Little is known about surgeon agreement and accuracy using arthroscopic evaluation of anterior cruciate ligament (ACL) tunnel positioning.
Purpose:
To investigate agreement on ACL tunnel position evaluated arthroscopically between operating surgeons and reviewing surgeons. We hypothesized that operating and evaluating surgeons would characterize tunnel positions significantly differently.
Study Design:
Controlled laboratory study.
Methods:
Twelve surgeons drilled ACL tunnels on 72 cadaveric knees using transtibial (TT), medial portal (MP), or 2-incision (TI) techniques and then completed a detailed assessment form on tunnel positioning. Then, 3 independent blinded surgeon reviewers each arthroscopically evaluated tunnel position and completed the assessment form. Statistical comparisons of tunnel position evaluation between operating and reviewing surgeons were completed. Three-dimensional (3D) computed tomography (CT) scans were performed and compared with arthroscopic assessments. Arthroscopic assessments were compared with CT tunnel location criteria.
Results:
Operating surgeons were significantly more likely to evaluate femoral tunnel position (92.6% vs 69.2%; P = .0054) and femoral back wall thickness as “ideal” compared with reviewing surgeons. Tunnels were judged ideal by reviewing surgeons more often when the TI technique was used compared with the MP and TT techniques. Operating surgeons were more likely to evaluate tibial tunnel position as ideal (95.5% vs 57.1%; P < .0001) and “acceptable” compared with reviewers. The ACL tunnels drilled using the TT technique were least likely to be judged as ideal on the tibia and the femur. Agreement among surgeons and observers was poor for all parameters (κ = −0.0053 to 0.2457). By 3D CT criteria, 88% of femoral tunnels and 78% of tibial tunnels were placed within applied criteria.
Conclusion:
Operating surgeons are more likely to judge their tunnels favorably than observers. However, independent surgeon reviewers appear to be more critical than results of 3D CT imaging measures. When subjectively evaluated arthroscopically, the TT technique yields more subjectively poorly positioned tunnels than the TI and MP techniques. Surgeons do not agree on the ideal placement for single-bundle ACL tunnels.
Clinical Relevance:
This study demonstrates that surgeons do not currently uniformly agree on ideal single-bundle tunnel placement and that the TT technique may yield more poorly placed tunnels.
AgliettiPBuzziRGironFSimeoneAJZaccherottiG. Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon: a 5-8-year follow-up. Knee Surg Sports Traumatol Arthrosc. 1997;5(3):138-144.
2.
BernardMHertelPHornungHCierpinskiT. Femoral insertion of the ACL: radiographic quadrant method. Am J Knee Surg. 1997;10(1):14-21, discussion 21-22.
3.
BirdJHCarmontMRDhillonM. Validation of a new technique to determine midbundle femoral tunnel position in anterior cruciate ligament reconstruction using 3-dimensional computed tomography analysis. Arthroscopy. 2011;27(9):1259-1267.
4.
ChengTLiuTZhangGZhangX. Computer-navigated surgery in anterior cruciate ligament reconstruction: are radiographic outcomes better than conventional surgery?Arthroscopy. 2011;27(1):97-100.
5.
ChhabraAStarmanJSFerrettiMVidalAFZantopTFuFH. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am. 2006;88Suppl 4:2-10.
6.
ChouteauJBenareauITestaRFessyMHLeratJLMoyenB. Comparative study of knee anterior cruciate ligament reconstruction with or without fluoroscopic assistance: a prospective study of 73 cases. Arch Orthop Trauma Surg. 2008;128(9):945-950.
7.
ColombetPRobinsonJChristelP. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy. 2006;22(9):984-992.
8.
DiamantopoulosAPLorbachOPaesslerHH. Anterior cruciate ligament revision reconstruction: results in 107 patients. Am J Sports Med. 2008;36(5):851-860.
9.
DoiMTakahashiMAbeMSuzukiDNaganoA. Lateral radiographic study of the tibial sagital insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2009;17(4):347-351.
10.
EdwardsABullAMAmisAA. The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament, part 1: tibial attachment. Knee Surg Sports Traumatol Arthrosc. 2007;15(12):1414-1421.
11.
EdwardsABullAMAmisAA. The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament, part 2: femoral attachment. Knee Surg Sports Traumatol Arthrosc. 2008;16(1):29-36.
12.
FerrettiMEkdahlMShenWFuFH. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy. 2007;23(11):1218-1225.
13.
ForsytheBKopfSWongAK. The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models. J Bone Joint Surg Am. 2010;92(6):1418-1426.
14.
FuFH. The clock-face reference: simple but nonanatomic. Arthroscopy. 2008;24(12):1433, author reply 1434.
15.
FuFHJordanSS. The lateral intercondylar ridge: a key to anatomic anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2007;89(10):2103-2104.
16.
GelberPEErquiciaJAbatF. Effectiveness of a footprint guide to establish an anatomic femoral tunnel in anterior cruciate ligament reconstruction: computed tomography evaluation in a cadaveric model. Arthroscopy. 2011;27(6):817-824.
17.
GuoLYangLWangAMWangXYDaiG. Roentgenographic measurement study for locating femoral insertion site of anterior cruciate ligament: a cadaveric study with X-Caliper. Int Orthop. 2009;33(1):133-137.
18.
