Tunnel placement in anterior cruciate ligament (ACL) reconstruction: quality control in a teaching hospital

Abstract

Correct placement of the femoral and tibial bone tunnels is decisive for a successful anterior cruciate ligament (ACL) reconstruction. Our method of tunnel placement was evaluated as part of quality control at a teaching hospital. The emphasis was placed mainly on investigating the influence of surgical experience on tunnel placement, and the effect of tunnel position on the clinical outcome. Seventeen surgeons with different levels of experience (between 0 and >150 ACL reconstructions) performed endoscopic ACL repair in uniform technique from August 2000 to August 2003 on 50 patients (18 women, 32 men, age range 18-43 years). The patients were available to clinical and radiological follow-up after an average of 19 months. The clinical outcome was classified according to the International Knee Documentation Committee (IKDC) standard evaluation form. The femoral tunnel was evaluated according to the quadrant method of Bernard and Hertel; the position of the tibial bone tunnel was assessed according to the criteria of Stäubli and Rauschnig. The IKDC score revealed 47 (94%) patients with a normal (A) or nearly normal (B) knee joint at follow-up. According to the quadrant method, the femoral canal was situated on average at 29% in the saggital plane. The tibial tunnel was situated on average at 43% of the a.p. diameter of the tibial condyle. Statistical analysis of our data showed no significant correlation between tunnel placement and surgical expertise. However, a highly significant correlation was found (alpha<0.01) between the femoral position of the tunnel in the sagittal plane and the IKDC score. The more anterior the femoral canal, the poorer the IKDC score. The method of tunnel placement in ACL reconstruction being investigated here only showed slight dependence on surgical experience, whereby good short-term clinical outcomes were achieved. Therefore, the method is suitable for application at a teaching hospital. A far too anterior femoral tunnel placement will probably lead to a decline in the clinical result.

Femoral tunnel drilling in anterior cruciate ligament reconstruction: Anteromedial or transtibial portal? Current review

“…Anatomic ACL graft positioning is considered a key factor for the proper postoperative knee function and restoration of the physiological kinematics of the knee joint in ACL reconstruction 2 . However, the optimum tunnel position for positioning the graft is debatable.…”

Análise radiológica do posicionamento dos túneis ósseos na cirurgia de reconstrução do ligamento cruzado anterior: comparação entre as técnicas aberta e artroscópica via portal anteromedial

“…Studies have demonstrated that incorrect positioning of the tunnels in the coronal and sagittal planes causes complications that modify the clinical results (6,7,12,16,17,20) , as well as being the commonest cause of lack of success in ACL reconstructions (21) . Several methods are currently used for assessing the positioning of the bone tunnels during or after ACL reconstruction.…”

Development of a femoral template for computer-assisted tunnel placement in anatomical double-bundle ACL reconstruction

“…These issues can lead to additional sources of failure [13]. Exact graft placement is one of the most complicated steps during ACL surgery, and large numbers of misplaced grafts have been reported [14][15][16]. These misplacements can be attributed in part to the nature of the arthroscopic procedure: The view is restricted to a local part of the ligament attachment site, and only a two-dimensional (2D) view of the three-dimensional (3D) reality can be displayed through the endoscope.…”

“…In an anatomical reconstruction with two bundles, graft placement becomes even more relevant than in single-bundle reconstructions; grafts must be positioned accurately not only with respect to the surrounding tissues, but also relative to one another. Since the femoral positioning is most important [16] and most difficult to achieve [14], this study is focused on the femoral attachment sites.…”

“…Studies to develop improved methods for accurate femoral tunnel positioning and drilling have encompassed radiographic guidelines [16,30], tensiometers and femoral aiming guides [31,32], computer-assisted fluoroscopic navigation [33][34][35], computer-assisted real-time navigation [36][37][38][39][40][41] and robotic-assisted surgery systems [42,43]. Passive computer-assisted navigation and active roboticassisted surgery systems can contribute to minimizing variation in graft placement.…”