Independent Drilling Outperforms Conventional Transtibial Drilling in Anterior Cruciate Ligament Reconstruction

Abstract

Background

Optimal tunnel placement is critical in anterior cruciate ligament reconstructive surgery, yet the method used to drill the tunnels may compromise their placement.

Hypothesis

An independent drilling method versus a conventional transtibial drilling method will place tunnels in different locations and produce reconstructions with different kinematics.

Study Design

Controlled laboratory study.

Methods

Ten pairs of knees had anterior cruciate ligament reconstructions produced by either a conventional transtibial drilling method or an independent drilling method. The location of the tunnels was recorded, and the knees were tested for laxity in the normal state, with the anterior cruciate ligament removed, and with the anterior cruciate ligament reconstructed. A surgical navigation system guided the placement of the independently drilled tunnels and measured joint laxity in response to various combinations of anterior force and rotational torques.

Results

The conventional transtibial drilling method used in this study placed tibial tunnels posterior and femoral tunnels superior relative to their footprints and resulted in more vertical grafts. In contrast, the independently drilled tibial and femoral tunnels were more anterior and central in their respective footprints, resulting in more horizontal grafts. The horizontal grafts of the independent drilling method were superior to the vertical grafts of this study’s transtibial drilling method in restoring normal anterior and rotational knee laxity.

Conclusion

An independent drilling method can produce tunnels with superior function compared with tunnels produced by a conventional transtibial drilling method.

Clinical Relevance

Single-bundle anterior cruciate ligament reconstructions will be improved if grafts are centered in their anatomical insertions by an independent drilling method versus grafts placed by a conventional transtibial drilling method.

Keywords

anterior cruciate ligament (ACL) reconstruction transtibial drilling independent drilling

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References

Amis

Jakob

. Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc. 1998;6(suppl 1):S2–S12.

Arnold

Kooloos

van Kampen

. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc. 2001;9:194–199.

Asagumo

Kimura

Kobayashi

Taki

Takagishi

. Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: surgical techniques, clinical outcomes, and complications. Arthroscopy. 2007;23:602–609.

Bernard

Hertel

Hornung

Cierpinski

. Femoral insertion of the ACL radiographic quadrant method. Am J Knee Surg. 1997;10:14–22.

Brown

Sklar

. Endoscopic anterior cruciate ligament reconstruction using quadrupled hamstring tendons and EndoButton femoral fixation. Tech Orthop. 1998;13:281–298.

Cha

Brucker

West

. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy. 2005;21:1275e1–1275e8.

Chhabra

Diduch

Blessey

Miller

. Recreating an acceptable angle of the tibial tunnel in the coronal plane in anterior cruciate ligament reconstruction using external landmarks. Arthroscopy. 2004;20:328–330.

Chhabra

Kline

Nilles

Harner

. Tunnel expansion after anterior cruciate ligament reconstruction with autogenous hamstrings: a comparison of the medial portal and transtibial techniques. Arthroscopy. 2006;22:1107–1112.

Christian

Indelicato

. Allograft anterior cruciate ligament reconstruction with patellar tendon: an endoscopic technique. Oper Tech Sports Med. 1993;1:51–57.

10.

Clancy

Nelson

Reider

Narechania

. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am. 1982;64:352–359.

11.

Colombet

Robinson

Christel

. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy. 2006;22:984–992.

12.

Cooper

Small

Urrea

. Factors affecting graft excursion patterns in endoscopic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 1998;6(suppl 1):S20–S24.

13.

Garofalo

Mouhsine

Chambat

Siegrist

. Anatomic anterior cruciate ligament reconstruction: the two incision technique. Knee Surg Sports Traumatol Arthrosc. 2006;14:510–516.

14.

Georgoulis

Papadonikolakis

Papageorgiou

Mitsou

Stergiiou

. Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament–deficient and reconstructed knee during walking. Am J Sports Med. 2003;31:75–79.

15.

