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Knee Surgery, Sports Traumatology, Arthroscopy
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 8/2015

01-08-2015 | Knee

Variability of tunnel positioning in fluoroscopic-assisted ACL reconstruction

Authors: Shafizadeh Sven, Balke Maurice, Juergen Hoeher, Banerjee Marc

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 8/2015

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Abstract

Purpose

Intraoperative fluoroscopy has been proposed as a feasible method to improve the accuracy of anatomical tunnel positioning. However, it has so far not been determined, whether this technique reduces the variability of tunnel positioning in a clinical set-up. Therefore, the purpose of this study was to determine the variability of tunnel positions applying intraoperative fluoroscopy.

Methods

Femoral and tibial tunnel positions of 112 fluoroscopic ACL reconstruction cases were determined according to validated radiological measurement methods. Mean positions, standard deviations and ranges were calculated to determine the variability of the tunnel positions. Subgroup variability analysis was performed to analyse cases in which tunnel positions were corrected.

Results

Applying intraoperative fluoroscopy, the variability of tunnel positions was found to be 3 % at the femur (range 15.4 %) and 2.3 % at the tibia (9.7 %). In 34 cases (30.0 %), non-satisfactory tunnel positions were identified and could be corrected achieving more accurate positions regarding to radiological parameters (14× femur, 16× tibia, 4× femur and tibia).

Conclusions

The results of the presented study indicate that intraoperative fluoroscopy allows to identify non-accurate tunnel positions regarding to radiological criteria. The determined low variability indicates that fluoroscopic-based ACL reconstruction can be recommended as a feasible, easy and effective adjunct that enables surgeons to create more consistent and reliable tunnel positions in ACL reconstruction.

