Top

Archives of Orthopaedic and Trauma Surgery

Published in:

01-12-2014 | Arthroscopy and Sports Medicine

Creation of femoral tunnel by outside-in technique for ACL reconstruction: an analysis

Authors: Skand Sinha, Ananta K. Naik, Durgashankar Meena, Vijay K. Jain, Rajendra K. Arya

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 12/2014

Abstract

Purpose

To study the outcome of ACL reconstruction by retrograde outside-in (OI) creation of femoral tunnel.

Methods

ACL reconstruction was done in 41 cases by OI technique. The tip of 115° femoral guide was placed at posterior aspect of femoral foot print of ACL. Reaming was done from outside-in over guide pin. The length of femoral tunnel was obtained by measuring guide pin. The location of intra-articular femoral tunnel aperture and graft was recorded. Tibial tunnel was created with 50° guide placed at tibial foot print of ACL. Post-operative digital radiograph was taken. Antero-posterior view was used to calculate coronal inclination of femoral tunnel. On lateral view femoral tunnel location was marked in relation to the intersection of Blumensaat line and posterior femoral cortical line. Lysholm scoring and pivot shift test were performed at follow-up. Objective measurement of anterior tibial translation was done by rolimeter (aircast) at 1 year.

Results

The mean femoral tunnel length recorded was 39.5 mm (±3.4). There was no incidence of femoral tunnel blow out or graft impingement. All cases had femoral tunnel aperture location posterior to posterior femoral cortical line and inferior to Blumensaat line. The mean coronal angle of femoral tunnel was 30.39° (±4.6). The mean preoperative Lysholm score of 53.5 (±13) increased to 95.2 (±3.5) 1 year after surgery. All the patients had full range of motion. The pivot shift test was negative and instrumented measurement of anterior translation of tibia was near normal in all cases.

Conclusion

OI technique of ACL reconstruction is a simple reproducible technique. The unconstrained placement and angling of femoral guide result in a femoral tunnel which is through footprint of ACL. The graft is placed very low, oblique and as posterior as possible on femoral side mimicking the native ACL.

Level of evidence

III.

Available only for authorised users

Hefzy MS, Grood ES, Noyes FR (1989) Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med 17(2):208–216PubMedCrossRef

Amis AA, Jakob RP (1998) Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 1(6 Suppl):S2–S12CrossRef

Gill TJ, Steadman JR (2002) Anterior cruciate ligament reconstruction the two-incision technique. Orthop Clin North Am 33:727–732PubMedCrossRef

Giron F, Buzzi R, Aglietti P (1999) Femoral tunnel position in anterior cruciate ligament reconstruction using three techniques: a cadaver study. Arthroscopy 15((7):750–756PubMedCrossRef

Topliss C, Webb J (2001) An audit of tunnel position in anterior cruciate ligament reconstruction. Knee 8(1):59–63PubMedCrossRef

Bedi A, Musahl V, Steuber V, Kendoff D, Choi D, Allen AA, Pearle AD, Altchek DW (2011) Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy 27(3):380–390PubMedCrossRef

Piasecki DP, Bach BR Jr, Espinoza Orias AA, Verma NN (2011) Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique? Am J Sports Med 39(6):1306–1315PubMedCrossRef

Bylski-Austrow DI, Grood ES, Hefzy MS, Holden JP, Butler DL (1990) Anterior cruciate ligament replacements: a mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension. J Orthop Res 8:522–531PubMedCrossRef

Zavras TD, Race A, Amis AA (2005) The effect of femoral attachment location on anterior cruciate ligament reconstruction: graft tension patterns and restoration of normal anterior-posterior laxity patterns. Knee Surg Sports Traumatol Arthrosc 13:92–100PubMedCrossRef

10.

Scopp JM, Jasper LE, Belkoff SM, Moorman CT 3rd (2004) The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20(3):294–299PubMedCrossRef

11.

Lee MC, Seong SC, Lee S, Chang CB, Park YK, Jo H, Kim CH (2007) Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 23:771–778PubMedCrossRef

12.

Steiner ME (2009) Independent drilling of tibial and femoral tunnels in anterior cruciate ligament reconstruction. J Knee Surg Apl 22(2):171–176CrossRef

13.

Lubowitz JH (2009) Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy 25(1):95–101PubMedCrossRef

14.

Greis PE, Burks RT, Bachus K, Luker MG (2001) The influence of tendon length and fit on the strength of a tendon-bone tunnel complex. A biomechanical and histologic study in the dog. Am J Sports Med 29(4):493–497PubMed

15.

Yamazaki S, Yasuda K, Tomita F, Minami A, Tohyama H (2006) The effect of intraosseous graft length on tendon-bone healing in anterior cruciate ligament reconstruction using flexor tendon. Knee Surg Sports Traumatol Arthrosc 14(11):1086–1093PubMedCrossRef

16.

Zantop T, Ferretti M, Bell KM, Brucker PU, Gilbertson L, Fu FH (2008) Effect of tunnel-graft length on the biomechanics of anterior cruciate ligament reconstructed knee: intraarticular study in goat model. Am J Sports Med 36(11):2158–2166PubMedCrossRef

17.

Lubowitz JH, Konicek J (2010) Anterior cruciate ligament femoral tunnel length: cadaveric analysis comparing anteromedial portal versus outside-in technique. Arthroscopy 26(10):1357–1362PubMedCrossRef

18.

Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett WE Jr (2008) Reconstruction technique affects femoral tunnel placement in anterior cruciate ligament reconstruction. Clin Orthop Relat Res 466(6):1467–1474PubMedCentralPubMedCrossRef

19.

