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The effect of tunnel placement on rotational stability after ACL reconstruction: evaluation with use of triaxial accelerometry in a porcine model

Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Conventional transtibial technique fails to restore the rotational knee stability in spite of successful anterior laxity, while anatomic anterior cruciate ligament reconstruction using the anteromedial portal technique has been developed expecting better rotational kinematics because of closer reproduction of the native anterior cruciate ligament anatomy. However, the rotational instability after those two procedures has not been fully examined especially in terms of dynamic component of the rotational stability. The purpose was to assess the effect of anatomic versus non-anatomic tunnel placement on rotational knee stability after anterior cruciate ligament reconstruction using triaxial accelerometry.

Methods

Sixteen porcine knees underwent a manual pivot-shift test at four different conditions: (1) anterior cruciate ligament intact, (2) anterior cruciate ligament deficient, (3) non-anatomic transtibial reconstruction, and (4) anatomic anteromedial portal reconstruction. The three-dimensional acceleration of knee motion during the pivot-shift test was recorded using a triaxial accelerometer.

Results

Both anterior cruciate ligament reconstructions decreased significantly the acceleration of the pivot-shift test from the increased level in the anterior cruciate ligament-deficient condition. However, the transtibial technique fails to reach the intact level of acceleration, while the anteromedial portal technique reduced the acceleration to even less than the intact level.

Conclusion

The transtibial anterior cruciate ligament reconstruction could not restore the dynamic rotational stability of the intact knee, whereas the anteromedial portal technique restored the dynamic rotational stability closer to the intact level.

Level of evidence

III.

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References

  1. Abebe ES, Moorman CT III, Dziedzic TS, Spritzer CE, Cothran RL, Taylor DC, Garrett WE Jr, DeFrate LE (2009) Femoral tunnel placement during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques. Am J Sports Med 37(10):1904–1911

    Article  PubMed  Google Scholar 

  2. Abebe ES, Utturkar GM, Taylor DC, Spritzer CE, Kim JP, Moorman CT III, Garrett WE, DeFrate LE (2011) The effects of femoral graft placement on in vivo knee kinematics after anterior cruciate ligament reconstruction. J Biomech 44(5):924–929

    Article  PubMed  CAS  Google Scholar 

  3. Alentorn-Geli E, Samitier G, Alvarez P, Steinbacher G, Cugat R (2010) Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up. Int Orthop 34(5):747–754

    Article  PubMed  Google Scholar 

  4. Araujo PH, van Eck CF, Macalena JA, Fu FH (2011) Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(8):1239–1242

    Article  PubMed  Google Scholar 

  5. Arneja S, McConkey MO, Mulpuri K, Chin P, Gilbart MK, Regan WD, Leith JM (2009) Graft tensioning in anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Arthroscopy 25(2):200–207

    Article  PubMed  Google Scholar 

  6. Bach BR Jr, Warren RF, Wickiewicz TL (1988) The pivot shift phenomenon: results and description of a modified clinical test for anterior cruciate ligament insufficiency. Am J Sports Med 16:571–576

    Article  PubMed  Google Scholar 

  7. 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):380–390

    Article  PubMed  Google Scholar 

  8. Bull AMJ, Amis AA (1998) The pivot-shift phenomenon: a clinical and biomechanical perspective. Knee 5:141–158

    Article  Google Scholar 

  9. Chhabra A, Diduch DR, Blessey PB, Miller MD (2004) Recreating an acceptable angle of the tibial tunnel in the coronal plane in anterior cruciate ligament reconstruction using external landmarks. Arthroscopy 20:328–330

    Article  PubMed  Google Scholar 

  10. Cohen SB, Fu FH (2007) Three-portal technique for anterior cruciate ligament reconstruction: use of a central medial portal. Arthroscopy 23:321–325

    Google Scholar 

  11. Colvin AC, Shen W, Musahl V, Fu FH (2009) Avoiding pitfalls in anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 17(8):956–963

