A Femoral Tunnel View Test During ACL Reconstruction.
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ABSTRACT:
SUBMITTER: Temponi EF
PROVIDER: S-EPMC5621967 | biostudies-literature | 2017 Aug
REPOSITORIES: biostudies-literature
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A Femoral Tunnel View Test During ACL Reconstruction.
Temponi Eduardo Frois EF Oliveira João Newton Penido JNP Soares Luiz Fernando Machado LFM de Carvalho Júnior Lúcio Honório LH
Arthroscopy techniques 20170731 4
Despite technologic advances in the surgical techniques for anterior cruciate ligament (ACL) reconstruction, some patients continue to have violation of the femoral cortex, commonly referred to as wall blowout. These posterior or lateral cortical breaches lead to loss of graft containment and subsequent difficulty with graft fixation. If this intraoperative error is not promptly recognized and treated, the graft is at an increased risk of premature failure. Thus, in these situations, recognizing ...[more]
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Project description:BackgroundIndependent transtibial pullout repair is a common surgical technique for repairing lateral meniscus posterior root tears (LMPRTs). The shared anterior cruciate ligament (ACL) bone tunnel technique is an alternative technique for LMPRT repair combined with ACL reconstruction (ACLR) to avoid the establishment of additional bone tunnels.PurposeTo compare the clinical outcomes of the shared ACL bone tunnel versus the independent transtibial pullout techniques for LMPRT repair combined with ACLR.Study designCohort study; Level of evidence, 3.MethodsBetween March 2014 and February 2018, a total of 48 patients were diagnosed with ACL injury with concomitant LMPRT; 22 patients underwent independent transtibial pullout repair (group T), and 26 patients underwent the shared ACL bone tunnel technique (group S). At a follow-up of >2 years, we compared knee functional recovery using the Lysholm, Tegner, and International Knee Documentation Committee scores and the pivot-shift test. Lateral meniscal extrusion, and cartilage degeneration on magnetic resonance imaging (MRI) scans were also compared. The healing status of the lateral meniscus posterior root was compared using second-look arthroscopy and MRI.ResultsThe duration of surgery was significantly shorter in group S compared with group T (98.3 ± 11.1 vs 127.9 ± 17.5 min; P = .001). At final follow-up, there were no significant differences between the 2 groups in knee functional scores, pivot shift, or grade of cartilage degeneration. Lateral meniscal extrusion was decreased in group S compared with group T (2.41 ± 0.61 vs 1.59 ± 1.35 mm; P = .014). Second-look arthroscopy revealed stable healing in 16 of 18 patients (88.9%) in group S and 10 of 15 patients (66.7%) in group T (P = .38).ConclusionBoth the shared ACL bone tunnel and the independent transtibial pullout techniques led to satisfactory clinical outcomes. The shared ACL bone tunnel technique is the simpler of the 2 procedures for combined LMPRT repair with ACLR.
| S-EPMC9393938 | biostudies-literature
Project description:Even after anterior cruciate ligament (ACL) tear, its remnant retains the vascularized synovial sheets, fibroblasts, myofibroblasts, and various mechanoreceptors within it. The aim of preserving the remnant is to retain these components during ACL reconstruction. In the recent past, there has been an increasing trend towards preserving remnants during ACL reconstruction. Although preserving remnants have physiological advantages, cyclops lesion and extension loss were among the most feared complications. Cyclops and loss of extension are due to the fallback of the remnant into the notch. Moreover, the mechanoreceptors present in the remnant are not active when the remnant is lax. These mechanoreceptors are active when the remnant is in tension. Thus, rather than merely preserving the remnant, it is essential to tension it for more physiological functions. Although there are various techniques of remnant tensioning described in the literature, these techniques require tampering of the fixation devices or an extra fixation device adding to the cost of surgery. We describe our modification of the remnant-tensioning method during anatomic ACL reconstruction. In this technique, the sutures holding the remnant are pulled out through the anatomic femoral tunnel and fixed with an interference screw along with the hamstring graft. This technique is cost-effective, reproducible, and does not require tampering with the fixation devices. Moreover, the direction of remnant pull will be the same as that of the reconstructed graft making both the graft and remnant anatomical in orientation. Suture management and visibility of the intraarticular structures during this procedure are a few downsides of this technique. The only prerequisite of this technique is a good quality remnant to hold the sutures.