Level of evidence

IV.
Literature
1.
Ahn JH, Lee YS, Chang MJ, Yim HS (2011) Analysis of revision anterior cruciate ligament reconstruction according to the combined injury, degenerative change, and MRI findings. Knee 18(6):382–386PubMedCrossRef
2.
Amis AA, Beynnon B, Blankevoort L, Chambat P, Christel P, Durselen L, Friederich N, Grood E, Hertel P, Jakob R et al (1994) Proceedings of the ESSKA scientific workshop on reconstruction of the anterior and posterior cruciate ligaments. Knee Surg Sports Traumatol Arthrosc 2(3):124–132PubMedCrossRef
3.
Barrett AM, Craft JA, Replogle WH, Hydrick JM, Barrett GR (2011) Anterior cruciate ligament graft failure: a comparison of graft type based on age and Tegner activity level. Am J Sports Med 39(10):2194–2198PubMedCrossRef
4.
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
5.
Bernard M, Hertel P (1996) Intraoperative and postoperative insertion control of anterior cruciate ligament-plasty. A radiologic measuring method (quadrant method). Unfallchirurg 99(5):332–340PubMed
6.
Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10(1):14–21PubMed
7.
Chouteau J, Benareau I, Testa R, Fessy MH, Lerat JL, Moyen B (2008) Comparative study of knee anterior cruciate ligament reconstruction with or without fluoroscopic assistance: a prospective study of 73 cases. Arch Orthop Trauma Surg 128(9):945–950PubMedCrossRef
8.
Group M (2013) Radiographic findings in revision anterior cruciate ligament reconstructions from the Mars cohort. J Knee Surg 26(4):239–247CrossRef
9.
Group M, Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, Allen CR, Cooper DE, DeBerardino TM, Lantz BB, Mann BJ, Stuart MJ (2010) Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med 38(10):1979–1986CrossRef
10.
Harner CD, Marks PH, Fu FH, Irrgang JJ, Silby MB, Mengato R (1994) Anterior cruciate ligament reconstruction: endoscopic versus two-incision technique. Arthroscopy 10(5):502–512PubMedCrossRef
11.
Hiraoka H, Kuribayashi S, Fukuda A, Fukui N, Nakamura K (2006) Endoscopic anterior cruciate ligament reconstruction using a computer-assisted fluoroscopic navigation system. J Orthop Sci 11(2):159–166PubMedCrossRef
12.
Howell SM (1998) Principles for placing the tibial tunnel and avoiding roof impingement during reconstruction of a torn anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 6(Suppl 1):S49–S55PubMedCrossRef
13.
14.
Kasten P, Szczodry M, Irrgang J, Kropf E, Costello J, Fu FH (2010) What is the role of intra-operative fluoroscopic measurements to determine tibial tunnel placement in anatomical anterior cruciate ligament reconstruction? Knee Surg Sports Traumatol Arthrosc 18(9):1169–1175PubMedCrossRef
15.
Kawakami Y, Hiranaka T, Matsumoto T, Hida Y, Fukui T, Uemoto H, Doita M, Tsuji M, Kurosaka M, Kuroda R (2012) The accuracy of bone tunnel position using fluoroscopic-based navigation system in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 20(8):1503–1510PubMedCrossRef
16.
Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum EB (1996) The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med 24(3):335–341PubMedCrossRef
17.
Klos TV, Habets RJ, Banks AZ, Banks SA, Devilee RJ, Cook FF (1998) Computer assistance in arthroscopic anterior cruciate ligament reconstruction. Clin Orthop Relat Res 354:65–69PubMedCrossRef
18.
Klos TV, Harman MK, Devilee RJ, Banks SA, Cook FF (1999) Patellar tendon graft position after anterior cruciate ligament reconstruction. Interobserver variability on lateral radiographs. Acta Orthop Scand 70(2):180–184PubMedCrossRef
19.
Klos TV, Harman MK, Habets RJ, Devilee RJ, Banks SA (2000) Locating femoral graft placement from lateral radiographs in anterior cruciate ligament reconstruction: a comparison of 3 methods of measuring radiographic images. Arthroscopy 16(5):499–504PubMedCrossRef
20.
Kodali P, Yang S, Koh J (2008) Computer-assisted surgery for anterior cruciate ligament reconstruction. Sports Med Arthrosc Rev 16(2):67–76CrossRef
21.
Koh J, Koo SS, Leonard J, Kodali P (2006) Anterior cruciate ligament (ACL) tunnel placement: a radiographic comparison between navigated versus manual ACL reconstruction. Orthopedics 29(10 Suppl):S122–S124PubMed
22.
Kopf S, Forsythe B, Wong AK, Tashman S, Irrgang JJ, Fu FH (2012) Transtibial ACL reconstruction technique fails to position drill tunnels anatomically in vivo 3D CT study. Knee Surg Sports Traumatol Arthrosc 20(11):2200–2207PubMedCentralPubMedCrossRef
23.
Landis JR, Koch GG (1977) An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics 33(2):363–374PubMedCrossRef
24.
Marchant BG, Noyes FR, Barber-Westin SD, Fleckenstein C (2010) Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions. Am J Sports Med 38(10):1987–1996PubMedCrossRef
25.
McConkey MO, Amendola A, Ramme AJ, Dunn WR, Flanigan DC, Britton CL, Group MK, Wolf BR, Spindler KP, Carey JL, Cox CL, Kaeding CC, Wright RW, Matava MJ, Brophy RH, Smith MV, McCarty EC, Vida AF, Wolcott M, Marx RG, Parker RD, Andrish JF, Jones MH (2012) Arthroscopic agreement among surgeons on anterior cruciate ligament tunnel placement. Am J Sports Med 40(12):2737–2746PubMedCrossRef
26.
Mehta VM, Paxton EW, Fithian DC (2009) Does the use of fluoroscopy and isometry during anterior cruciate ligament reconstruction affect surgical decision making? Clin J Sport Med 19(1):46–48PubMedCrossRef
27.