    Article  PubMed  Google Scholar 

  12. Conner CS, Perez BA, Morris RP, Buckner JW, Buford WL Jr, Ivey FM (2010) Three femoral fixation devices for anterior cruciate ligament reconstruction: comparison of fixation on the lateral cortex versus the anterior cortex. Arthroscopy 26:796–807

    Article  PubMed  Google Scholar 

  13. Dargel J, Koebke J, Bruggemann GP, Pennig D, Schmidt-Wiethoff R (2009) Tension degradation of anterior cruciate ligament grafts with dynamic flexion-extension loading: a biomechanical model in porcine knees. Arthroscopy 25:1115–1125

    Article  PubMed  Google Scholar 

  14. Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T (2009) Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 17:220–227

    Article  PubMed  Google Scholar 

  15. Debandi A, Maeyama A, Lu S, Hume C, Asai S, Goto B, Hoshino Y, Smolinski P, Fu FH (2011) Biomechanical comparison of three anatomic ACL reconstructions in a porcine model. Knee Surg Sports Traumatol Arthrosc 19(5):728–735

    Article  PubMed  Google Scholar 

  16. Gadikota HR, Wu JL, Seon JK, Sutton K, Gill TJ, Li GME (2010) Single-tunnel double-bundle anterior cruciate ligament reconstruction with anatomical placement of hamstring tendon graft: can it restore normal knee kinematics? Am J Sports Med 38:713–720

    Article  PubMed  Google Scholar 

  17. Galway HR, MacIntosh DL (1980) The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 147:45–50

    PubMed  Google Scholar 

  18. George MS, Dunn WR, Spindler KP (2006) Current concepts review: revision anterior cruciate ligament reconstruction. Am J Sports Med 34:2026–2037

    Article  PubMed  Google Scholar 

  19. Giron F, Cuomo P, Edwards A, Bull AM, Amis AA, Aglietti P (2007) Double-bundle “anatomic” anterior cruciate ligament reconstruction: A cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy 23:7–13

    Article  PubMed  Google Scholar 

  20. Harner CD, Giffin JR, Dunteman RC, Annunziata C, Friedman M (2000) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. J Bone Jt Surg Am 82:1652–1664

    Google Scholar 

  21. Heming JF, Rand J, Steiner ME (2007) Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 35:1708–1715

    Article  PubMed  Google Scholar 

  22. Herbort M, Lenschow S, Fu FH, Petersen W, Zantop T (2010) ACL mismatch reconstructions: influence of different tunnel placement strategies in single-bundle ACL reconstructions on the knee kinematics. Knee Surg Sports Traumatol Arthrosc 18(11):1551–1558

    Article  PubMed  Google Scholar 

  23. Hofbauer M, Valentin P, Kdolsky R, Ostermann RC, Graf A, Figl M, Aldrian S (2010) Rotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1201–1207

    Article  PubMed  CAS  Google Scholar 

  24. Hoshino Y, Kuroda R, Nagamune K, Yagi M, Mizuno K, Yamaguchi M, Muratsu H, Yoshiya S, Kurosaka M (2007) In vivo measurement of the pivot-shift test in the anterior cruciate ligament- deficient knee using an electromagnetic device. Am J Sports Med 35:1098–1104

    Article  PubMed  Google Scholar 

  25. Howell SM, Gittins ME, Gottlieb JE, Traina SM, Zoellner TM (2001) The relationship between the angle of the tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament reconstruction. Am J Sports Med 29(5):567–574

    PubMed  CAS  Google Scholar 

  26. Hughston JC, Andrews JR, Cross MJ, Moschi A (1976) Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Jt Surg Am 58:159–172

    CAS  Google Scholar 

  27. Iriuchishima T, Tajima G, Ingham SJ, Shen W, Horaguchi T, Saito A, Smolinski P, Fu FH (2009) Intercondylar roof impingement pressure after anterior cruciate ligament reconstruction in a porcine model. Knee Surg Sports Traumatol Arthrosc 17:590–594