| S-EPMC8626705 | biostudies-literature
Project description:Purpose:To examine the ability of surgeons to identify the osseous landmarks associated with the femoral anterior cruciate ligament (ACL) footprint and locate optimal tunnel placement on 3-dimensional (3D) printed models compared with intraoperative placement. Methods:Twelve sports fellowship-trained orthopaedic surgeons were asked to identify a femoral landmark and an ACL footprint on 10 different 3D printed knees. The 3D models were made based on 20 real patients with different anatomical morphology who later received ACL reconstructive surgery using independent drilling. ImageJ software was used to quantify the measurements, which were then analyzed using descriptive statistics. Results:Overall, none of the surgeons were able to consistently identify the junction of the bony ridges. The mean error per participant ranged from 2.81 to 7.34 mm in the proximal direction (P = 3.30e-05) and from 2.42 to 8.05 mm in the posterior direction (P =4.88e-12). None of the surgeons were able to appropriately identify the center of the femoral footprint on the anatomic 3D models. The difference between the center of the footprint surgeons identified on the 3D model and the tunnel graft location in surgery was significantly different (P = .0046). On average, the magnitude of the error when the surgeons performed the actual surgery was 3.72 ± 2.43 mm, whereas on the 3D models it was 5.82 ± 1.97 mm. Conclusions:Experienced sports fellowship-trained orthopaedic surgeons were unable to correctly identify the junction of the intercondylar and bifurcate ridges and the native ACL footprint on 3D models. Operatively placed tunnels were more accurate implying that looking either through a scope or soft-tissue landmarks play a significant role in surgeons ACL footprint localization. Clinical Relevance:The graft position for ACL reconstruction plays an important role on the kinematics of the knee. This paper shows that soft tissue landmarks are needed to provide reliable reference points for reconstruction.
| S-EPMC7451917 | biostudies-literature
Project description:Contemporary anterior cruciate ligament reconstruction attempts to replicate the anatomical insertion sites on both the femoral and tibial sides to restore knee stability. Creation of the femoral tunnel by independently reaming through an anteromedial portal may allow surgeons to more reproducibly place the tunnel within the anatomic femoral footprint relative to a transtibial approach. However, inherent to the technique is the risk of iatrogenic injury to the articular cartilage of the medial femoral condyle as the reamers are passed adjacent to the condyle. This is particularly an issue with the use of standard nonflexible guide pins and reamers, which are placed with the knee in hyperflexion. We describe a relatively straightforward technique that can be used with standard equipment and that can be quite useful in avoiding this pitfall of the transportal approach.
| S-EPMC5368344 | biostudies-literature
Project description:Bone tunnel creation in the anatomical location is essential in anterior cruciate ligament (ACL) reconstruction with an autogenous graft and is commonly performed with a drill bit matched to graft diameter. Anatomic rectangular tunnel ACL reconstruction with a bone–patellar tendon–bone autograft has been developed to anatomically create bone tunnels inside the ACL footprints and has been reported to achieve excellent outcomes. To make the rectangular tunnel, the surgeon needs to dilate 2 adjacent bone tunnels after creation of 2 round tunnels with a drill bit, while the tunnel wall occasionally cracks during dilating. An ultrasonic (US) device was developed with improvement of output power and has been implemented with a rectangular shape blade in the field of arthroscopic surgery. This US device can provide a precise and effective bone cut compared to drills. We introduced this device to clinically create a rectangular tunnel during ACL reconstruction. The US device can be useful for rectangular femoral tunnel creation and can create a precise rectangular femoral tunnel in the ACL footprint. Technique Video Video 1 Rectangular femoral tunnel creation with the ultrasonic device.
