Posteriorly Positioned Femoral Grafts Decrease Long-term Failure in Anterior Cruciate Ligament Reconstruction, Femoral and Tibial Graft Positions Did Not Affect Long-term Reported Outcome

Overview

Journal Knee Surg Sports Traumatol Arthrosc

Publisher Wiley

Specialties Emergency Medicine
General Surgery
Orthopedics

Date 2022 Feb 3

PMID 35112176

Authors

Tim T C R de Mees

Max Reijman

Jan Hendrik Waarsing

Duncan E Meuffels

Affiliations

Soon will be listed here.

Abstract

Purpose: To investigate the effect that femoral and tibial tunnel positions have on long-term reported and clinical outcome and to identify a safe zone based on favourable outcome.

Methods: Seventy-eight patients from a previous randomised controlled trial were included and were followed with a mean follow-up of 11.4 years. All patients had primary trans-tibial anterior cruciate ligament reconstruction performed. The femoral and tibial tunnel positions were visualised and translated in percentages with three-dimensional computed tomography post-operatively. There were 3 separate outcome variables: patient-reported outcome measured with the IKDC Subjective Knee Form, overall failure, and radiographic osteoarthritis. The correlation between tunnel aperture positions and outcome was determined with multivariate regression. The area with best outcome was defined as the safe zone and was determined with Youden's index in conjunction with receiver operating characteristics.

Results: No significant relationship was found between tunnel aperture positions and IKDC Subjective Knee Form at 10-year follow-up. The posterior-to-anterior femoral tunnel aperture position parallel to Blumensaat line showed a significant relationship (p = 0.03) to overall failure at 10-year follow-up. The mean posterior-to-anterior tunnel position of the group that did not fail was 37.7% compared to 44.1% in the overall failure group. Femoral tunnel apertures placed further anteriorly had more overall failures at long-term. The cut-off point lies at 35.0% from posterior-to-anterior parallel to Blumensaat. Of the 16 overall failures, 15 (93.8%) were placed further anteriorly than the cut-off point. No significant relationship was found between tunnel aperture positions and radiographic osteoarthritis.

Conclusion: Femoral and tibial tunnel positions were not associated with long-term patient-reported outcome and radiographic osteoarthritis. Long-term overall failure was more frequently seen in patients with a more anteriorly placed femoral tunnel. This study identified a safe zone located at the most posterior 35% of the femoral condyle parallel to Blumensaat. This knowledge offers guidance to surgeons to operate more precisely and accurately and reconstruct a long-lasting graft.

Level Of Evidence: Level III.

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References

Inderhaug E, Strand T, Fischer-Bredenbeck C, Solheim E . Effect of a too posterior placement of the tibial tunnel on the outcome 10-12 years after anterior cruciate ligament reconstruction using the 70-degree tibial guide. Knee Surg Sports Traumatol Arthrosc. 2013; 22(5):1182-9. DOI: 10.1007/s00167-013-2593-x. View

Westermann R, Wolf B, Elkins J . Optimizing Graft Placement in Anterior Cruciate Ligament Reconstruction: A Finite Element Analysis. J Knee Surg. 2016; 30(2):97-106. DOI: 10.1055/s-0036-1581137. View

Tampere T, Devriendt W, Cromheecke M, Luyckx T, Verstraete M, Victor J . Tunnel placement in ACL reconstruction surgery: smaller inter-tunnel angles and higher peak forces at the femoral tunnel using anteromedial portal femoral drilling-a 3D and finite element analysis. Knee Surg Sports Traumatol Arthrosc. 2018; 27(8):2568-2576. DOI: 10.1007/s00167-018-5272-0. View

Kohn M, Sassoon A, Fernando N . Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis. Clin Orthop Relat Res. 2016; 474(8):1886-93. PMC: 4925407. DOI: 10.1007/s11999-016-4732-4. View

Lertwanich P, Martins C, Asai S, Ingham S, Smolinski P, Fu F . Anterior cruciate ligament tunnel position measurement reliability on 3-dimensional reconstructed computed tomography. Arthroscopy. 2010; 27(3):391-8. DOI: 10.1016/j.arthro.2010.08.018. View

Ahn J, Kim J, Kang H . Anatomic Placement of the Femoral Tunnels in Double-Bundle Anterior Cruciate Ligament Reconstruction Correlates With Improved Graft Maturation and Clinical Outcomes. Arthroscopy. 2015; 31(11):2152-61. DOI: 10.1016/j.arthro.2015.04.098. View

