The Apex of the Deep Cartilage: A Landmark and New Technique to Help Identify Femoral Tunnel Placement in Anterior Cruciate Ligament Reconstruction

Hart, Adam; Han, Yung; Martineau, Paul A.

doi:10.1016/j.arthro.2015.03.026

Cited by 33 publications

(39 citation statements)

References 47 publications

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“…As we used after a 7 mm diameter drill, we placed the center of the tunnel at 5 mm anteriorly relative to the CLR. The proximal and distal positions in the notch were controlled using the Apex of the Posterior Cartilage (Hart et al, 2015 ) at the posterior part of the lateral condyle. We placed the drill tip 10 mm from this apex (Fig.…”

Section: Methodsmentioning

confidence: 99%

The capsular line reference, a new arthroscopic reference for posterior/anterior femoral tunnel positioning in anterior cruciate ligament reconstruction

2018

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BackgroundFemoral malposition is the first cause for graft rupture during ACL reconstruction. Arthroscopic landmarks can be difficult to identify. So, landmark has to be found for reliable tunnel placement. A proximal-distal reference was described as “Apex reference” reported by Hart et al. but no posterior/anterior reference exists in the literature.The purpose of this study was to do a 3D CT-scan assessment of the femoral tunnel positioning using the Capsular Line Reference (CLR) as a landmark for posterior/anterior placement in ACL reconstruction. We hypothesized the CLR could provide a precise and reliable antero/posterior femoral tunnel positioning less than 2 mm from the Bernard & Hertel posterior quarter.MethodsSeven cadaveric knee specimens with a mean age of 79.2 ± 11 years were used. Using standard approaches, the CLR was identified corresponding to a white line (the capsule) appearing at the posterior border of the femoral condyle after bony debridement of the medial and posterior part of the lateral femoral condyle. The center of the tunnel was marked. An inside-out technique with anteromedial drilling technique was performed using an 8-mm diameter reamer. The distal femurs were sawed and a CT-scan was done for each specimen to obtain 3-dimensional image reconstructions. These 3D reconstructions were analyzed to measure the position tunnel center on the posterior/anterior axis and the distance from the posterior/anterior quadrant according to the Bernard & Hertel method.ResultsThe mean position for the posterior/anterior axis was 27.0 ± 1.8% (25–28.9) with a median of 26.9%. The position from the first quarter of the Bernard & Hertel method was 0.9 ± 0.8 mm (0–1.8) with a median of 0.8 mm.ConclusionThe CLR is a reliable and reproducible arthroscopic landmark to place the femoral tunnel for ACL reconstruction in the anterior/posterior axis. Proximal/distal position depends on the choice of the surgeon to reproduce anteromedial or posterolateral fibers.

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Section: Methodsmentioning

confidence: 99%

The capsular line reference, a new arthroscopic reference for posterior/anterior femoral tunnel positioning in anterior cruciate ligament reconstruction

2018

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“…identified the ADC on the 3D MRIs of all the patients. 20 That same point was then marked on the 3D models using multiplanar DICOM views overlaid on the 3D model to serve as a reference point for the measurements.…”

Section: D Model Generationmentioning

confidence: 99%

“…6 Surgeons use radiography, computer-assisted systems, drill guides, general rules of thumb, and anatomic reference points to aid with proper graft positioning. 4,16,18,20,36 However, intraoperative positioning still represents a challenge that is ultimately determined by the surgeon's working knowledge of the musculoskeletal system. The intercondylar and bifurcate ridges have been defined as specific intra-articular femoral landmarks that can be used intraoperatively to assess ideal graft position.…”

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confidence: 99%

Effect of Teaching Session on Resident Ability to Identify Anatomic Landmarks and Anterior Cruciate Ligament Footprint: A Study Using 3-Dimensional Modeling

