formed fibrous tissue, which surrounded the tendon graft, was significantly greater than the posterior width (P = .001). The center of the grafted tendon was slightly (mean, 2.5% of the tunnel diameter) but significantly (P = .0310) shifted posteriorly from the tunnel center. On the axial T2-VISTA images, the center of the AM graft was slightly but significantly shifted posteriorly (3.9%; P = .022) and medially (5.5%; P = .002) from the tunnel center. The center of the posterolateral (PL) graft was not significantly shifted to any direction from the center of the tunnel. CONCLUSION The grafted tendons were not shifted anteriorly in the femoral tunnel 1 year after anatomic double-bundle ACL reconstruction. The PL graft was located approximately at the center of the tunnel outlet, while the AM graft was slightly but significantly shifted posteriorly and proximally.
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Affiliation(s)
- Jun Onodera
- Department of Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazunori Yasuda
- Department of Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Research Center for Knee Surgery, Yagi Orthopaedic Hospital, Sapporo, Japan
| | - Tetsuro Masuda
- Department of Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshie Tanabe
- Department of Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuto Kitamura
- Department of Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tomonori Yagi
- Research Center for Knee Surgery, Yagi Orthopaedic Hospital, Sapporo, Japan
| | - Eiji Kondo
- Department of Advanced Therapeutic Research for Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Qin L, Li M, Yao W, Shen J. Relationship between bony tunnel and knee function in patients after patellar dislocation triple surgeries-a CT-based study. Sci Rep 2017; 7:41360. [PMID: 28120923 PMCID: PMC5264162 DOI: 10.1038/srep41360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 12/19/2016] [Indexed: 01/11/2023] Open
Abstract
We aimed to assess the CT-based bony tunnel valuations and their correlation with knee function after patellar dislocation triple surgeries. A retrospective study was performed on 66 patients (70 knees) who underwent patellar dislocation triple surgeries. The surgery was MPFL reconstruction primarily, combined with lateral retinaculum release and tibial tubercle osteotomy. CT examinations were performed to determine the femoral tunnel position, along with the patellar and femoral tunnel width 3 days and more than 1 year after operation for follow-up. Functional evaluation based on Kujala and Lysholm scores was also implemented. We compared tunnel width of the first and last examinations and correlated femoral tunnel position of the last examination with knee function. At the last follow-up, femoral tunnel position in the anterior-posterior direction was moderately correlated with knee function. Femoral tunnel position in the proximal-distal direction was not associated with postoperative knee function. Patellar and femoral tunnel width increased significantly at the last follow-up. However, no significant functional difference was found between patients with and without femoral tunnel enlargement. Our results suggested that the tunnel malposition in anterior-posterior position based on CT was related to impaired knee function during the follow-ups.
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Affiliation(s)
- Le Qin
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Mei Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Weiwu Yao
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Ji Shen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
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Lee DH, Kim HJ, Ahn HS, Bin SI. Comparison of femur tunnel aperture location in patients undergoing transtibial and anatomical single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2016; 24:3713-3721. [PMID: 26040654 DOI: 10.1007/s00167-015-3657-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 05/19/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE Although three-dimensional computed tomography (3D-CT) has been used to compare femoral tunnel position following transtibial and anatomical anterior cruciate ligament (ACL) reconstruction, no consensus has been reached on which technique results in a more anatomical position because methods of quantifying femoral tunnel position on 3D-CT have not been consistent. This meta-analysis was therefore performed to compare femoral tunnel location following transtibial and anatomical ACL reconstruction, in both the low-to-high and deep-to-shallow directions. METHODS This meta-analysis included all studies that used 3D-CT to compare femoral tunnel location, using quadrant or anatomical coordinate axis methods, following transtibial and anatomical (AM portal or OI) single-bundle ACL reconstruction. RESULTS Six studies were included in the meta-analysis. Femoral tunnel location was 18 % higher in the low-to-high direction, but was not significant in the deep-to-shallow direction, using the transtibial technique than the anatomical methods, when measured using the anatomical coordinate axis method. When measured using the quadrant method, however, femoral tunnel positions were significantly higher (21 %) and shallower (6 %) with transtibial than anatomical methods of ACL reconstruction. CONCLUSION The anatomical ACL reconstruction techniques led to a lower femoral tunnel aperture location than the transtibial technique, suggesting the superiority of anatomical techniques for creating new femoral tunnels during revision ACL reconstruction in femoral tunnel aperture location in the low-to-high direction. However, the mean difference in the deep-to-shallow direction differed by method of measurement. LEVEL OF EVIDENCE Meta-analysis, Level II.
