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Evaluation and Comparison of Femoral Tunnel Placement During Anterior Cruciate Ligament Reconstruction Using 3-Dimensional Computed Tomography: Effect of Notchplasty on Transtibial and Medial Portal Drilling.

Dugas JR, Pace JL, Bolt B, Wear SA, Beason DP, Cain EL - Orthop J Sports Med (2014)

Bottom Line: Advocates of medial portal drilling claim that the transtibial technique results in a more vertical positioning of the graft, which could lead to subsequent failure and/or a residual pivot shift on postoperative examination.However, advocates of transtibial drilling state that with appropriate placement and adequate notchplasty, their technique places the graft in a more anatomically correct position on the wall, negating the resultant potential for pivot shift and early postoperative failure.Both drilling techniques place the graft in an anatomically correct position.

View Article: PubMed Central - PubMed

Affiliation: American Sports Medicine Institute, Birmingham, Alabama, USA.

ABSTRACT

Background: Advocates of medial portal drilling claim that the transtibial technique results in a more vertical positioning of the graft, which could lead to subsequent failure and/or a residual pivot shift on postoperative examination. However, advocates of transtibial drilling state that with appropriate placement and adequate notchplasty, their technique places the graft in a more anatomically correct position on the wall, negating the resultant potential for pivot shift and early postoperative failure.

Hypothesis: Transtibial femoral drilling can adequately reproduce the femoral origin of the anterior cruciate ligament (ACL) and place the graft in an anatomical position equivalent to medial portal drilling.

Study design: Controlled laboratory study.

Methods: Ten matched-pair cadaveric knees (N = 20) were scanned using computed tomography (CT), and 3-dimensional images of the native ACL origin were reconstructed. The matched pairs were then randomized into transtibial and medial portal groups. The femoral tunnel was drilled in each knee according to group. A bamboo skewer was placed in the femoral tunnel, and the knees underwent a second CT scan. Arthroscopic notchplasty was performed, and the femoral tunnels were redrilled. Radiographs confirmed placement, and the post-notchplasty tunnel was reamed with a 4-mm reamer. The knees underwent a third CT scan. CT scans compared femoral tunnel placement with the native ACL footprint before and after notchplasty.

Results: The post-notchplasty transtibial group revealed an average of 68.3% coverage of the native ACL femoral origin. The medial portal group revealed an average of 60.8% coverage, with 1 instance of perforation of the posterior cortex. There were no instances of perforation in the transtibial group.

Conclusion: Both drilling techniques place the graft in an anatomically correct position.

Clinical relevance: Transtibial drilling of the femur can adequately place the entry tunnel at the origin of the ACL's native footprint.

No MeSH data available.


Related in: MedlinePlus

Anterior surface anatomy of mounted knees at 90° of flexion, neutral varus/valgus, and neutral internal/external rotation.
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fig1-2325967114525572: Anterior surface anatomy of mounted knees at 90° of flexion, neutral varus/valgus, and neutral internal/external rotation.

Mentions: The matched pairs of knees were randomized: 10 knees were placed in the transtibial group and 10 knees were placed in the medial portal group, with 1 knee from each matched pair in each group. Each knee was removed from its respective pot and mounted individually on an apparatus using a C-clamp with the knee in the “mounted” position: flexion to 90°, neutral varus/valgus, and neutral internal/external rotation. Although the knee was initially mounted at 90°, this apparatus allowed for a full range of knee flexion and extension. Prior to beginning arthroscopic evaluation, the skin was removed from the anterior aspect of the knee, and the surface anatomy was marked using a surgical marker (patella, tibial tubercle, patellar tendon, joint line) (Figure 1). The surgical procedures were performed by 2 fellowship-trained sports medicine subspecialty certified orthopaedic surgeons with assistance by a current orthopaedic sports medicine fellow.


Evaluation and Comparison of Femoral Tunnel Placement During Anterior Cruciate Ligament Reconstruction Using 3-Dimensional Computed Tomography: Effect of Notchplasty on Transtibial and Medial Portal Drilling.

Dugas JR, Pace JL, Bolt B, Wear SA, Beason DP, Cain EL - Orthop J Sports Med (2014)

Anterior surface anatomy of mounted knees at 90° of flexion, neutral varus/valgus, and neutral internal/external rotation.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2 - License 3
Show All Figures
getmorefigures.php?uid=PMC4555567&req=5

fig1-2325967114525572: Anterior surface anatomy of mounted knees at 90° of flexion, neutral varus/valgus, and neutral internal/external rotation.
Mentions: The matched pairs of knees were randomized: 10 knees were placed in the transtibial group and 10 knees were placed in the medial portal group, with 1 knee from each matched pair in each group. Each knee was removed from its respective pot and mounted individually on an apparatus using a C-clamp with the knee in the “mounted” position: flexion to 90°, neutral varus/valgus, and neutral internal/external rotation. Although the knee was initially mounted at 90°, this apparatus allowed for a full range of knee flexion and extension. Prior to beginning arthroscopic evaluation, the skin was removed from the anterior aspect of the knee, and the surface anatomy was marked using a surgical marker (patella, tibial tubercle, patellar tendon, joint line) (Figure 1). The surgical procedures were performed by 2 fellowship-trained sports medicine subspecialty certified orthopaedic surgeons with assistance by a current orthopaedic sports medicine fellow.

Bottom Line: Advocates of medial portal drilling claim that the transtibial technique results in a more vertical positioning of the graft, which could lead to subsequent failure and/or a residual pivot shift on postoperative examination.However, advocates of transtibial drilling state that with appropriate placement and adequate notchplasty, their technique places the graft in a more anatomically correct position on the wall, negating the resultant potential for pivot shift and early postoperative failure.Both drilling techniques place the graft in an anatomically correct position.

View Article: PubMed Central - PubMed

Affiliation: American Sports Medicine Institute, Birmingham, Alabama, USA.

ABSTRACT

Background: Advocates of medial portal drilling claim that the transtibial technique results in a more vertical positioning of the graft, which could lead to subsequent failure and/or a residual pivot shift on postoperative examination. However, advocates of transtibial drilling state that with appropriate placement and adequate notchplasty, their technique places the graft in a more anatomically correct position on the wall, negating the resultant potential for pivot shift and early postoperative failure.

Hypothesis: Transtibial femoral drilling can adequately reproduce the femoral origin of the anterior cruciate ligament (ACL) and place the graft in an anatomical position equivalent to medial portal drilling.

Study design: Controlled laboratory study.

Methods: Ten matched-pair cadaveric knees (N = 20) were scanned using computed tomography (CT), and 3-dimensional images of the native ACL origin were reconstructed. The matched pairs were then randomized into transtibial and medial portal groups. The femoral tunnel was drilled in each knee according to group. A bamboo skewer was placed in the femoral tunnel, and the knees underwent a second CT scan. Arthroscopic notchplasty was performed, and the femoral tunnels were redrilled. Radiographs confirmed placement, and the post-notchplasty tunnel was reamed with a 4-mm reamer. The knees underwent a third CT scan. CT scans compared femoral tunnel placement with the native ACL footprint before and after notchplasty.

Results: The post-notchplasty transtibial group revealed an average of 68.3% coverage of the native ACL femoral origin. The medial portal group revealed an average of 60.8% coverage, with 1 instance of perforation of the posterior cortex. There were no instances of perforation in the transtibial group.

Conclusion: Both drilling techniques place the graft in an anatomically correct position.

Clinical relevance: Transtibial drilling of the femur can adequately place the entry tunnel at the origin of the ACL's native footprint.

No MeSH data available.


Related in: MedlinePlus