The Journal of Knee Surgery, Table of Contents

J Knee Surg 2022; 35(13): 1467-1473
DOI: 10.1055/s-0041-1726418

Original Article

Reconstruction of the Anterior Cruciate Ligament Using Ruler-Assisted Positioning of the Femoral Tunnel Relative to the Posterior Apex of the Deep Cartilage: A Single-Center Case Series

Yan Dong

¹Department of Orthopedics, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China

,

Jiaguang Tang

¹Department of Orthopedics, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China

,

Peng Cui

¹Department of Orthopedics, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China

,

Songpo Shen

¹Department of Orthopedics, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China

,

Guodong Wang

¹Department of Orthopedics, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China

,

Jian Li

²Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China

,

Xiaochuan Kong

²Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China

,

Gang Hong

²Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China

,

Shuo Yuan

²Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China

,

Lei Zang

²Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China

› Author Affiliations

Abstract

The techniques available to locate the femoral tunnel during anterior cruciate ligament (ACL) reconstruction have notable limitations. To evaluate whether the femoral tunnel center could be located intraoperatively with a ruler, using the posterior apex of the deep cartilage (ADC) as a landmark. This retrospective case series included consecutive patients with ACL rupture who underwent arthroscopic single-bundle ACL reconstruction at the Department of Orthopedics, Beijing Tongren Hospital between January 2014 and May 2018. During surgery, the ADC of the femoral lateral condyle was used as a landmark to locate the femoral tunnel center with a ruler. Three-dimensional computed tomography (CT) was performed within 3 days after surgery to measure the femoral tunnel position by the quadrant method. Arthroscopy was performed 1 year after surgery to evaluate the intra-articular conditions. Lysholm and International Knee Documentation Committee (IKDC) scores were determined before and 1 year after surgery. The final analysis included 82 knees of 82 patients (age = 31.7 ± 6.1 years; 70 males). The femoral tunnel center was 26 ± 1.5% in the deep-shallow (x-axis) direction and 31 ± 3.1% in the high-low (y-axis) direction, close to the “ideal” values of 27 and 34%. Lysholm score increased significantly from 38.5 (33.5–47) before surgery to 89 (86–92) at 1 year after surgery (p < 0.001). IKDC score increased significantly from 42.5 (37–47) before surgery to 87 (83.75–90) after surgery (p < 0.001). Using the ADC as a landmark, the femoral tunnel position can be accurately selected using a ruler.

Keywords

Keywords

anterior cruciate ligament - anatomic reconstruction - ruler - bone tunnel - secondary exploration