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Affiliation(s)
- Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyeong-Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, 388-1, Poongnap-2dong, Songpa-gu, Seoul, 138-736, Korea.
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Irvine JN, Arner JW, Thorhauer E, Abebe ES, D'Auria J, Schreiber VM, Harner CD, Tashman S. Is There a Difference in Graft Motion for Bone-Tendon-Bone and Hamstring Autograft ACL Reconstruction at 6 Weeks and 1 Year? Am J Sports Med 2016; 44:2599-2607. [PMID: 27411358 DOI: 10.1177/0363546516651436] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone-patellar tendon-bone (BTB) grafts are generally believed to heal more quickly than soft tissue grafts after anterior cruciate ligament (ACL) reconstruction, but little is known about the time course of healing or motion of the grafts within the bone tunnels. HYPOTHESIS Graft-tunnel motion will be greater in hamstring (HS) grafts compared with BTB grafts and will be less at 1 year than at 6 weeks. STUDY DESIGN Controlled laboratory study. METHODS Twelve patients underwent anatomic single-bundle ACL reconstruction using HS or BTB autografts (6 per group) with six 0.8-mm tantalum beads embedded in each graft. Dynamic stereo x-ray images were collected at 6 weeks and 1 year during treadmill walking and stair descent and at 1 year during treadmill running. Tibiofemoral kinematics and bead positions were evaluated. Graft-tunnel motion was based on bead range of motion during the loading response phase (first 10%) of the gait cycle. RESULTS During treadmill walking, there was no difference in femoral tunnel or tibial tunnel motion between BTB or HS grafts at 6 weeks (BTB vs HS: 2.00 ± 1.05 vs 1.25 ± 0.67 mm [femoral tunnel]; 1.20 ± 0.63 vs 1.27 ± 0.71 mm [tibial tunnel]), or 1 year (BTB vs HS: 1.62 ± 0.76 vs 1.08 ± 0.26 mm [femoral tunnel]; 1.58 ± 0.75 vs 1.68 ± 0.53 mm [tibial tunnel]). During stair descent, there was no difference in femoral or tibial tunnel motion between BTB and HS grafts at 6 weeks or 1 year. With running, there was no difference between graft types at 1 year. For all results, P values were > .05. Knee kinematics were consistent with the literature. CONCLUSION During walking and stair descent, ACL reconstruction using suspensory fixation yielded no difference between graft types in femoral or tibial tunnel motion at 6 weeks or 1 year. All subjects were asymptomatic with knee kinematics similar to that of the literature. The significance of persistent, small (1 to 3 mm) movements at 1 year for healing or graft performance is unknown. CLINICAL RELEVANCE These study results may have significant implications for graft choice, rehabilitation strategies, and timing for return to sports.
