Rate of Tibial Tunnel Malposition Is Not Changed by Drilling Entirely Within the Stump of Preserved Remnants During ACL Reconstruction: A Prospective Comparative 3D-CT Study

Abstract

Background: Remnant preservation during anterior cruciate ligament (ACL) reconstruction (ACLR) is controversial, and it is unclear whether the stump aids or obscures tibial tunnel positioning. Purpose/Hypothesis: The aim of this study was to determine whether the rate of tibial tunnel malposition is influenced by remnant preservation. The hypothesis was that using a remnant-preserving technique to drill entirely within the tibial stump would result in a significant reduction in tibial tunnel malposition as determined by postoperative 3-dimensional computed tomography (3D-CT). Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing ACLR between October 2018 and December 2019 underwent surgery with a remnant-preserving technique (RP group) if they had a large stump present (>50% of the native ACL length) or if there was no remnant or if it was <50% of the native length of the ACL, they underwent remnant ablation (RA group) and use of standard landmarks for tunnel positioning. The postoperative tunnel location was reported as a percentage of the overall anteroposterior (AP) and mediolateral (ML) dimensions of the tibia on axial 3D-CT. The tunnel was classified as anatomically placed if the center lay between 30% and 55% of the AP length and between 40% and 51% of the ML length. Results: Overall, 52 patients were included in the study (26 in each group). The mean tunnel positions were 36.8% ± 5.5% AP and 46.7% ± 2.9% ML in the RP group and 35.6% ± 4.8% AP and 47.3% ± 2.3% ML in the RA group. There were no significant differences in the mean AP ( P = .134) and ML ( P = .098) tunnel positions between the groups. Inter- and intraobserver reliability varied between fair to excellent and good to excellent, respectively. There was no significant difference in the rate of malposition between groups (RP group, 7.7%; RA group, 11.5%; P ≥ .999). Conclusion: Drilling entirely within the ACL tibial stump using a remnant-preserving reconstruction technique did not significantly change the rate of tunnel malposition when compared with stump ablation and utilization of standard landmarks.

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

“…The femoral tunnel aperture position resembles the anatomy best if it is placed posteriorly and around middle‐height in the lateral condyle [5, 31, 36, 39, 55, 60]. The tibial tunnel aperture position resembles the ACL best when placed between the eminences and slightly more anteriorly than the midline [4, 8, 15, 28, 31, 32, 39, 47].…”

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment

“…While there was consensus on the benefits of remnant-preserving ACL reconstruction, there was also agreement that it is a challenging surgical technique. Nevertheless, there is no scientific evidence for an increased complication rate for this technique (tunnel malposition or cyclops lesions) [32,33].…”

Single AnteroMedial Bundle Biological Augmentation: SAMBBA Plus Technique for Combined ACL Repair and Reconstruction

“… 4 , 15 , 16 Additionally, complications associated with remnant-preserving techniques, such as the development of symptomatic cyclops lesions and an increase in the rate of tibial tunnel malposition, have been negated in the recent literature. 17 , 18 …”