References
1 Siegel L, Vandenakker-Albanese C, Siegel D. Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Clin J Sport Med 2012; 22 (04) 349-355
2 Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev 2016; 4: CD011166
3 Alazzawi S, Sukeik M, Ibrahim M, Haddad FS. Surgical treatment of anterior cruciate ligament injury in adults. Br J Hosp Med (Lond) 2016; 77 (04) 227-231
4 Marcio, Bottene, Villa, et al. Individualized anatomical anterior cruciate ligament reconstruction. Oper Tech Orthop 2017
5 Marchant BG, Noyes FR, Barber-Westin SD, Fleckenstein C. Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions. Am J Sports Med 2010; 38 (10) 1987-1996
6 Jepsen CF, Lundberg-Jensen AK, 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) 1326-1333
7 Jorge PB, Escudeiro D, Severino NR. et al. Positioning of the femoral tunnel in anterior cruciate ligament reconstruction: functional anatomical reconstruction. BMJ Open Sport Exerc Med 2018; 4 (01) e000420
8 Hart A, Han Y, Martineau PA. The apex of the deep cartilage: a landmark and new technique to help identify femoral tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy 2015; 31 (09) 1777-1783
9 Ferretti M, Ekdahl M, Shen W, Fu FH. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy 2007; 23 (11) 1218-122
10 Ziegler CG, Pietrini SD, Westerhaus BD. et al. Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med 2011; 39 (04) 743-752
11 van Eck CF, Morse KR, Lesniak BP. et al. Does the lateral intercondylar ridge disappear in ACL deficient patients?. Knee Surg Sports Traumatol Arthrosc 2010; 18 (09) 1184-1188
12 Lee BI, Kwon SW, Kim JB, Choi HS, Min KD. Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. Arthroscopy 2008; 24 (05) 560-568
13 Adachi N, Ochi M, Uchio Y, Iwasa J, Ryoke K, Kuriwaka M. Mechanoreceptors in the anterior cruciate ligament contribute to the joint position sense. Acta Orthop Scand 2002; 73 (03) 330-334
14 Muneta T, Koga H, Ju YJ, Horie M, Nakamura T, Sekiya I. Remnant volume of anterior cruciate ligament correlates preoperative patients' status and postoperative outcome. Knee Surg Sports Traumatol Arthrosc 2013; 21 (04) 906-913
15 Gohil S, Annear PO, Breidahl W. Anterior cruciate ligament reconstruction using autologous double hamstrings: a comparison of standard versus minimal debridement techniques using MRI to assess revascularisation. A randomised prospective study with a one-year follow-up. J Bone Joint Surg Br 2007; 89 (09) 1165-1171
16 Elazab A, Lee YS, Kang SG. Femoral footprint reconstruction with a direct viewing of the posterior insertion using a trans-septal portal in the outside-in anterior cruciate ligament reconstruction. Arthrosc Tech 2015; 5 (01) e49-e54
17 Lee SH, Lee ES, Ko TW, Lee YS. Femoral tunnel placement in single-bundle, remnant-preserving anterior cruciate ligament reconstruction using a posterior trans-septal portal. Knee 2019; 26 (03) 628-635
18 Forsythe B, Kopf S, Wong AK. et al. The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models. J Bone Joint Surg Am 2010; 92 (06) 1418-1426
19 Bird JH, Carmont MR, Dhillon M. et al. Validation of a new technique to determine midbundle femoral tunnel position in anterior cruciate ligament reconstruction using 3-dimensional computed tomography analysis. Arthroscopy 2011; 27 (09) 1259-1267
20 Kumar S, Kumar A, Kumar R. Accurate positioning of femoral and tibial tunnels in single bundle anterior cruciate ligament reconstruction using the indigenously made bernard and hurtle grid on a transparency sheet and C-arm. Arthrosc Tech 2017; 6 (03) e757-e761
21 Inderhaug E, Larsen A, Strand T, Waaler PA, Solheim E. The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2016; 24 (01) 154-160
22 Sirleo L, Innocenti M, Innocenti M, Civinini R, Carulli C, Matassi F. Post-operative 3D CT feedback improves accuracy and precision in the learning curve of anatomic ACL femoral tunnel placement. Knee Surg Sports Traumatol Arthrosc 2018; 26 (02) 468-477
23 Ahn JH, Kim S, Kim J. Is intraoperative fluoroscopy necessary in anterior cruciate ligament double-bundle reconstruction? A prospective randomized controlled trial. Orthop Traumatol Surg Res 2019; 105 (06) 1093-1099
24 Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken) 2011; 63 (Suppl. 11) S208-S228
25 Chung KS, Ha JK, Ra HJ, Kim SB, Lee GH, Kim JG. Does synovialization after anterior cruciate ligament reconstruction have a positive effect on functional performance, outcomes scores, stability and muscle strength? A 2-year follow-up study after reconstruction. Arch Orthop Trauma Surg 2017; 137 (12) 1725-1733
26 Ahn JH, Yoo JC, Yang HS, Kim JH, Wang JH. Second-look arthroscopic findings of 208 patients after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2007; 15 (03) 242-248
27 Luites JWH, Verdonschot N. Radiographic positions of femoral ACL, AM and PL centres: accuracy of guidelines based on the lateral quadrant method. Knee Surg Sports Traumatol Arthrosc 2017; 25 (08) 2321-2329
28 Bali K, Dhillon MS, Vasistha RK, Kakkar N, Chana R, Prabhakar S. Efficacy of immunohistological methods in detecting functionally viable mechanoreceptors in the remnant stumps of injured anterior cruciate ligaments and its clinical importance. Knee Surg Sports Traumatol Arthrosc 2012; 20 (01) 75-80
29 Moloney G, Araujo P, Rabuck S. et al. Use of a fluoroscopic overlay to assist arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med 2013; 41 (08) 1794-1800
30 Inderhaug E, Larsen A, Waaler PA, Strand T, Harlem T, Solheim E. The effect of intraoperative fluoroscopy on the accuracy of femoral tunnel placement in single-bundle anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25 (04) 1211-1218
31 Hoshino Y, Kuroda R, Nishizawa Y. et al. 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 (04) 1145-1151
32 Kazusa H, Nakamae A, Ochi M. Augmentation technique for anterior cruciate ligament injury. Clin Sports Med 2013; 32 (01) 127-140
33 Nawabi DH, Tucker S, Schafer KA. et al. ACL fibers near the lateral intercondylar ridge are the most load bearing during stability examinations and isometric through passive flexion. Am J Sports Med 2016; 44 (10) 2563-2571
34 Iriuchishima T, Ryu K, Aizawa S, Fu FH. Blumensaat's line is not always straight: morphological variations of the lateral wall of the femoral intercondylar notch. Knee Surg Sports Traumatol Arthrosc 2016; 24 (09) 2752-2757
35 Iriuchishima T, Goto B, Ryu K, Fu FH. The Blumensaat's line morphology influences to the femoral tunnel position in anatomical ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27 (11) 3638-3643
36 Iwasaki K, Inoue M, Kasahara Y. et al. Inclination of Blumensaat's line influences on the accuracy of the quadrant method in evaluation for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28 (06) 1885-1893
37 Yahagi Y, Iriuchishima T, Horaguchi T, Suruga M, Tokuhashi Y, Aizawa S. The importance of Blumensaat's line morphology for accurate femoral ACL footprint evaluation using the quadrant method. Knee Surg Sports Traumatol Arthrosc 2018; 26 (02) 455-461