Meuffels DE, Reijman M, Verhaar JA (2012) Computer-assisted surgery is not more accurate or precise than conventional arthroscopic ACL reconstruction: a prospective randomized clinical trial. J Bone Joint Surg Am 94(17):1538–1545PubMedCrossRef
28.
Moloney G, Araujo P, Rabuck S, Carey R, Rincon G, Zhang X, Harner C (2013) Use of a fluoroscopic overlay to assist arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med 41(8):1794–1800PubMedCrossRef
29.
Musahl V, Burkart A, Debski RE, Van Scyoc A, Fu FH, Woo SL (2003) Anterior cruciate ligament tunnel placement: comparison of insertion site anatomy with the guidelines of a computer-assisted surgical system. Arthroscopy 19(2):154–160PubMedCrossRef
30.
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
31.
Picard F, DiGioia AM, Moody J, Martinek V, Fu FH, Rytel M, Nikou C, LaBarca RS, Jaramaz B (2001) Accuracy in tunnel placement for ACL reconstruction. Comparison of traditional arthroscopic and computer-assisted navigation techniques. Comput Aided Surg 6(5):279–289PubMedCrossRef
32.
Piefer JW, Pflugner TR, Hwang MD, Lubowitz JH (2012) Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature. Arthroscopy 28(6):872–881PubMedCrossRef
33.
Pinczewski LA, Salmon LJ, Jackson WF, von Bormann RB, Haslam PG, Tashiro S (2008) Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 90(2):172–179PubMedCrossRef
34.
Plaweski S, Cazal J, Rosell P, Merloz P (2006) Anterior cruciate ligament reconstruction using navigation: a comparative study on 60 patients. Am J Sports Med 34(4):542–552PubMedCrossRef
35.
Sadoghi P, Kropfl A, Jansson V, Muller PE, Pietschmann MF, Fischmeister MF (2011) Impact of tibial and femoral tunnel position on clinical results after anterior cruciate ligament reconstruction. Arthroscopy 27(3):355–364PubMedCrossRef
36.
Shafizadeh S, Balke M, Wegener S, Tjardes T, Bouillon B, Hoeher J, Baethis H (2011) Precision of tunnel positioning in navigated anterior cruciate ligament reconstruction. Arthroscopy 27(9):1268–1274PubMedCrossRef
37.
Siebold R (2011) The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(5):699–706PubMedCrossRef
38.
Siebold R, Ellert T, Metz S, Metz J (2008) 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 24(5):585–592PubMedCrossRef
39.
Singh AP, Singh BK (2011) The use of intra-operative image intensifier control for the ACL surgeon. Knee 18(6):379–381PubMedCrossRef
40.
Staubli HU, Rauschning W (1994) Tibial attachment area of the anterior cruciate ligament in the extended knee position. Anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo. Knee Surg Sports Traumatol Arthrosc 2(3):138–146PubMedCrossRef
41.
Sullivan JP, Matava MJ, Flanigan DC, Gao Y, Britton CL, Amendola A, Group M, Wolf BR (2012) Reliability of tunnel measurements and the quadrant method using fluoroscopic radiographs after anterior cruciate ligament reconstruction. Am J Sports Med 40(10):2236–2241PubMedCrossRef
42.
Taketomi S, Inui H, Nakamura K, Hirota J, Takei S, Takeda H, Tanaka S, Nakagawa T (2012) Three-dimensional fluoroscopic navigation guidance for femoral tunnel creation in revision anterior cruciate ligament reconstruction. Arthrosc Tech 1(1):e95–e99PubMedCentralPubMedCrossRef
43.
Trojani C, Sbihi A, Djian P, Potel JF, Hulet C, Jouve F, Bussiere C, Ehkirch FP, Burdin G, Dubrana F, Beaufils P, Franceschi JP, Chassaing V, Colombet P, Neyret P (2011) Causes for failure of ACL reconstruction and influence of meniscectomies after revision. Knee Surg Sports Traumatol Arthrosc 19(2):196–201PubMedCrossRef
44.
Tsuda E, Ishibashi Y, Fukuda A, Yamamoto Y, Tsukada H, Ono S (2010) Tunnel position and relationship to postoperative knee laxity after double-bundle anterior cruciate ligament reconstruction with a transtibial technique. Am J Sports Med 38(4):698–706PubMedCrossRef
45.
Wolf BR, Ramme AJ, Wright RW, Brophy RH, McCarty EC, Vidal AR, Parker RD, Andrish JT, Amendola A, Group MK (2013) Variability in ACL tunnel placement: observational clinical study of surgeon ACL tunnel variability. Am J Sports Med 41(6):1265–1273PubMedCrossRef
46.
Wright R, Spindler K, Huston L, Amendola A, Andrish J, Brophy R, Carey J, Cox C, Flanigan D, Jones M, Kaeding C, Marx R, Matava M, McCarty E, Parker R, Vidal A, Wolcott M, Wolf B, Dunn W (2011) Revision ACL reconstruction outcomes: MOON cohort. J Knee Surg 24(4):289–294PubMedCentralPubMedCrossRef
47.
Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, Allen CR, Cooper DE, DeBerardino TM, Lantz BB, Mann BJ, Stuart MJ (2010) Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med 38(10):1979–1986PubMedCrossRef
48.
Zantop T, Wellmann M, Fu FH, Petersen W (2008) Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 36(1):65–72PubMedCrossRef
49.
Zhu W, Lu W, Han Y, Hui S, Ou Y, Peng L, Fen W, Wang D, Zhang L, Zeng Y (2013) Application of a computerised navigation technique to assist arthroscopic anterior cruciate ligament reconstruction. Int Orthop 37(2):233–238PubMedCentralPubMedCrossRef
Metadata
Title
Variability of tunnel positioning in fluoroscopic-assisted ACL reconstruction
Authors
Shafizadeh Sven
Balke Maurice
Juergen Hoeher
Banerjee Marc
Publication date
01-08-2015
Publisher
Springer Berlin Heidelberg
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 8/2015
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-014-3029-y

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