| S-EPMC10466142 | biostudies-literature
Project description:Background Bone tunnel enlargement is a well-established phenomenon following anterior cruciate ligament (ACL) reconstruction, and is related to soft tissue grafts, suspension fixation devices, and absorbable implants. Severe tunnel enlargement can lead to reconstruction failure. The correlation between bone tunnel enlargement following ACL reconstruction and original bone tunnel diameter has not been elucidated. Purpose To determine whether bone tunnel enlargement after ACL reconstruction with hamstring autograft is dependent on original tunnel diameter established during primary ACL reconstruction. Materials and Methods A retrospective review was conducted on 56 patients scheduled for ACL revision surgery who had undergone computed tomography (CT) scanning as part of their preoperative evaluation. All patients had undergone previous hamstring ACL reconstruction. Original femoral and tibial bone tunnel diameters were extracted from operative reports, and femoral and tibial bone tunnel enlargement was assessed on CT serial sections. The correlation between original tunnel diameter and bone tunnel enlargement was investigated using regression analysis. Results Mean tibial bone tunnel enlargement was significantly and inversely dependent on the original tibial bone tunnel diameter with a correlation coefficient of -0.55 per unit (7 mm = +1.93 mm, 8 mm = +1.43 mm, 9 mm = 0.83 mm, p = 0.007). Thus, every additional increase (mm) in diameter of the original tibial bone tunnel reduces the extend of tunnel widening by 0.55 mm. Conclusions The results of this study indicate that tibial bone tunnel enlargement following ACL reconstruction is dependent on original tibial bone tunnel diameter with smaller diameter tunnels developing more tunnel enlargement than larger tunnels. The contributing factors remain unclear and need to be further investigated.
| S-EPMC5553504 | biostudies-other
Project description:BackgroundIn anterior cruciate ligament (ACL) reconstruction, minimizing the graft-tunnel motion (GTM) will promote graft-to-bone healing and avoid graft loosening or tearing as well as potential bone tunnel enlargement. A nearly isometric state of the graft can be achieved by placing the tunnel properly to theoretically gain better graft-to-bone healing. However, little clinical evidence is available to quantify the relation between GTM and tunnel position.PurposeTo find the proper zones for the femoral and tibial tunnel apertures that minimize the GTM, referred to as the "nearly isometric zone," through use of intraoperative GTM measurement and 3-dimensional computed tomography (3D-CT).Study designCross-sectional study; Level of evidence, 3.MethodsA total of 100 patients were enrolled in this study. Nearly isometric ACL reconstruction was performed, and an intra-articular GTM measuring device was designed to measure and record the amplitude of GTM while the knee was flexed from 0° to 120°. Postoperatively, the patients underwent multislice CT, and the images were used to create 3D-CT models. After tibial aperture examination, 5 patients were excluded due to the divergence of tibial aperture, and therefore 95 patients remained in the study. Patients were divided into 2 groups according to whether the lateral intercondylar ridge was absent or present. The Bernard-Hertel grid coordinates (h, t) of the femoral tunnel were then quantified.ResultsThe maximal GTM (mGTM) was a mean ± SD of 1.06 ± 0.66 mm (range, 0.0-3.0 mm). The mGTM in patients with a lateral intercondylar ridge was significantly lower than that in patients without a lateral intercondylar ridge (0.81 ± 0.39 vs 1.59 ± 0.73 mm, respectively; P < .0001). The average h and t were 0.227 ± 0.079 and 0.429 ± 0.770, respectively. Notably, in 1 patient, the mGTM was 0 mm whereas the coordinates (h, t) of the femoral tunnel were 0.250 and 0.255. The overall GTM slowly increased before 90° but increased significantly after the knee was bent 105° (P = .010). Correlation analysis showed that the t coordiinate had significant correlation with mGTM (R = 0.581; P < .001). A gradient pattern was created to show the nearly isometric blue zone (mGTM <0.5 mm), which was found to overlap with the IDEAL (isometric, direct insertion, eccentric, anatomic, low tension-flexion pattern) position.ConclusionA method of measuring intraoperative GTM and quantifying femoral tunnel position on postoperative 3D-CT was successfully developed. The presence of a lateral condylar ridge can significantly reduce mGTM. A nearly isometric zone was described that was consistent with the IDEAL concept.