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Affiliation(s)
- James N Irvine
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Justin W Arner
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eric Thorhauer
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Ermias S Abebe
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jennifer D'Auria
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Verena M Schreiber
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Fujii M, Sasaki Y, Araki D, Furumatsu T, Miyazawa S, Ozaki T, Linde-Rosen M, Smolinski P, Fu FH. Evaluation of the semitendinosus tendon graft shift in the bone tunnel: an experimental study. Knee Surg Sports Traumatol Arthrosc 2016; 24:2773-2777. [PMID: 25472684 DOI: 10.1007/s00167-014-3461-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/21/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to measure the semitendinosus tendon graft shift at the tunnel aperture with graft bending using a simulated femoral bone tunnel. METHODS Eight semitendinosus tendon grafts were used in this study. The median age of the specimen was 53 years (range 46-63). After stripping excess soft tissue, the semitendinosus tendon was doubled over the loop of the EndoButton CL (Smith and Nephew Inc.). The diameter of the graft was measured using a graft-sizing tube (Smith and Nephew Inc.) and verified to be 7.0 mm. A custom-made aluminium fixture, the size was 40.0 mm(3), with 7.0-mm-diameter hole was used as a simulated femoral bone tunnel. The graft was inserted to the tunnel, and EndoButton was positioned to the outside of the tunnel on the fixture. The distal end of the graft was tensioned with 30 N at an angle of 15°, 30°, 45°, 60°, 75° that reproduced the graft bending angle during knee range of motion. The photograph of the tunnel aperture was taken at each graft bending angle using a digital camera, and the graft shift amount in the simulated tunnel was analysed using the computer software (ImageJ). RESULTS The amount of the graft shift significantly increased when the graft bending angle was increased (P < 0.05). The biggest shift was observed when the graft bending angle was 75° in all specimens, and the value was 1.10 mm ± 0.12. CONCLUSION The present study suggests that even if the femoral tunnel was created in the centre of the ACL insertion site, the graft shifted within the tunnel in the direction of the tension applied to the graft during knee range of motion. Surgeons may have to consider the graft shift within the bone tunnel as well as the tunnel position in the restoration of the native ACL anatomy.
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Affiliation(s)
- Masataka Fujii
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Yusuke Sasaki
- Department of Orthopaedic Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Daisuke Araki
- Department of Orthopaedic Surgery, Kobe University, Kobe, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Shinichi Miyazawa
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Monica Linde-Rosen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Furumatsu T, Kodama Y, Maehara A, Miyazawa S, Fujii M, Tanaka T, Inoue H, Ozaki T. The anterior cruciate ligament-lateral meniscus complex: A histological study. Connect Tissue Res 2015; 57:91-8. [PMID: 26631325 DOI: 10.3109/03008207.2015.1081899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The anterior root of the lateral meniscus (LM) dives underneath the tibial attachment of the anterior cruciate ligament (ACL). Although the distinct role of meniscal attachments has been investigated, the relationship between the LM anterior insertion (LMAI) and ACL tibial insertion (ACLTI) remains unclear. This study histologically analyzed the LMAI and ACLTI. Samples were divided into four regions in an anterior-to-posterior direction. Histological measurements of these insertion sites were performed using safranin O-stained coronal sections. Distribution and signal densities of type I and II collagen were quantified. The ACLTI and LMAI formed the ACL-LM complex via fiber connections. The anterior part of the ACLTI had a widespread attachment composed of dense fibers. Attachment fibers of the LMAI became dense and wide gradually at the middle-to-posterior region. The ACL-LM transition zone (ALTZ) was observed between the LMAI and the lateral border of the ACLTI at the middle part of the ACL tibial footprint. Type II collagen density of the LMAI was higher than that of the ACLTI and ALTZ. Our results can help create an accurate tibial bone tunnel within the dense ACL attachment during ACL reconstruction surgery.