Hantes

Zachos

Basdekis

Zibis

Dailiana

Malizos

. Differences in graft orientation using the transtibial and anteromedial portal technique in ACL reconstruction: an MRI prospective study. J Bone Joint Surg Br. 2006;88(suppl 1):93.

16.

Hardin

Bach

Bush-Joseph

Farr

. Endoscopic single incision anterior cruciate ligament reconstruction using patellar tendon autograft: surgical technique. Am J Knee Surg. 1992;5:144–155.

17.

Harner

Honkamp

Ranawat

. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy. 2008;24:113–115.

18.

Hefzy

Grood

Noyes

. Factors affecting the region of most isometric femoral attachments, part II: the anterior cruciate ligament. Am J Sports Med. 1989;17:208–216.

19.

Heming

Rand

Steiner

. Anatomic limitations of transtibial drilling in ACL reconstruction. Am J Sports Med. 2007;35:1708–1715.

20.

Howell

. Principles for placing the tibial tunnel and avoiding roof impingement during reconstruction of a torn anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 1998;6(suppl 1):S49–S55.

21.

Howell

Barad

. Knee extension and its relationship to the slope of the intercondylar roof: implications for positioning the tibial tunnel in anterior cruciate ligament reconstructions. Am J Sports Med. 1995;23:288–294.

22.

Howell

Clark

. Tibial tunnel placement in anterior cruciate ligament reconstructions and graft impingement. Clin Orthop Relat Res. 1992;283:187–195.

23.

Howell

Deutsch

. Comparison of endoscopic and two-incision techniques for reconstructing a torn anterior cruciate ligament using hamstring tendons. Arthroscopy. 1999;15:594–606.

24.

Howell

Gittins

Gottlieb

Traina

Zoellner

. The relationship between the angle of the tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament reconstruction. Am J Sports Med. 2001;29:567–574.

25.

Howell

Wallace

Hull

Deutsch

. Evaluation of the single-incision arthroscopic technique for anterior cruciate ligament replacement. Am J Sports Med. 1999;27:284–293.

26.

Jackson

Gasser

. Tibial tunnel placement in ACL reconstruction. Arthroscopy. 1994;10:124–131.

27.

Kendoff

Meller

Marquard

. Navigated measurement of tibial translation and rotation in the ACL deficient knee. J Bone Joint Surg Br. 2006;88(suppl 3):445.

28.

Khalfayan

Sharkey

Alexander

Bruckner

Bynum

. The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med. 1996;24:335–341.

29.

Kocher

Steadman

Briggs

Sterett

Hawkins

. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:629–634.

30.

Kondo

Yasuda

Ichiyama

Azuma

Tohyama

. Radiologic evaluation of femoral and tibial tunnels created with the transtibial tunnel technique for anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2007;23:869–876.

31.

Loh

Fukuda

Tsuda

Steadman

Woo

. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy. 2003;19:297–304.

32.

Mae

Shino

Miyama

. Single- versus two-femoral socket anterior cruciate ligament reconstruction technique: biomechanical analysis using a robotic simulator. Arthroscopy. 2001;17:708–716.

33.

Markolf

Park

Jackson

McAllister

. Simulated pivot-shift testing with single- and double-bundle anterior cruciate ligament reconstructions. J Bone Joint Surg Am. 2008;90:1681–1690.

34.

Morgan

Kalman

Grawl

. Definitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy. 1995;11:275–288.

35.

Muneta

Koga

Morito

Yagishita

Sekiya

. A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction. Arthroscopy. 2006;22:252–258.

36.

Muneta

Yamamoto

Ishibashi

Asahina

Murakami

Furuya

. The effects of tibial tunnel placement and roofplasty on reconstructed anterior cruciate ligament knees. Arthroscopy. 1995;11:57–62.

37.

Odensten

Gillquist

. Functional anatomy of the anterior cruciate ligament and a rational for reconstruction. J Bone Joint Surg Am. 1985;67:257–262.

38.

