Top

Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

16-05-2023 | KNEE

The tibial tunnel drilling angles of 60° provided a lower ultimate load to failure on a single bundle posterior cruciate ligament graft using interference screw fixation compared to 30°/45°

Authors: Xiaohui Zhang, Fei Teng, Bin Geng, Fan Lu, Zhongcheng Liu, Laiwei Guo, Hua Han, Meng Wu, Yayi Xia, Yuanjun Teng

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 9/2023

Abstract

Purpose

To biomechanically compare the initial fixation strength of grafts among three tibial tunnel angles (30°/45°/60°) in transtibial posterior cruciate ligament (PCL) reconstruction.

Methods

A series of transtibial PCL reconstruction models were established with porcine tibias and bovine tendons. Specimens were randomly assigned to three groups according to the angles between the tibial tunnel and the perpendicular line of the tibial shaft: Group A (30°, n = 12), Group B (45°, n = 12), and Group C (60°, n = 12). The area of the tunnel entrance, the segmental bone mineral density (sBMD) of the graft fixation site of the tibia and the maximum insertion torque of the interference screw were measured. Finally, load to failure tests were carried out on the graft-screw-tibia constructs at the same rate.

Results

Ultimate load to failure in Group C (335.2 ± 107.5 N) was significantly lower than that in Group A (584.1 ± 127.9 N, P < 0.01) and Group B (521.9 ± 95.9 N, P < 0.01). There were no significant differences between biomechanical properties of Groups A and B (n.s.). The posterior part fractures of the tibial tunnel exit occurred in eight specimens of Group C. In addition, the ultimate load was proven to be related to insertion torque (rho = 0.7, P < 0.01), sBMD (rho = 0.7, P < 0.01), and the area of the tunnel entrance (rho =− 0.4, P = 0.01).

Conclusion

The ultimate load to failure was significantly lower in tibial PCL interference screw fixation for tunnels drilled at 60° compared to 30°/45°. In addition, the ultimate load was significantly correlated with insertion torque, sBMD and the area of the tunnel entrance. Given that the load to failure of distal fixation may not be sufficient for early postoperative rehabilitation, a 60° tunnel should not be recommended to drill in tibia during PCL reconstruction.

Available only for authorised users

Ahn JH, Bae JH, Lee YS, Choi K, Bae TS, Wang JH (2009) An anatomical and biomechanical comparison of anteromedial and anterolateral approaches for tibial tunnel of posterior cruciate ligament reconstruction: evaluation of the widening effect of the anterolateral approach. Am J Sports Med 37:1777–1783CrossRefPubMed

Alentorn-Geli E, Stuart JJ, James Choi JH, Toth AP, Moorman CT 3rd, Taylor DC (2017) Posterolateral portal tibial tunnel drilling for posterior cruciate ligament reconstruction: technique and evaluation of safety and tunnel position. Knee Surg Sports Traumatol Arthrosc 25:2474–2480CrossRefPubMed

Ammann E, Hecker A, Bachmann E, Snedeker JG, Fucentese SF (2022) Evaluation of tibial fixation devices for quadrupled hamstring ACL reconstruction. Orthop J Sports Med 10:23259671221096108CrossRefPubMedPubMedCentral

Brand JC Jr, Pienkowski D, Steenlage E, Hamilton D, Johnson DL, Caborn DN (2000) Interference screw fixation strength of a quadrupled hamstring tendon graft is directly related to bone mineral density and insertion torque. Am J Sports Med 28:705–710CrossRefPubMed

Brown GA, Pena F, Grontvedt T, Labadie D, Engebretsen L (1996) Fixation strength of interference screw fixation in bovine, young human, and elderly human cadaver knees: influence of insertion torque, tunnel-bone block gap, and interference. Knee Surg Sports Traumatol Arthrosc 3:238–244CrossRefPubMed