Fernandes T, Fregni F, Weaver K, Pedrinelli A, Camanho G, Hernandez A . The influence of femoral tunnel position in single-bundle ACL reconstruction on functional outcomes and return to sports. Knee Surg Sports Traumatol Arthrosc. 2012; 22(1):97-103. DOI: 10.1007/s00167-012-2288-8. View

Sundemo D, Martensson J, Hamrin Senorski E, Svantesson E, Kartus J, Sernert N . No correlation between femoral tunnel orientation and clinical outcome at long-term follow-up after non-anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019; 27(11):3400-3410. PMC: 6800880. DOI: 10.1007/s00167-019-05366-w. View

Meuffels D, Potters J, Koning A, Brown Jr C, Verhaar J, Reijman M . Visualization of postoperative anterior cruciate ligament reconstruction bone tunnels: reliability of standard radiographs, CT scans, and 3D virtual reality images. Acta Orthop. 2011; 82(6):699-703. PMC: 3247888. DOI: 10.3109/17453674.2011.623566. View

10.

Higgins L, Taylor M, Park D, Ghodadra N, Marchant M, Pietrobon R . Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Joint Bone Spine. 2007; 74(6):594-9. DOI: 10.1016/j.jbspin.2007.01.036. View

11.

Mitchell J, Dean C, Chahla J, Menge T, Cram T, LaPrade R . Posterior Wall Blowout in Anterior Cruciate Ligament Reconstruction: A Review of Anatomic and Surgical Considerations. Orthop J Sports Med. 2016; 4(6):2325967116652122. PMC: 4904427. DOI: 10.1177/2325967116652122. View

12.

Vijayan S, Kyalakond H, Kulkarni M, Aroor M, Shetty S, Bhat V . Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal. Musculoskelet Surg. 2021; 107(1):37-45. PMC: 10020253. DOI: 10.1007/s12306-021-00727-6. View

13.

Achtnich A, Ranuccio F, Willinger L, Pogorzelski J, Imhoff A, Braun S . High incidence of partially anatomic tunnel placement in primary single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017; 26(2):462-467. DOI: 10.1007/s00167-017-4555-1. View

14.

Staubli H, Rauschning W . Tibial attachment area of the anterior cruciate ligament in the extended knee position. Anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo. Knee Surg Sports Traumatol Arthrosc. 1994; 2(3):138-46. DOI: 10.1007/BF01467915. View

15.

Jepsen C, Lundberg-Jensen A, Faunoe P . Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? A clinical, prospective, randomized, double-blind study. Arthroscopy. 2007; 23(12):1326-33. DOI: 10.1016/j.arthro.2007.09.010. View

16.

Seo S, Kim C, Lee C, Kwon Y, Kim M, Kim O . Effect of Femoral Tunnel Position on Stability and Clinical Outcomes After Single-Bundle Anterior Cruciate Ligament Reconstruction Using the Outside-In Technique. Arthroscopy. 2019; 35(6):1648-1655. DOI: 10.1016/j.arthro.2018.11.055. View

17.

Stone A, Chahla J, Manderle B, Beletsky A, Bush-Joseph C, Verma N . ACL Reconstruction Graft Angle and Outcomes: Transtibial vs Anteromedial Reconstruction. HSS J. 2020; 16(Suppl 2):256-263. PMC: 7749890. DOI: 10.1007/s11420-019-09707-w. View

18.

Meuffels D, Reijman M, Verhaar J . Computer-assisted surgery is not more accurate or precise than conventional arthroscopic ACL reconstruction: a prospective randomized clinical trial. J Bone Joint Surg Am. 2012; 94(17):1538-45. DOI: 10.2106/JBJS.K.00878. View

19.

Xu H, Zhang C, Zhang Q, Du T, Ding M, Wang Y . A Systematic Review of Anterior Cruciate Ligament Femoral Footprint Location Evaluated by Quadrant Method for Single-Bundle and Double-Bundle Anatomic Reconstruction. Arthroscopy. 2016; 32(8):1724-34. DOI: 10.1016/j.arthro.2016.01.065. View

20.

Meer B, Meuffels D, Vissers M, Bierma-Zeinstra S, Verhaar J, Terwee C . Knee injury and Osteoarthritis Outcome Score or International Knee Documentation Committee Subjective Knee Form: which questionnaire is most useful to monitor patients with an anterior cruciate ligament rupture in the short term?. Arthroscopy. 2013; 29(4):701-15. DOI: 10.1016/j.arthro.2012.12.015. View