Posteriorly positioned femoral grafts decrease long-term failure in anterior cruciate ligament reconstruction, femoral and tibial graft positions did not affect long-term reported outcome

Abstract

Purpose To investigate the effect that femoral and tibial tunnel positions have on long-term reported and clinical outcome and to identify a safe zone based on favourable outcome. Methods Seventy-eight patients from a previous randomised controlled trial were included and were followed with a mean follow-up of 11.4 years. All patients had primary trans-tibial anterior cruciate ligament reconstruction performed. The femoral and tibial tunnel positions were visualised and translated in percentages with three-dimensional computed tomography post-operatively. There were 3 separate outcome variables: patient-reported outcome measured with the IKDC Subjective Knee Form, overall failure, and radiographic osteoarthritis. The correlation between tunnel aperture positions and outcome was determined with multivariate regression. The area with best outcome was defined as the safe zone and was determined with Youden’s index in conjunction with receiver operating characteristics. Results No significant relationship was found between tunnel aperture positions and IKDC Subjective Knee Form at 10-year follow-up. The posterior-to-anterior femoral tunnel aperture position parallel to Blumensaat line showed a significant relationship (p = 0.03) to overall failure at 10-year follow-up. The mean posterior-to-anterior tunnel position of the group that did not fail was 37.7% compared to 44.1% in the overall failure group. Femoral tunnel apertures placed further anteriorly had more overall failures at long-term. The cut-off point lies at 35.0% from posterior-to-anterior parallel to Blumensaat. Of the 16 overall failures, 15 (93.8%) were placed further anteriorly than the cut-off point. No significant relationship was found between tunnel aperture positions and radiographic osteoarthritis. Conclusion Femoral and tibial tunnel positions were not associated with long-term patient-reported outcome and radiographic osteoarthritis. Long-term overall failure was more frequently seen in patients with a more anteriorly placed femoral tunnel. This study identified a safe zone located at the most posterior 35% of the femoral condyle parallel to Blumensaat. This knowledge offers guidance to surgeons to operate more precisely and accurately and reconstruct a long-lasting graft. Level of evidence Level III.

ACL surgery: reasons for failure and management

“…This greater rotational instability increases shear stress on ACL-R, cartilage, and menisci, which increases the risk of ACL re-rupture and wear (27,28,29). The higher re-rupture rate of more anteriorly placed femoral tunnel apertures was also shown in a recent subanalysis of a randomized controlled trial with a follow-up of about 11 years (30). This study identified a safe zone parallel to the Blumensaat line at the most posterior 35% of the femoral condyle.…”

Anterior cruciate ligament reconstruction with all-soft tissue quadriceps tendon versus quadriceps tendon with bone block

“…Stiffness was defined as loss of range of motion (ROM) > 10° of flexion or > 3° of extension [19]. Clinical failure encompassed all retears as well as patients with Lachman ≥ 2B, pivot shift ≥ 2 + , or KT difference ≥ 5 mm at final follow‐up [8, 13].…”

Anatomic anterior cruciate ligament reconstruction: Freddie Fu's paradigm

“…The surgeon must be certain that they see the true posterior margin of the condyle and not J o u r n a l P r e -p r o o f mistake the lateral intercondylar ridge for the posterior margin. The most common error is overly anterior placement of the femoral tunnel, so care is taken to place it posteriorly on the condyle [57]. On the tibial side, the tibial spine, intermeniscal ligament, and anterior horn of the lateral meniscus are landmarks for tibial tunnel placement [24,31,58].…”