Chia SL, Kapoor V, Ali MM, Lie D, Chang PC, Mitra AK et al (2002) The posterior cruciate ligament: an anthropometric study in Asians and evaluation of safe limits for bony tunnel creation during reconstruction. Ann Acad Med Singap 31:631–635PubMed

Gwinner C, Jung TM, Schatka I, Weiler A (2019) Posterior laxity increases over time after PCL reconstruction. Knee Surg Sports Traumatol Arthrosc 27:389–396CrossRefPubMed

Harvey AR, Thomas NP, Amis AA (2003) The effect of screw length and position on fixation of four-stranded hamstring grafts for anterior cruciate ligament reconstruction. Knee 10:97–102CrossRefPubMed

Jaglowski JR, Williams BT, Turnbull TL, LaPrade RF, Wijdicks CA (2016) High-load preconditioning of soft tissue grafts: an in vitro biomechanical bovine tendon model. Knee Surg Sports Traumatol Arthrosc 24:895–902CrossRefPubMed

10.

Jarvinen TL, Nurmi JT, Sievanen H (2004) Bone density and insertion torque as predictors of anterior cruciate ligament graft fixation strength. Am J Sports Med 32:1421–1429CrossRefPubMed

11.

Kim SJ, Kim TE, Jo SB, Kung YP (2009) Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am 91:2543–2549CrossRefPubMed

12.

Kopf S, Martin DE, Tashman S, Fu FH (2010) Effect of tibial drill angles on bone tunnel aperture during anterior cruciate ligament reconstruction. J Bone Joint Surg Am 92:871–881CrossRefPubMed

13.

Krott NL, Wengle L, Whelan D, Wild M, Betsch M (2022) Single and double bundle posterior cruciate ligament reconstruction yield comparable clinical and functional outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 30:2388–2399CrossRefPubMed

14.

LaPrade RF, Cinque ME, Dornan GJ, DePhillipo NN, Geeslin AG, Moatshe G et al (2018) Double-bundle posterior cruciate ligament reconstruction in 100 patients at a mean 3 years’ follow-up: outcomes were comparable to anterior cruciate ligament reconstructions. Am J Sports Med 46:1809–1818CrossRefPubMed

15.

Lee YS, Ra HJ, Ahn JH, Ha JK, Kim JG (2011) Posterior cruciate ligament tibial insertion anatomy and implications for tibial tunnel placement. Arthroscopy 27:182–187CrossRefPubMed

16.

Levy BA, Piepenbrink M, Stuart MJ, Wijdicks CA (2021) Posterior cruciate ligament reconstruction with independent suture tape reinforcement: an in vitro biomechanical full construct study. Orthop J Sports Med 9:2325967120981875CrossRefPubMedPubMedCentral

17.

Li Y, Chen XZ, Zhang J, Song GY, Li X, Feng H (2016) What role does low bone mineral density play in the “killer turn” effect after transtibial posterior cruciate ligament reconstruction? Orthop Surg 8:483–489CrossRefPubMedPubMedCentral

18.

Li Y, Zhang J, Song G, Li X, Feng H (2016) The mechanism of “killer turn” causing residual laxity after transtibial posterior cruciate ligament reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol 3:13–18PubMedPubMedCentral

19.

Lin Y, Huang Z, Zhang K, Pan X, Huang X, Li J et al (2020) Lower tibial tunnel placement in isolated posterior cruciate ligament reconstruction: clinical outcomes and quantitative radiological analysis of the killer turn. Orthop J Sports Med 8:2325967120923950CrossRefPubMedPubMedCentral

20.

Lockwood WC, Marchetti DC, Dahl KD, Mikula JD, Williams BT, Kheir MM et al (2017) High-load preconditioning of human soft tissue hamstring grafts: an in vitro biomechanical analysis. Knee Surg Sports Traumatol Arthrosc 25:138–143CrossRefPubMed

21.

MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF (2006) Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy 22:320–328CrossRefPubMed

22.