    Article  PubMed  Google Scholar 

  28. Jagodzinski M, Richter GM, Passler HH (2000) Biomechanical analysis of knee hyperextension and of the impingement of the anterior cruciate ligament: a cinematographic MRI study with impact on tibial tunnel positioning in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 8:11–19

    Article  PubMed  CAS  Google Scholar 

  29. Kanamori A, Woo SL, Ma CB, Zeminski J, Rudy TW, Li G, Livesay GA (2000) The forces in the anterior cruciate ligament and knee kinematics during a simulated pivot shift test: a human cadaveric study using robotic technology. Arthroscopy 16(6):633–639

    Article  PubMed  CAS  Google Scholar 

  30. Kamath GV, Redfern JC, Greis PE, Burks RT (2011) Revision anterior cruciate ligament reconstruction. Am J Sports Med 39(1):199–217

    Article  PubMed  Google Scholar 

  31. Karlsson J, Irrgang JJ, van Eck CF, Samuelsson K, Mejia HA, Fu FH (2011) Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique. Am J Sports Med 39(9):2016–2026

    Article  PubMed  Google Scholar 

  32. Kato Y, Ingham SJM, Linde-Rosen M, Smolinski P, Horaguchi T, Fu FH (2010) Biomechanics of the porcine triple bundle anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 18:20–25

    Article  PubMed  Google Scholar 

  33. Kato Y, Ingham SJ, Kramer S, Smolinski P, Saito A, Fu FH (2010) Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surg Sports Traumatol Arthrosc 18:2–10

    Article  PubMed  Google Scholar 

  34. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ (2004) Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med 32:629–634

    Article  PubMed  Google Scholar 

  35. Kopf S, Forsythe B, Wong AK, Tashman S, Anderst W, Irrgang JJ, Fu FH (2010) Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. J Bone Jt Surg Am 92(6):1427–1431

    Article  Google Scholar 

  36. Lane CG, Warren R, Pearle AD (2008) The pivot shift. J Am Acad Orthop Surg 16(12):679–688

    PubMed  Google Scholar 

  37. Lane CG, Warren RF, Stanford FC, Kendoff D, Pearle AD (2008) In vivo analysis of the pivot shift phenomenon during computer navigated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 16:487–492

    Article  PubMed  Google Scholar 

  38. Leitze Z, Losee RE, Jokl P, Johnson TR, Feagin JA (2005) Implications of the pivot shift in the ACL-deficient knee. Clin Orthop Relat Res 436:229–236

    Article  PubMed  Google Scholar 

  39. Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2002) Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy 19:297–304

    Google Scholar 

  40. Losee RE, Johnson TR, Southwick WO (1978) Anterior subluxation of the lateral tibial plateau. A diagnostic test and operative repair. J Bone Jt Surg Am 60(8):1015–1030

    CAS  Google Scholar 

  41. Maeyama A, Hoshino Y, Debandi A, Kato Y, Saeki K, Asai S, Goto B, Smolinski P, Fu FH (2011) Evaluation of rotational instability in the anterior cruciate ligament deficient knee using triaxial accelerometer: a biomechanical model in porcine knees. Knee Surg Sports Traumatol Arthrosc 19(8):1233–1238

    Article  PubMed  Google Scholar 

  42. Maeyama A, Naito M, Moriyama S, Yoshimura I (2008) Evaluation of dynamic instability of the dysplastic hip with use of triaxial accelerometry. J Bone Jt Surg Am 90:85–92

    Article  Google Scholar 

  43. Maeyama A, Naito M, Moriyama S, Yoshimura I (2009) Periacetabular osteotomy reduces the dynamic instability of dysplastic hips. J Bone Jt Surg Br 91-B:1438–1442