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Project description:Post-traumatic patellofemoral osteoarthritis (OA) is prevalent after anterior cruciate ligament reconstruction (ACLR) and early cartilage degradation may be especially common in the femoral trochlear cartilage. Determining the presence of and factors associated with early femoral trochlear cartilage degradation, a precursor to OA, is a critical preliminary step in identifying those at risk for patellofemoral OA development and designing interventions to combat the disease. Early cartilage degradation can be detected using quantitative magnetic resonance imaging measures, such as tissue T2 relaxation time. The purposes of this study were to (i) compare involved (ACLR) versus uninvolved (contralateral) femoral trochlear cartilage T2 relaxation times 6 months after ACLR, and (ii) determine the relationship between walking speed and walking mechanics 3 months after ACLR and femoral trochlear cartilage T2 relaxation times 6 months after ACLR. Twenty-six individuals (age 23?±?7 years) after primary, unilateral ACLR participated in detailed motion analyses 3.3?±?0.6 months after ACLR and quantitative magnetic resonance imaging 6.3?±?0.5 months after ACLR. There were no limb differences in femoral trochlear cartilage T2 relaxation times. Slower walking speed was related to higher (worse) femoral trochlear cartilage T2 relaxation times in the involved limb (Pearson's r: -0.583, p?=?0.002) and greater interlimb differences in trochlear T2 relaxation times (Pearson's r: -0.349, p?=?0.080). Walking mechanics were weakly related to trochlear T2 relaxation times. Statement of clinical significance: Slower walking speed was by far the strongest predictor of worse femoral trochlear cartilage health, suggesting slow walking speed may be an early clinical indicator of future patellofemoral OA after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:645-652, 2020.
| S-EPMC7028512 | biostudies-literature
Project description:BackgroundAdequate pain control following anterior cruciate ligament reconstruction (ACL) often requires regional nerve block. The femoral nerve block (FNB) has been traditionally employed. Ultrasound application to regional nerve blocks allows for the use of alternatives such as the saphenous nerve block following ACL reconstruction.Questions/purposesThis study evaluated postoperative analgesia provided by the subsartorial saphenous nerve block (SSNB) compared to that provided by the traditional FNB for patients undergoing ACL reconstruction with patellar tendon (bone-tendon-bone (BTB)) autografts.MethodsA randomized, blinded, controlled clinical trial was conducted using 80 ASA I-III patients, ages 16-65, undergoing ACL reconstruction with BTB. The individuals assessing all outcome measures were blinded to the treatment group. Postoperatively, all patients received cryotherapy and parenteral hydromorphone to achieve numeric rating scale pain scores less than 4. At discharge, patients were given prescriptions for oral opioid analgesics and a scheduled NSAID. Patients were instructed to complete pain diaries and record oral opioid utilization. Patients were contacted on postoperative days (POD) 1 and 2 to ascertain the level of patient satisfaction with the analgesic regimen.ResultsNo differences between the two groups were found. Patient demographics and postoperative pain scores at rest were not different. In addition, there was no difference in opioid use, as measured in daily oral morphine equivalents between groups. A small but statistically significant report of higher patient satisfaction with the FNB was found on POD 1 but not on POD 2.ConclusionThese data support our hypothesis that the SSNB provides similar and adequate postoperative analgesia when compared to the FNB, following arthroscopic ACL reconstruction with patellar tendon autograft.
| S-EPMC4171445 | biostudies-literature
Project description:Knee joint functional deficits are common after anterior cruciate ligament (ACL) injury, but different assessment methods of joint function seem to provide contradicting information complicating recovery monitoring. We previously reported improved perceived knee function and functional performance (forward lunge ground contact time) in patients with an ACL injury from pre to 10 months post ACL reconstruction without improvement in knee-specific biomechanics. To further investigate this discrepancy, we additionally analyzed knee extensor and flexor muscle strength, and movement quality in the forward lunge (subjective and objective evaluations) and performed a full lower limb biomechanical analysis of the forward lunge movement. We included 12 patients with an ACL injury (tested before and after ACL reconstructive surgery) and 15 healthy controls from the previous study to the current investigation. Outcome measures were obtained pre and ~11 months post ACL reconstruction for the patients and at a single time point for the controls. Objective movement quality in the patients with an ACL injury showed an improvement from their pre reconstruction surgery visit to the post reconstruction visit but this was not observable in the subjective evaluation. Knee extensor muscle strength declined after the ACL reconstruction by 29% (p = 0.002) and both knee extensors (p < 0.001) and flexors (p = 0.027) were weaker in the patients post ACL reconstruction compared to healthy controls. ACL injured patients had an altered movement strategy in the forward lunge with reduced knee extensors contribution and increased hip extensor contribution compared to the controls both before and after the reconstruction. The altered movement strategy was associated with knee extensor muscle strength. This explorative study with a limited sample size found that clinicians should be aware that significant functional deficits in the knee extensor muscles, both in isolated muscle strength testing and during a functional movement, may be present although patients perceive an improvement in their knee function and present good functional performance without obvious movement quality issues.
| S-EPMC9576999 | biostudies-literature