Margheritini F, Mauro CS, Rihn JA, Stabile KJ, Woo SL, Harner CD (2004) Biomechanical comparison of tibial inlay versus transtibial techniques for posterior cruciate ligament reconstruction: analysis of knee kinematics and graft in situ forces. Am J Sports Med 32:587–593CrossRefPubMed

23.

Margheritini F, Rihn JA, Mauro CS, Stabile KJ, Woo SL, Harner CD (2005) Biomechanics of initial tibial fixation in posterior cruciate ligament reconstruction. Arthroscopy 21:1164–1171CrossRefPubMed

24.

Ochiai S, Hagino T, Senga S, Yamashita T, Haro H (2019) Treatment outcome of reconstruction for isolated posterior cruciate injury: subjective and objective evaluations. J Knee Surg 32:506–512CrossRefPubMed

25.

Okoroafor UC, Saint-Preux F, Gill SW, Bledsoe G, Kaar SG (2016) Nonanatomic tibial tunnel placement for single-bundle posterior cruciate ligament reconstruction leads to greater posterior tibial translation in a biomechanical model. Arthroscopy 32:1354–1358CrossRefPubMed

26.

Teng Y, Da L, Jia G, Hu J, Liu Z, Zhang S et al (2022) What is the maximum tibial tunnel angle for transtibial PCL reconstruction? A comparison based on virtual radiographs, CT images, and 3D knee models. Clin Orthop Relat Res. https://doi.org/10.1097/corr.0000000000002111CrossRefPubMedPubMedCentral

27.

Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL (2012) Posterior cruciate ligament: anatomy, biomechanics, and outcomes. Am J Sports Med 40:222–231CrossRefPubMed

28.

Weimann A, Wolfert A, Zantop T, Eggers AK, Raschke M, Petersen W (2007) Reducing the “killer turn” in posterior cruciate ligament reconstruction by fixation level and smoothing the tibial aperture. Arthroscopy 23:1104–1111CrossRefPubMed

29.

Winkler PW, Zsidai B, Wagala NN, Hughes JD, Horvath A, Senorski EH et al (2021) Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation. Knee Surg Sports Traumatol Arthrosc 29:682–693CrossRefPubMed

30.

Yang F, Yokoe T, Ouchi K, Tajima T, Chosa E (2023) Influence of the tibial tunnel angle and posterior tibial slope on “killer turn” during posterior cruciate ligament reconstruction: a three-dimensional finite element analysis. J Clin Med 12:805CrossRefPubMedPubMedCentral

Title: The tibial tunnel drilling angles of 60° provided a lower ultimate load to failure on a single bundle posterior cruciate ligament graft using interference screw fixation compared to 30°/45°
Authors: Xiaohui Zhang
Fei Teng
Bin Geng
Fan Lu
Zhongcheng Liu
Laiwei Guo
Hua Han
Meng Wu
Yayi Xia
Yuanjun Teng
Publication date: 16-05-2023
Publisher: Springer Berlin Heidelberg
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 9/2023
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-023-07428-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The tibial tunnel drilling angles of 60° provided a lower ultimate load to failure on a single bundle posterior cruciate ligament graft using interference screw fixation compared to 30°/45°

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 9/2023

High degree of consensus amongst an expert panel regarding focal resurfacing of chondral and osteochondral lesions of the femur with mini-implants

Bicruciate-retaining total knee arthroplasty procedure reduced tensile force in the middle and posterior components of lateral collateral ligament during deep knee flexion activities with no effect on tensile force of the medial collateral ligament

Larger bone marrow lesion volume before medial open-wedge high tibial osteotomy correlates with better improvement of clinical scores in patients with knee osteoarthritis

Additional anteromedial staple fixation prevents changes in the posterior tibial slope in retrotuberosity bi-planar open-wedge high tibial osteotomy

Arthroscopic modified Broström procedure achieved similar favorable short term outcomes to open procedure for chronic lateral ankle instability cases with generalized joint laxity

In closed wedge distal femur osteotomies for correction of valgus malalignment overcorrection of mLDFA should be avoided