Ferraz V, Westerberg P, Brand JC (2013) Anterior cruciate ligament femoral socket drilling with a retrograde reamer: lessons from the learning curve. Arthrosc Tech 2(4):e389–e393PubMedCentralPubMedCrossRef

20.

Lubowitz JH, Amhad CH, Anderson K (2011) All Inside anterior cruciate ligament graft link technique: second-generation, no-incision anterior cruciate ligament reconstruction. Arthroscopy 27(5):717–727PubMedCrossRef

21.

Buda R, Ruffilli A, Cavallo M, Paliazzi G, Badassarri M, Ferranti Calderoni E, Natali S, Giannini S (2013) Anatomic all inside cal reconstruction: surgical techniques and results. J Orthop 5(3):135–138

22.

Fu FH, Karlsson J (2010) A long journey to be anatomic. Knee Surg Sports Traumatol Arthrosc 18(9):1151–1153PubMedCrossRef

23.

Fu FH, Jordan SS (2007) The lateral intercondylar ridge–a key to anatomic anterior cruciate ligament reconstruction. J Bone Joint Surg Am 89(10):2103–2104PubMedCrossRef

24.

Christel P, Boueri W (2011) Contemporary anterior cruciate ligament reconstruction. In: Jason LD (ed) Modern arthroscopy, p 197–224 (ISBN: 978-953-307-771-0)

25.

Arnold MP, Kooloos J, van Kampen A (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 9(4):194–199PubMedCrossRef

26.

Snyder GM, Johnson DL (2011) Anatomic graft placement in ACL surgery: plain radiographs are all we need. Orthopedics 34(2):116–118PubMedCrossRef

27.

Amis AA, Beynon B, Blankevoort L, Chambat P, Christel P, Durslen L, Friederich N, Grood E, Hertel P, Jacobn R, Muller W, O’Brian M, Connor JO (1994) Proceedings of the ESSKA scientific workshop on reconstruction of the anterior and posterior cruciate ligaments. Knee Surg Sports Traumatol Arthrosc 2:124–132PubMedCrossRef

28.

Flik KR, Bach BR Jr (2005) Anterior cruciate ligament reconstruction using a two incision arthroscopy-assisted technique with patellar tendon autograft. Techniques orthopaedics 20(4):372–376CrossRef

29.

Bedi A, Raphael B, Maderazo A, Pavlov H, Williams RJ 3rd (2010) Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy 26(3):342–350PubMedCrossRef

30.

Gadikota HR, Sim JA, Hosseini A, Gill TJ, Li G (2012) The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint. Am J Sports Med 40(4):882–888PubMedCentralPubMedCrossRef

31.

Robert Henri E, Bouguennec Nicolas, Vogeli Denis, Berton Eric, Bowen Mark (2013) Coverage of the anterior cruciate ligament femoral footprint using 3 different approaches in single-bundle reconstruction: a cadaveric study analyzed by 3-dimensional computed tomography. Am J Sports Med 41:2375PubMed

32.

Shin Young-Soo, Ro Kyung-Han, Lee Jong-Hee, Lee Dae-Hee (2013) Location of the femoral tunnel aperture in single-bundle anterior cruciate ligament reconstruction: comparison of the transtibial, anteromedial portal, and outside-in techniques. Am J Sports Med 41:2533PubMedCrossRef

33.

Simmons R, Howell SM, Hull ML (2003) 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 85(6):1018–1029PubMed

34.

Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Knee SLW (2003) 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 paper. Arthroscopy 19(3):297–304PubMedCrossRef

35.

Moisala AS, Järvelä T, Harilainen A, Sandelin J, Kannus P, Järvinen M (2007) The effect of graft placement on the clinical outcome of the anterior cruciate ligament reconstruction: a prospective study. Knee Surg Sports Traumatol Arthrosc 15(7):879–887PubMedCrossRef

36.

Behrend H, Stutz G, Kessler MA, Rukavina A, Giesinger K, Kuster MS (2006) Tunnel placement in anterior cruciate ligament (ACL) reconstruction: quality control in a teaching hospital. Knee Surg Sports Traumatol Arthrosc 14(11):1159–1165PubMedCrossRef

37.

James HL, Sam A, Brian RW, Armin A-H, John K (2013) Technique for creating the anterior cruciate ligament femoral socket: optimizing femoral footprint anatomic restoration using outside-in drilling. Arthrosc J Arthrosc Relat Surg 29(3):522–528CrossRef

38.

Musahl V, Plakseychuk A, VanScyoc A, Sasaki T, Debski RE, McMahon PJ, Fu FH (2005) Varying femoral tunnels between the anatomical footprint and isometric positions: effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med 33(5):712–718PubMedCrossRef

Title: Creation of femoral tunnel by outside-in technique for ACL reconstruction: an analysis
Authors: Skand Sinha
Ananta K. Naik
Durgashankar Meena
Vijay K. Jain
Rajendra K. Arya
Publication date: 01-12-2014
Publisher: Springer Berlin Heidelberg
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 12/2014
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-014-2078-5

At a glance: The STEP trials

Springer Medicine

Creation of femoral tunnel by outside-in technique for ACL reconstruction: an analysis

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Please log in to get access to this content

Other articles of this Issue 12/2014

Think twice before re-manipulating distal metaphyseal forearm fractures in children

Arthroscopic posterior cruciate ligament reconstruction by using hamstring tendon autograft and transosseous screw fixation: minimal 3 years follow-up

Hamstring tendon autograft versus LARS artificial ligament for arthroscopic posterior cruciate ligament reconstruction in a long-term follow-up

Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft

Loss of notochordal cell phenotype in 3D-cell cultures: implications for disc physiology and disc repair

The effectiveness of skeletal imaging for quality assessment in posterior cruciate ligament reconstruction: reliability and validity of radiographs and computed tomography