Femoral Tunnel Malposition in ACL Revision Reconstruction

Abstract

The Multicenter Anterior Cruciate Ligament (ACL) Revision Study (MARS) group was formed to study a large cohort of revision ACL reconstruction patients. The purpose of this subset analysis study of the MARS database is to describe specific details of femoral tunnel malposition and subsequent management strategies that surgeons chose in the revision setting. The design of this study is a case series. The multicenter MARS database is compiled from a questionnaire regarding 460 ACL reconstruction revision cases returned by 87 surgeons. This subset analysis described technical aspects and operative findings in specifically those cases in which femoral tunnel malposition was cited as the cause of primary ACL reconstruction failure. Of the 460 revisions included for study, 276 (60%) cases cited a specific “technical cause of failure.” Femoral tunnel malposition was cited in 219 (47.6%) of 460 cases. Femoral tunnel malposition was cited as the only cause of failure in 117 cases (25.4%). Surgeons judged the femoral tunnel too vertical in 42 cases (35.9%), too anterior in 35 cases (29.9%), and too vertical and anterior in 31 cases (26.5%). Revision reconstruction involved the drilling of an entirely new femoral tunnel in 91 cases (82.1%). For primary reconstruction, autograft tissue was used in 82 cases (70.1%). For revision reconstruction, autograft tissue was used in 61 cases (52.1%) and allograft tissue in 56 cases (47.9%). Femoral tunnel malposition in primary ACL reconstruction was the most commonly cited reason for graft failure in this cohort. Graft selection is widely variable among surgeons.

Double-bundle revision anterior cruciate ligament reconstruction is effective in rescuing failed primary reconstruction and re-introducing patients to physical exercise

“…In the present study, tunnel positioning in the primary ACL reconstruction was correct in only 6 out of 34 patients (17.6%). Malposition of the femoral tunnel accounted for primary graft failure in 28 cases (82.4%), which was at the high end of the previously reported range (37-85%) (28)(29)(30)(31). The lesions of the anterior cruciate ligament identified intra-operatively in the present study included graft absorption (n=4, 11.8%), ACL rupture (n=10, 29.4%) and ACL laxity (n=20, 58.8%).…”

Anatomic anterior cruciate ligament reconstruction with 70° arthroscope for better placement of Femoral and Tibial Tunnels

“…Regarding ACLR, consistent and accurate tunnel placement is crucial to avoid complications because small changes in tunnel position can affect the knee stability and outcomes [12,13] . ACL anatomy has been well described by the use of radiographic and cadaveric measures [14,15] .…”

“…Among the various parameters for successful anatomic anterior cruciate ligament reconstruction, either double bundle or single bundle, tunnel placement is the most important aspects of successful anterior cruciate ligament reconstructions (ACLR). The most common cause of ACL reconstructions failure is incorrect tunnel placement, with the femoral tunnel more frequently misplaced than the tibial tunnel [2][3][4] . Most surgeons use a 30° arthroscope through a anterolateral portal (AL) for viewing the femoral footprint in ACLR and make femoral tunnel through accessory medial portal.…”

Identification of Anterior Cruciate Ligament Tunnel Drilling Technique Using X-Ray

“…Various techniques exist for ACL reconstruction, each with their own rationale, advantages, and limitations. Tunnel position is a key determinant in ACL reconstruction, with tunnel malposition cited as a leading cause of graft failure after ACL reconstruction (1).…”