Paessler

Rossis

Mastrokalos

Kotsovolos

. Anteromedial vs. transtibial technique for correct femoral tunnel placement during arthroscopic ACL reconstruction with hamstrings: an in vivo study. J Bone Joint Surg Br. 2004;suppl 3:234.

39.

Panni

Milano

Tartarone

Demontis

Fabbriciani

. Clinical radiographic results of ACL reconstruction: a 5- to 7- year follow-up study of outside-in versus inside-out reconstruction techniques. Knee Surg Sports Traumatol Arthrosc. 2001;9:77–85.

40.

Picard

DiGioia

Moody

. Accuracy in tunnel placement for ACL reconstruction: comparison of traditional arthroscopic and computer-assisted navigation techniques. Comput Aided Surg. 2002;6:279–289.

41.

Raffo

Pizzarello

Richmond

Pathare

. A reproducible landmark for the tibial tunnel origin in anterior cruciate ligament reconstruction: avoiding a vertical graft in the coronal plane. Arthroscopy. 2008;24:843–845.

42.

Ristanis

Stergiou

Patras

Vasiliadis

Giakas

Georgoulis

. Excessive tibial rotation during high-demand activities is not restored by anterior cruciate ligament reconstruction. Arthroscopy. 2005;21:1323–1329.

43.

Rosenberg

. Technique for Endoscopic Method of ACL Reconstruction Technical Bulletin. Norwood, Mass: Acufex Microsurgical; 1989.

44.

Rue

J-P

Ghodadra

Bach

. Femoral tunnel placement in single-bundle anterior cruciate ligament reconstruction: a cadaveric study relating transtibial lateralized femoral tunnel position to the anteromedial and posterolateral bundle femoral origins of the anterior cruciate ligament. Am J Sports Med. 2008;36:73–79.

45.

Scopp

Jasper

Belkoff

Moorman

. The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy. 2004;20:294–299.

46.

Simmons

Howell

Hull

. Effect of the angle of the femoral and tibial tunnels in the coronal plane and incremental excision of the posterior cruciate ligament on tension of an anterior cruciate ligament graft: an in vitro study. J Bone Joint Surg Am. 2003;85:1018–1029.

47.

Sommer

Friederich

Müller

. Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc. 2000;8:207–213.

48.

Steiner

. Evaluation and management of ACL injuries. In: McKeon

Bono

Richmond

, eds. Knee Arthroscopy. New York: Springer-Verlag; 2008.

49.

Steiner

Brown

Zarins

Brownstein

Koval

Stone

. Measurement of anterior-posterior knee displacement: comparison of instrumented devices and clinical examination. J Bone Joint Surg Am. 1990;72:1307–1315.

50.

Steiner

Murray

Rodeo

. Strategies to improve anterior cruciate ligament healing and graft placement. Am J Sports Med. 2008;36:176–189.

51.

Tashman

Collon

Anderson

Kolowich

Anderst

. Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:975–983.

52.

Woo

Kanamori

Zeminski

Yagi

Papageorgiou

. The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon: a cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am. 2002;84:907–914.

53.

Yagi

Wong

Kanamori

Debski

Woo

. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002;30:660–666.

54.

Yamamoto

Hsu

Woo

Van Scyoc

Takakura

Debski

. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med. 2004;32:1825–1832.

55.

Yasuda

Kondo

Ichiyama

. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy. 2004;20:1015–1025.

56.

Zantop

Herbort

Raschke

Petersen

. The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation. Am J Sports Med. 2007;35:223–227.

57.

Zavras

Race

Bull

AMJ

Amis

. A comparative study of “isometric” points for anterior cruciate ligament graft attachment. Knee Surg Sports Traumatol Arthrosc. 2001;9:28–33.

58.

Zelle

Vidal

Brucker

. Double-bundle reconstruction of the anterior cruciate ligament: anatomic and biomechanical rationale. J Am Acad Orthop Surg. 2007;15:87–96.