Arthroscopic Agreement Among Surgeons on Anterior Cruciate Ligament Tunnel Placement

McConkey, Mark O.; Amendola, Annunziato; Ramme, Austin J.; Dunn, Warren R.; Flanigan, David C.; Britton, Carla; Wolf, Brian R.; Spindler, Kurt P.; Carey, James L.; Cox, Charles L.; Kaeding, Christopher C.; Wright, Rick W.; Matava, Matthew J.; Brophy, Robert H.; Smith, Matthew V.; McCarty, Eric C.; Vida, Armando F; Wolcott, Michelle; Marx, Robert G.; Parker, Richard D.; Andrish, Jack F; Jones, Morgan H.

doi:10.1177/0363546512461740

Cited by 40 publications

(36 citation statements)

References 47 publications

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“…Achieving an anatomic footprint is considered critical to achieving tibiofemoral stability after an ACL reconstruction [1,3,10,11,30,38,43], yet there is currently little agreement on the ideal footprint placement of a singlebundle ACL reconstruction. McConkey et al [30] showed that when 12 surgeons reviewed the femoral and tibial tunnels in 72 cadaveric knees, there was poor agreement (\5%) on what was considered the ideal tunnel placement, although 88% of the femoral tunnels and 78% of the tibial tunnels were created within the study criteria [4].…”

Section: Discussionmentioning

confidence: 99%

“…McConkey et al [30] showed that when 12 surgeons reviewed the femoral and tibial tunnels in 72 cadaveric knees, there was poor agreement (\5%) on what was considered the ideal tunnel placement, although 88% of the femoral tunnels and 78% of the tibial tunnels were created within the study criteria [4]. An anatomic femoral footprint with the TT technique can be achieved if the tibial tunnel is placed further posterior and medial [11,34].…”

Section: Discussionmentioning

confidence: 99%

“…Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed outpatient orthopaedic surgeries in the United States and is typically performed in the setting of sports injuries [18,24,26,30,31]. Because many patients who undergo these procedures are young and active, surgical stabilization of the knee is an attractive option [1,18,25,41].…”

Section: Introductionmentioning

confidence: 99%

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Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Arno

Bell

Alaia

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Considerable debate remains over which anterior cruciate ligament (ACL) reconstruction technique can best restore knee stability. Traditionally, femoral tunnel drilling has been done through a previously drilled tibial tunnel; however, potential nonanatomic tunnel placement can produce a vertical graft, which although it would restore sagittal stability, it would not control rotational stability. To address this, some suggest that the femoral tunnel be created independently of the tibial tunnel through the use of an anteromedial (AM) portal, but whether this results in a more anatomic footprint or in stability comparable to that of the intact contralateral knee still remains controversial. Questions/purposes (1) Does the AM technique achieve footprints closer to anatomic than the transtibial (TT) technique? (2) Does the AM technique result in stability equivalent to that of the intact contralateral knee? (3) Are there differences in patient-reported outcomes between the two techniques? Methods Twenty male patients who underwent a bonepatellar tendon-bone autograft were recruited for this study, 10 in the TT group and 10 in the AM group. Patients in each group were randomly selected from four surgeons at our institution with both groups demonstrating similar demographics. The type of procedure chosen for each patient was based on the preferred technique of the surgeon. Some surgeons exclusively used the TT technique, whereas other surgeons specifically used the AM technique. Surgeons had no input on which patients were chosen to participate in this study. Mean postoperative time was 13 ± 2.8 and 15 ± 3.2 months for the TT and AM groups, respectively. Patients were identified retrospectively as having either the TT or AM Technique from our institutional database. At followup, clinical outcome scores were gathered as well as the footprint placement and knee stability assessed. To assess the footprint placement and knee stability, three-dimensional surface models of the femur, tibia, and ACL were created from MRI scans. The femoral and tibial footprints of the ACL reconstruction as compared with the intact contralateral ACL were determined. In addition, the AP displacement and rotational displacement of the femur were determined. Lastly, as a secondary measurement of stability, KT-1000 measurements were obtained at the followup visit. An a priori sample size calculation indicated that with 2n = 20 patients, we could detect a difference of 1 mm with 80% power at p \ 0.05. A Welch two-sample t-test (p \ 0.05) was performed to determine differences in the footprint measurements, AP displacement, rotational displacement, and KT-1000 measurements between the TT and AM groups. We further used the confidence interval approach with 90% confidence intervals on the pairwise mean group differences using a Games-Howell post hoc test to assess equivalence between the TT and AM groups for the previously mentioned measures. Results The AM and TT techniques were the same in terms of footprint except in the distal...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Arno

Bell

Alaia

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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“…Since the anatomic insertion areas allow for different anatomic tunnel positions and no tunnel position so far has been found to be superior to others, certain variability of tunnel positions can be assumed. McConkey et al [21] found in a cadaver study that there was a poor agreement among surgeons on tunnel positioning. In this study, tunnel positions of 12 surgeons completed femoral and tibial tunnel positioning on 72 cadaver knees, which were then evaluated by three independent reviewers on 3D-CT scan analysis.…”

Section: Discussionmentioning

confidence: 99%

Variability of tunnel positioning in ACL reconstruction

Shafizadeh

Balke

Hagn

et al. 2014

Arch Orthop Trauma Surg

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This study demonstrates that a reasonable inter- and intra-observer variability in ACL tunnel positioning exists even among experienced surgeons. Although deviations of 2-3 mm may seem to be acceptable at first sight, a range of up to 18.3 mm indicates that outliers exist, which can cause graft failure. More reliable reconstruction techniques should be developed to reduce the variability in tunnel positioning.

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“…A recent survey showed a clear change in surgical technique with 63% of North American surgeons and 81% of surgeons worldwide preferring drilling through an anteromedial portal. 6 These approaches have been evaluated with cadaveric models, with McConkey and colleagues 11 finding femoral tunnels were ideal 86% of time using 2-incision technique, 66% of time using the anteromedial portal, and only 51% of the time with transtibial technique. Similar findings were shown by Gadikota and colleagues, 9 with significantly more of the femoral tunnel within the ACL footprint for anteromedial portal (86%) and outside-in (89%) techniques compared with the transtibial technique (73%).…”

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confidence: 99%

Location, Location, Location

Owens¹

2013

Am J Sports Med

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Arthroscopic Agreement Among Surgeons on Anterior Cruciate Ligament Tunnel Placement

Abstract: This study demonstrates that surgeons do not currently uniformly agree on ideal single-bundle tunnel placement and that the TT technique may yield more poorly placed tunnels.

Cited by 40 publications

References 47 publications

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Variability of tunnel positioning in ACL reconstruction

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