HarnerCDBaekGHVogrinTMCarlinGJKashiwaguchiSWooSL. Quantitative analysis of human cruciate ligament insertions. Arthroscopy. 1999;15(7):741-749.
19.
HarterRAOsternigLRSingerKMJamesSLLarsonRLJonesDC. Long-term evaluation of knee stability and function following surgical reconstruction for anterior cruciate ligament insufficiency. Am J Sports Med. 1988;16(5):434-443.
20.
HutchinsonMRBaeTS. Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med. 2001;29(6):777-780.
21.
IriuchishimaTInghamSJTajimaG. Evaluation of the tunnel placement in the anatomical double-bundle ACL reconstruction: a cadaver study. Knee Surg Sports Traumatol Arthrosc. 2010;18(9):1226-1231.
KhalfayanEESharkeyPFAlexanderAHBrucknerJDBynumEB. The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med. 1996;24(3):335-341.
25.
KongcharoensombatWOchiMAbouheifM. The transverse ligament as a landmark for tibial sagittal insertions of the anterior cruciate ligament: a cadaveric study. Arthroscopy. 2011;27(10):1395-1399.
26.
KopfSMusahlVTashmanSSzczodryMShenWFuFH. A systematic review of the femoral origin and tibial insertion morphology of the ACL. Knee Surg Sports Traumatol Arthrosc. 2009;17(3):213-219.
27.
LandisJRKochGG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174.
28.
LintnerDMDewittSEMoseleyJB. Radiographic evaluation of native anterior cruciate ligament attachments and graft placement for reconstruction: a cadaveric study. Am J Sports Med. 1996;24(1):72-78.
29.
LohJCFukudaYTsudaESteadmanRJFuFHWooSL. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. 2002 Richard O’Connor Award. Arthroscopy. 2003;19(3):297-304.
30.
LorenzSElserFMittererMObstTImhoffAB. Radiologic evaluation of the insertion sites of the 2 functional bundles of the anterior cruciate ligament using 3-dimensional computed tomography. Am J Sports Med. 2009;37(12):2368-2376.
31.
MarchantBGNoyesFRBarber-WestinSDFleckensteinC. Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions. Am J Sports Med. 2010;38(10):1987-1996.
32.
MehtaVMPaxtonEWFithianDC. Does the use of fluoroscopy and isometry during anterior cruciate ligament reconstruction affect surgical decision making?Clin J Sport Med. 2009;19(1):46-48.
33.
MochizukiTMunetaTNagaseTShirasawaSAkitaKISekiyaI. Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2006;22(4):356-361.
34.
MusahlVBurkartADebskiREVan ScyocAFuFHWooSL. Anterior cruciate ligament tunnel placement: comparison of insertion site anatomy with the guidelines of a computer-assisted surgical system. Arthroscopy. 2003;19(2):154-160.
35.
NoyesFRBarber-WestinSD. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Am J Sports Med. 2006;34(4):678-679, author reply 679-680.
36.
RaffoCSPizzarelloPRichmondJCPathareN. A reproducible landmark for the tibial tunnel origin in anterior cruciate ligament reconstruction: avoiding a vertical graft in the coronal plane. Arthroscopy. 2008;24(7):843-845.
37.
RammeAJWolfBRWarmeBA. Surgically oriented measurements for three-dimensional characterization of tunnel placement in anterior cruciate ligament reconstruction. Comput Aided Surg. 2012;17(5):221-231.
38.
RihnJAIrrgangJJChhabraAFuFHHarnerCD. Does irradiation affect the clinical outcome of patellar tendon allograft ACL reconstruction?Knee Surg Sports Traumatol Arthrosc. 2006;14(9):885-896.
39.
RueJPHGhodadraNBachBR. Femoral tunnel placement in single-bundle anterior cruciate ligament reconstruction. Am J Sport Med. 2008;36(1):73-79.
40.
SadoghiPKropflAJanssonVMullerPEPietschmannMFFischmeisterMF. Impact of tibial and femoral tunnel position on clinical results after anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(3):355-364.
41.
SalmonLJPinczewskiLARussellVJRefshaugeK. Revision anterior cruciate ligament reconstruction with hamstring tendon autograft: 5- to 9-year follow-up. Am J Sports Med. 2006;34(10):1604-1614.
42.
ShafizadehSBalkeMWegenerS. Precision of tunnel positioning in navigated anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(9):1268-1274.
43.
SieboldREllertTMetzSMetzJ. Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for double-bundle bone tunnel placement. A cadaver study. Arthroscopy. 2008;24(5):585-592.
44.
SieboldREllertTMetzSMetzJ. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy. 2008;24(2):154-161.
45.
SinghAPSinghBK. The use of intra-operative image intensifier control for the ACL surgeon. Knee. 2011;18(6):379-381.
46.
SommerCFriederichNFMullerW. Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc. 2000;8(4):207-213.
47.
SpindlerKRKuhnJEFreedmanKBMatthewsCEDittusRSHarrellFE. Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring. Does it really matter? A systematic review. Am J Sports Med. 2004;32(8):1986-1995.
48.
TakahashiMDoiMAbeMSuzukiDNaganoA. Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med. 2006;34(5):787-792.
49.
ZantopTWellmannMFuFHPetersenW. Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med. 2008;36(1):65-72.
50.
ZieglerCGPietriniSDWesterhausBD. Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2011;39(4):743-752.