Laverdière

Harvey

Schupbach

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: Femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) is an intricate procedure that requires highly specific surgical skills. Purpose: To report the ability of residents to identify femoral landmarks and the native ACL footprint before and after a structured formal teaching session as a reflection of overall surgical skill training for orthopaedic surgery residents in Canada. Study Design: Controlled laboratory study. Methods: A total of 13 senior orthopaedic residents were asked to identify a femoral landmark and an ACL footprint on ten 3-dimensional (3D)–printed knee models before and after a teaching session during the fall of 2018. The 3D models were made based on actual patients with different anatomic morphologic features. ImageJ software was used to quantify the measurements, which were then analyzed through use of descriptive statistics. Results: Before and after the teaching session, residents attempted to identify a specific anatomic location (bifurcate and intercondylar ridge intersection) with a mean error per participant ranging from 5.00 to 10.95 mm and 4.79 to 12.13 mm in magnitude, respectively. Furthermore, before and after the teaching session, residents identified the specific position to perform the surgical procedure (ACL femoral footprint), with a mean error per participant ranging from 4.58 to 8.80 mm and 3.87 to 11.07 mm in magnitude, respectively. The teaching session resulted in no significant improvement in identification of either the intersection of the bifurcate and intercondylar ridges ( P = .9343 in the proximal-distal axis and P = .8133 in the anteroposterior axis) or the center of the femoral footprint ( P = .7761 in the proximal-distal axis and P = .9742 in the anteroposterior axis). Conclusion: Although a formal teaching session was combined with a hands-on session that entailed real surgical instrumentation and fresh cadaveric specimens, the intervention seemed to have no direct impact on senior residents’ performance or their ability to demonstrate the material taught. This puts into question the format and efficacy of present teaching methods. Also, it is possible that the 3D spatial perception required to perform these skills is not something that can be taught effectively through a teaching session or at all. Further investigation is required regarding the effectiveness and application of surgical skill laboratories and simulations on the competencies of orthopaedic residents.

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“…The tip of the guide hook is pointed toward the posterosuperior corner of the ACL remnant and its center is usually corresponding with the posterior cartilage edge in the anteroposterior direction (Fig 2). 4 The accurate placement of the femoral tunnel is localized by passing a guide pin inside the joint. After then, smaller sleeve for the guide pin is removed.…”

Section: Tunnels Preparation and Graft Passagementioning

confidence: 99%

Femoral Footprint Reconstruction With a Direct Viewing of the Posterior Insertion Using a Trans-Septal Portal in the Outside-In Anterior Cruciate Ligament Reconstruction

Elazab

Lee

Kang

2016

Arthroscopy Techniques

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We established a technique for femoral tunnel preparation through direct vision of the femoral footprint with maximum preservation to the native anterior cruciate ligament (ACL) remnant using a posterior trans-septal portal. Anterior arthroscopy is difficult for the proper tunnel placement without sacrificing the ACL remnant. Posterior arthroscopy could be helpful for viewing the posterior insertion of the ACL remnant that provides excellent femoral footprint exposure without sacrificing the native ACL remnant. Therefore, a posterolateral portal technique using a 70° arthroscope through a posterolateral portal is introduced. However, using the 70° arthroscope, an oblique view is displayed and distorted view could be seen. Therefore, to achieve the goal of posterior arthroscopy and avoid obstacles of the posterolateral view with the 70° arthroscope, we introduce this technique that uses the posterior trans-septal portal with a 30° arthroscope that provides an excellent viewing to the femoral footprint through a hole of the posterior septum.

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The Apex of the Deep Cartilage: A Landmark and New Technique to Help Identify Femoral Tunnel Placement in Anterior Cruciate Ligament Reconstruction

Abstract: Current commercially available transtibial femoral offset guides cannot reach the center of the ACL's femoral footprint and therefore should not be used. Alternative techniques, such as referencing from the ADC through an anteromedial (AM) portal, are recommended.

Cited by 33 publications

References 47 publications

The capsular line reference, a new arthroscopic reference for posterior/anterior femoral tunnel positioning in anterior cruciate ligament reconstruction

The capsular line reference, a new arthroscopic reference for posterior/anterior femoral tunnel positioning in anterior cruciate ligament reconstruction

Effect of Teaching Session on Resident Ability to Identify Anatomic Landmarks and Anterior Cruciate Ligament Footprint: A Study Using 3-Dimensional Modeling

Femoral Footprint Reconstruction With a Direct Viewing of the Posterior Insertion Using a Trans-Septal Portal in the Outside-In Anterior Cruciate Ligament Reconstruction

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