Arthroscopically Pertinent Landmarks for Tunnel Positioning in Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstructions

Ziegler, Connor G.; Pietrini, Sean D.; Westerhaus, Benjamin D.; Anderson, Christopher; Wijdicks, Coen A.; Johansen, Steinar; Engebretsen, Lars; LaPrade, Robert F.

doi:10.1177/0363546510387511

Cited by 175 publications

(177 citation statements)

References 57 publications

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“…Concerns about the optimal position for ACL reconstruction have sparked extensive study into the shape, orientation, and attachment points of the native ligament, especially regarding the femoral attachment. 7,8,10,15,24,28,32 The femoral soft tissue attachment of the ACL is not a circle but an ellipse, as recently highlighted by Fu and Jordan,9 who noted along with others that the majority of the fibers lie posterior and proximal to the lateral intercondylar ridge. More recently, Iwahashi et al 14 demonstrated a direct and indirect insertion of the ACL on the femoral condyle, with the direct insertion of the ligament acting as ''a key link between the ligament and bone to transmit mechanical load to the joint.''…”

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confidence: 90%

Cortical Bony Thickening of the Lateral Intercondylar Wall: The Functional Attachment of the Anterior Cruciate Ligament

et al. 2016

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Background: The anatomy of the anterior cruciate ligament (ACL) has become the subject of much debate. There has been extensive study into attachment points of the native ligament, especially regarding the femoral attachment. Some of these studies have suggested that fibers in the ACL are of differing functional importance. Fibers with higher functional importance would be expected to exert larger mechanical stress on the bone. According to Wolff’s law, cortical thickening would be expected in these areas. Purpose: To examine cortical thickening in the region of the ACL footprint (ie, the functional footprint of the ACL). Study Design: Descriptive laboratory study. Methods: Using micro–computed tomography with resolutions ranging from 71 to 91 μm, the cortical thickness of the lateral wall of the intercondylar notch in 17 cadaveric knees was examined, along with surface topography. After image processing, the relationship between the cortical thickening and surface topology was visually compared. Results: A pattern of cortical thickening consistent with the functional footprint of the ACL was found. On average, this area was 3 times thicker than the surrounding bone and significantly thicker than the remaining lateral wall ( P < .0001). This thickening was roughly elliptical in shape (with a mean centroid at 23.5 h:31 t on a Bernard and Hertel grid) and had areas higher on the wall where greater thickness was present. The relationship to previously reported osseous landmarks was variable, although the patterns were broadly consistent with those reported in previous studies describing direct and indirect fibers of the ACL. Conclusion: The findings of this study are consistent with those of recent studies describing fibers in the ACL of differing functional importance. The area in which the thickening was found has been defined and is likely to represent the functional footprint of the ACL. Clinical Relevance: This information is of value to surgeons when determining the optimal place to position the femoral attachment site of the reconstructed ACL.

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confidence: 90%

Cortical Bony Thickening of the Lateral Intercondylar Wall: The Functional Attachment of the Anterior Cruciate Ligament

et al. 2016

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“…We advocate using a direct measurement technique for anatomic placement of the femoral sockets by locating the AM and posterolateral (PL) bundles based on the work by Ziegler et al 31 ( Fig 4). This is performed with the curved measurement/marking tool and is now possible with a new calibrated RF devicedthe Caliblator (Arthrex).…”

Section: Femoral Socket Preparationmentioning

confidence: 99%

TriLink: Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Yasen

Logan

Smith

et al. 2014

Arthroscopy Techniques

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Cadaveric and clinical biomechanical studies show improved kinematic restoration using double-bundle anterior cruciate ligament (ACL) reconstruction techniques. These have been criticized in the past for being technically challenging. We present a novel 3-socket approach for anatomic "all-inside" double-bundle reconstruction using a single hamstring tendon fashioned to create a trifurcate graft: the TriLink technique. The semitendinosus alone is harvested, quadrupled, and attached to 3 suspensory fixation devices in a Y-shaped configuration, creating a 4-stranded tibial limb and 2 double-stranded femoral limbs. A medial viewing/lateral working arthroscopic approach is adopted using specifically designed instrumentation. Anatomic placement of the 2 femoral tunnels is performed by a validated direct measurement technique. A single mid-bundle position is used on the tibia. Both femoral and tibial sockets are created in a retrograde manner using outside-to-in drilling. This is a simplified operative technique for anatomic double-bundle ACL reconstruction that maximizes bone preservation. The TriLink construct replicates the 2 bundles of the ACL, conferring native functional anisometry and improving femoral footprint coverage while avoiding the complexities and pitfalls of doubleetibial tunnel techniques. Preservation of the gracilis reduces the morbidity of hamstring harvest and allows greater flexibility in graft choice in cases requiring multiligament reconstruction.

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“…Imagefree navigation systems use landmarks to create anatomical reference frames that relate the position and orientation of the reference frames that are attached to the patient's bones, to the underlying bony anatomy (Siston et al 2007). Finally, different landmarks can be used to determine the insertion locations in ligament reconstruction (Schottle et al 2007, Ziegler et al 2010. Anatomical features have thus proven to be applicable throughout all steps of the patient treatment process: diagnosis, preoperative planning, intraoperative navigation and postoperative follow-up.…”

Section: Anatomical Landmarks In Orthopedicsmentioning

confidence: 99%

Patient-Specific Modelling in Orthopedics: From Image to Surgery

Gomes

Cauter

Beule

et al. 2012

Biomedical Imaging and Computational Modeling in Biomechanics

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In orthopedic surgery, to decide upon intervention and how it can be optimized, surgeons usually rely on subjective analysis of medical images of the patient, obtained from computed tomography, magnetic resonance imaging, ultrasound or other techniques. Recent advancements in computational performance, image analysis and in silico modeling techniques have started to revolutionize clinical practice through the development of quantitative tools, including patient-specific models aiming at improving clinical diagnosis and surgical treatment. Anatomical and surgical landmarks as well as features extraction can be automated allowing for the creation of general or patient-specific models based on statistical shape models. Preoperative virtual planning and rapid prototyping tools allow the implementation of customized surgical solutions in real clinical environments. In the present chapter we discuss the applications of some of these techniques in orthopedics and present new computer-aided tools that can take us from image analysis to customized surgical treatment.

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Arthroscopically Pertinent Landmarks for Tunnel Positioning in Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstructions

Abstract: These clinically relevant arthroscopic landmarks may enhance single- and double-bundle ACL reconstructions through improved tunnel placement.

Cited by 175 publications

References 57 publications

Cortical Bony Thickening of the Lateral Intercondylar Wall: The Functional Attachment of the Anterior Cruciate Ligament

Cortical Bony Thickening of the Lateral Intercondylar Wall: The Functional Attachment of the Anterior Cruciate Ligament

TriLink: Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Patient-Specific Modelling in Orthopedics: From Image to Surgery

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