    Google Scholar 

  44. Matsumoto H (1990) Mechanism of the pivot shift. J Bone Jt Surg Br 72-B:816–821

    Google Scholar 

  45. Miyatake S, Kondo E, Tohyama H, Kitamura N, Yasuda K (2010) Biomechanical evaluation of a novel application of a fixation device for bone-tendon-bone graft (EndoButton CL BTB) to soft-tissue grafts in anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 26:1226–1232

    Article  PubMed  Google Scholar 

  46. Musahl V, Voos JE, O’Loughlin PF, Choi D, Stueber V, Kendoff D, Pearle AD (2010) Comparing the stability of different single- and double-bundle anterior cruciate ligament reconstruction techniques: a cadaveric study using navigation. Arthroscopy 26:41–48

    Article  Google Scholar 

  47. Nakajima H, Kondo M, Kurosawa H, Fukubayashi T (1979) Insufficiency of the anterior cruciate ligament. Review of our 118 cases. Arch Orthop Trauma Surg 95(4):233–240

    Article  PubMed  CAS  Google Scholar 

  48. Noyes FR, Grood ES, Cummings JF, Wroble RR (1991) An analysis of the pivot shift phenomenon: the knee motions and subluxations induced by different examiners. Am J Sports Med 19:148–155

    Article  PubMed  CAS  Google Scholar 

  49. Shen W, Forsythe B, Ingham SM, Honkamp NJ, Fu FH (2008) Application of the anatomic double-bundle reconstruction concept to revision and augmentation anterior cruciate ligament surgeries. J Bone Jt Surg Am 90(Suppl 4):20–34

    Article  Google Scholar 

  50. Slocum DB, James SL, Larson RL, Singer KM (1976) Clinical test for anterolateral rotary instability of the knee. Clin Orthop Relat Res 118:63–69

    PubMed  Google Scholar 

  51. Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR 3rd, Ciccotti MG (1997) The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 25(2):191–195

    Article  PubMed  CAS  Google Scholar 

  52. Sohn D, Garrett W (2009) Transitioning to anatomic anterior cruciate ligament graft placement. J Knee Surg 22:155–160

    Article  PubMed  Google Scholar 

  53. Steiner ME, Battaglia TC, Heming JF, Rand JD, Festa A, Baria M (2009) Independent drilling outperforms conventional transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 37(10):1912–1919

    Article  PubMed  Google Scholar 

  54. Tashiro Y, Okazaki K, Miura H, Matsuda S, Yasunaga T, Hashizume M, Nakanishi Y, Iwamoto Y (2009) Quantitative assessment of rotatory instability after anterior cruciate ligament reconstruction. Am J Sports Med 37:909–916

    Article  PubMed  Google Scholar 

  55. Tashman S, Collon D, Anderson K, Kolowich P, Anderst W (2004) Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med 32:975–983

    Article  PubMed  Google Scholar 

  56. van Eck CF, Schreiber VM, Liu TT, Fu FH (2010) The anatomic approach to primary, revision and augmentation anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1154–1163

    Article  PubMed  Google Scholar 

  57. Woo SL, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu FH (2002) The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon. A cadaveric study comparing anterior tibial and rotational loads. J Bone Jt Surg Am 84:907–914

    Google Scholar 

  58. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL (2002) Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 30:660–666

    PubMed  Google Scholar 

  59. Zantop T, Diermann N, Schumacher T, Schanz S, Fu FH, Petersen W (2008) Anatomical and nonanatomical double-bundle anterior cruciate ligament reconstruction. Am J Sports Med 36:678–685

    Article  PubMed  Google Scholar 

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Correspondence to Freddie H. Fu.

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Debandi, A., Maeyama, A., Hoshino, Y. et al. The effect of tunnel placement on rotational stability after ACL reconstruction: evaluation with use of triaxial accelerometry in a porcine model. Knee Surg Sports Traumatol Arthrosc 21, 589–595 (2013). https://doi.org/10.1007/s00167-012-1961-2

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  • DOI: https://doi.org/10.1007/s00167-012-1961-2

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