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Affiliation(s)
- Takayuki Furumatsu
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
| | - Yuya Kodama
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
| | - Ami Maehara
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
| | - Shinichi Miyazawa
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
| | - Masataka Fujii
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
| | - Takaaki Tanaka
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
| | - Hiroto Inoue
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
| | - Toshifumi Ozaki
- a Department of Orthopaedic Surgery , Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences , Kitaku , Okayama Japan
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Tachibana Y, Mae T, Shino K, Kanamoto T, Sugamoto K, Yoshikawa H, Nakata K. Morphological changes in femoral tunnels after anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:3591-600. [PMID: 25160473 DOI: 10.1007/s00167-014-3252-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/17/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Few studies investigated the enlargement inside the tunnel as well as the morphological change at the aperture after anterior cruciate ligament (ACL) reconstruction, whereas the tunnel enlargement has been well documented. The purposes were to evaluate the change in the cross-sectional area along the femoral tunnel and to morphologically clarify the enlargement at the femoral tunnel aperture after anatomic triple-bundle (ATB) ACL reconstruction. METHODS The study included 15 patients with unilateral ACL rupture. ATB ACL reconstruction was performed using semitendinosus tendon autografts. Three-dimensional computer models of the femur and bone tunnels were reconstructed from computed tomography images obtained 3 weeks and 1 year postoperatively. The cross-sectional area at the aperture as well as inside the tunnel was compared between the two periods. Likewise, the location of tunnel walls and center in the tunnel footprint were evaluated. RESULTS The cross-sectional area enlarged by 22.7 % for anteromedial/intermediate graft (P = 0.002) and 28.6 % for posterolateral graft (P = 0.002) at the aperture, while decreased by 36.2 % at 10 mm from the aperture for anteromedial/intermediate graft (P = 0.004). Both the anterior and posterior walls shifted anteriorly, while the distal wall shifted distally in both tunnels. Consequently, the center in the footprint significantly shifted anteriorly (4.9-6.6 %) and distally (2.2-2.6 %) in both tunnels. CONCLUSIONS The femoral tunnel enlargement occurred at the aperture after ATB ACL reconstruction, but did not occur in the middle of the femoral tunnel. The morphology at the aperture changed with time after surgery as the tunnel walls translated anteriorly and distally. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Yuta Tachibana
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Konsei Shino
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Takashi Kanamoto
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Kazuomi Sugamoto
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
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Pansard E, Klouche S, Vardi G, Greeff E, Hardy P, Ferguson M. How accurate are anatomic landmarks for femoral tunnel positioning in anterior cruciate ligament reconstruction? An in vivo imaging analysis comparing both anteromedial portal and outside-in techniques. Arthroscopy 2015; 31:882-9. [PMID: 25636986 DOI: 10.1016/j.arthro.2014.11.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/07/2014] [Accepted: 11/21/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the ability of 2 independent surgical techniques, an inside-out technique and an outside-in technique, using bony landmarks on the femoral wall, to place the anterior cruciate ligament graft anatomically. METHODS A retrospective single-center study was conducted in 2012 and included patients who underwent anterior cruciate ligament reconstruction. Two techniques were used: The lateral condylar wall was visualized from the anterolateral portal and tunnels were drilled "outside-in" in one group, whereas viewing was performed from the anteromedial portal and retrograde drilling ("inside-out") was performed in the other group. The primary outcome measure was the placement of the tunnel center point on postoperative computed tomography scans with 3-dimensional reconstruction, according to the radiographic quadrant method of Bernard and Hertel. The measurements were compared with optimal placements according to Bird et al. Their reliability was assessed with Spearman (rho) and intraclass correlation coefficients. RESULTS Forty patients were included, with 20 in each group; the mean age was 29.8 ± 9.6 years, and there were 33 men and 7 women. The interobserver reliability and intraobserver reliability of measurements were good, with a Spearman ρ between 0.46 (P = .002) and 0.93 (P < .001) and an intraclass correlation coefficient between 0.44 (P = .001) and 0.86 (P < .001). The femoral tunnel positions of both techniques were close to the previously published anatomic placements, but there was a significant difference between our results and the theoretical position in proximal-distal measurements (P = .01). There was no difference in the anteroposterior measurements. There was no statistical difference in the accuracy of placement of the femoral tunnel center point between these 2 independent techniques. CONCLUSIONS The direct arthroscopic visualization of bony landmarks seems sufficient for accurate positioning of the femoral tunnel whatever the drilling technique. This finding is clinically relevant because the routine use of direct measurement techniques or intraoperative radiographs may not be necessary to obtain anatomic tunnel placement. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Erwan Pansard
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa; Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France; Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France.
| | - Shahnaz Klouche
- Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France; Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France
| | - Glen Vardi
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa
| | - Eugene Greeff
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa
| | - Philippe Hardy
- Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France; Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France
| | - Mark Ferguson
- Rosebank Clinic, Center for Sport Medicine and Orthopaedic Surgery, Johannesburg, South Africa
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