Remnant preservation does not affect accuracy of tibial tunnel positioning in single-bundle ACL reconstruction

Kosy, Jonathan D.; Walmsley, K.; Gordon, Elizabeth A.; Heddon, Sadie V.; Anaspure, Rahul; Schranz, Peter; Mandalia, Vipul

doi:10.1007/s00167-020-06125-y

Cited by 12 publications

(27 citation statements)

References 30 publications

(52 reference statements)

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“…The surgeon has to consider numerous factors whilst operating within the anatomic boundaries of the femoral intercondylar notch and tibial eminences. Of these factors, tunnel positioning is most essential to achieve an anatomic graft position and an excellent ACL reconstruction [ 2 , 3 , 9 , 20 , 21 , 23 , 24 , 28 , 36 , 40 , 41 , 43 , 46 , 51 , 57 ].…”

Section: Introductionmentioning

confidence: 99%

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

Mees

Reijman

Waarsing

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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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.

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Section: Introductionmentioning

confidence: 99%

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

Mees

Reijman

Waarsing

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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“…The average IKDC was 88.7 ± 14.1, and the average Lysholm score was 89.4 ± 12.3, with a minimum follow-up of two years. Unlike for the anterior cruciate ligament (ACL), the extant literature on the posterior cruciate ligament (PCL) does not demonstrate the superiority of these techniques compared to conventional techniques [9,12,23], due to a lack of prospective, randomised studies, making it hard to decide whether preserving the remnant is advantageous or not. Nevertheless, some authors have described favourable results (IKDC rating of A or B in 97% to 100%) after chronic PCLR (> 6 months) ( [1].…”

Section: Discussionmentioning

confidence: 99%

Good clinical and radiological results following remnant-preserving posterior cruciate ligament reconstruction: a systematic review

D’Ambrosi

Hallé

Hardy

2022

Knee Surg Sports Traumatol Arthrosc

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Purpose The objective of this systematic literature review was to report the results and complications of recent remnant preservation techniques in posterior cruciate ligament (PCL) reconstruction. Methods A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms “posterior cruciate ligament” or “PCL” and “remnant preserving.” The outcome measures extracted from the studies were the Lysholm score, the International Knee Documentation Committee’s (IKDC) subjective and objective scores, Tegner scores, Orthopädische Arbeitsgruppe Knie (OAK) rate of return to sports, and rate of complications. Data were also extracted from studies that used stress radiographs to perform a quantitative assessment of the preoperative and postoperative anteroposterior stability. Results The systematic review included 13 studies. The patient cohort of consisted of 643 participants (544 [84.6%] men and 99 [15.4%] women) with a mean age of 32.9 ± 4.0 years. The mean postoperative follow-up was 34.5 ± 10.9 months (range: 24–96 months), while the mean time from injury to surgery was 14.4 ± 9.9 months (range: 0–240 months). All studies reported clinically significant improvement at final follow-up, as evident from the measured subjective and objective IKDC scores, Lysholm score, Tegner score, and OAK rate. Only three studies reported return to sports activity, with a mean percentage of 90.8% (99/109). All studies showed a significant improvement in posterior translation, from 11.5 ± 1.2 mm to 3.3 ± 1.1 mm, using radiography (side-to-side difference). This systematic review revealed 13 (2.0%) failures and 33 (5.1%) minor complications: 10 (1.6%) cases of stiffness, 21 (4.9%) screws removal, 1 (0.2%) injury of the peroneal nerve, and 1 (0.2%) fibular fracture. Conclusions With the currently available data, all studies included in the review on posterior cruciate ligament reconstruction with remnant preservation demonstrated satisfactory outcomes at mid-term follow-up (> 24 months), despite varying surgical techniques and graft types, and intervals from injury to surgery. For clinical relevance, standard PCL reconstruction is a highly effective operation in terms of improvement in functional status, knee stability, quality of life, and cost effectiveness. The remnant preservation technique requires more comprehensive diagnostic assessments of the PCL remnant patterns and more complicated surgical procedures. Given the absence so far of high quality studies with long-term follow-up, the remnant-preserving techniques should be recommended only by experienced knee arthroscopic surgeons. Level of evidence Level IV. Study registration reviewregistry1376—www.researchregistry.com.

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“…In a recent study by Kosy et al, 20 the authors evaluated the accuracy and precision of the tibial tunnel in the RP and RA groups using the mean AP (38.7%) and ML (49.1%) positions determined by Lertwanich et al 21 as the reference standard. Those authors reported no significant differences between groups regarding these metrics, and their work is therefore broadly consistent with the findings of the current study.…”

Section: Discussionmentioning

confidence: 99%

“…Those authors reported no significant differences between groups regarding these metrics, and their work is therefore broadly consistent with the findings of the current study. However, in light of the reported variation in the center of the anatomic footprint when correlated with 3D-CT, it is unsurprising that Kosy et al 20 reported accuracies between 4.8% and 6.1% and a precision between 2.8% and 3.9% when using a specific point as a reference standard. It could perhaps be argued that these metrics are incorrectly used because none of the intraoperative steps taken or landmarks used actually sought to achieve this specific position that was identified only on postoperative CT.…”

Section: Discussionmentioning

confidence: 99%

“…The most proximal tibial axial section in which it was possible to view the entire tibia was identified and used to determine the location of the center of the tibial tunnel. To record the tunnel location, a rectangle was overlaid at the maximal extents of the tibia in the anteroposterior (AP) and mediolateral (ML) directions, in accordance with the methodology described by Kosy et al, 20 and the center of the tibial tunnel was reported as a percentage of the overall AP and ML dimensions of the rectangle ( Figure 3 ). These measurements were made independently by 3 orthopaedic surgeons (L.F.P., L.F.P., P.J.L.G.)…”

Section: Methodsmentioning

confidence: 99%

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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

Pádua

Saithna²,

Chagas

et al. 2021

Orthopaedic Journal of Sports Medicine

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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.

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Remnant preservation does not affect accuracy of tibial tunnel positioning in single-bundle ACL reconstruction

Cited by 12 publications

References 30 publications

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

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

Good clinical and radiological results following remnant-preserving posterior cruciate ligament reconstruction: a systematic review

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

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