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Increased revision rate with posterior tibial tunnel placement after using the 70-degree tibial guide in ACL reconstruction

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To map knee morphology radiographically in a population with a torn ACL and to investigate whether anatomic factors could be related to outcomes after ACL reconstruction at mid- to long-term follow-up. Further, we wanted to assess tibial tunnel placement after using the 70-degree “anti-impingement” tibial tunnel guide and investigate any relation between tunnel placement and revision surgery.

Methods

Patients undergoing ACL reconstruction involving the 70-degree tibial guide from 2003 to 2008 were included. Two independent investigators analysed pre- and post-operative radiographs. Demographic data and information on revision surgery were collected from an internal database. Anatomic factors and post-operative tibial tunnel placements were investigated as predictors of revision.

Results

Three-hundred and seventy-seven patients were included in the study. A large anatomic variation with significant differences between men and women was seen. None of the anatomic factors could be related to a significant increase in revision rate. Patients with a posterior tibial tunnel placement, defined as 50 % or more posterior on the Amis and Jakob line, did, however, have a higher risk of revision surgery compared to patients with an anterior tunnel placement (P = 0.03).

Conclusion

Use of the 70-degree tibial guide did result in a high incidence (47 %) of posterior tibial tunnel placements associated with an increased rate of revision surgery. The current study was, however, not able to identify any anatomic variation that could be related to a higher risk of revision surgery. Avoiding graft impingement from the femoral roof in anterior tibial tunnel placements is important, but the insight that overly posterior tunnel placement can lead to inferior outcome should also be kept in mind when performing ACL surgery.

Level of evidence

IV.

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References

  1. Aglietti P, Buzzi R, Giron F, Simeone AJ, Zaccherotti G (1997) Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon. A 5–8-year follow-up. Knee Surg Sports Traumatol Arthrosc 5:138–144

    Article  CAS  PubMed  Google Scholar 

  2. Amis AA, Jakob RP (1998) Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 6:S2–12

    Article  PubMed  Google Scholar 

  3. Benjaminse A, Gokeler A, van der Schans CP (2006) Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 36:267–288

    Article  PubMed  Google Scholar 

  4. Berg EE (1992) Tibial bone plug nonunion: a cause of anterior cruciate ligament reconstructive failure. Arthroscopy 8:380–384

    Article  CAS  PubMed  Google Scholar 

  5. Bird JH, Carmont MR, Dhillon M, Smith N, Brown C, Thompson P, Spalding T (2011) Validation of a new technique to determine midbundle femoral tunnel position in anterior cruciate ligament reconstruction using 3-dimensional computed tomography analysis. Arthroscopy 27:1259–1267

    Article  PubMed  Google Scholar 

  6. Bracht H, Verhelst L, Stuyts B, Page B, Bellemans J, Verdonk P (2013) Anatomic single-bundle ACL surgery: consequences of tibial tunnel diameter and drill-guide angle on tibial footprint coverage. Knee Surg Sports Traumatol Arthrosc 22:1030–1039

    PubMed  Google Scholar 

  7. Buzzi R, Zaccherotti G, Giron F, Aglietti P (1999) The relationship between the intercondylar roof and the tibial plateau with the knee in extension: relevance for tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy 15:625–631

    Article  CAS  PubMed  Google Scholar 

  8. Cuomo P, Edwards A, Giron F, Bull AMJ, Amis AA, Aglietti P (2006) Validation of the 65° Howell guide for anterior cruciate ligament reconstruction. Arthroscopy 22:70–75

    Article  PubMed  Google Scholar 

  9. Crawford NS, Waterman BR, Lubowitz JH (2013) Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy 29:1566–1571

    Article  PubMed  Google Scholar 

  10. Haasper C, Kopf S, Lorenz S, Middleton KK, Tashman S, Fu FH (2013) Influence of tibial rotation on tibial tunnel position measurements using lateral fluoroscopy in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23:649–654

    Article  PubMed  Google Scholar 

  11. 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–S55

    Article  PubMed  Google Scholar 

  12. Howell SM, Barad SJ (1995) Knee extension and its relationship to the slope of the intercondylar roof. Implications for positioning the tibial tunnel in anterior cruciate ligament reconstructions. Am J Sports Med 23:288–294

    Article  CAS  PubMed  Google Scholar 

  13. Howell SM, Taylor MA (1993) Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. J Bone Joint Surg Am 75:1044–1055

    Article  CAS  PubMed  Google Scholar 

  14. Howell SM, Wallace MP, Hull ML, Deutsch ML (1999) Evaluation of the single-incision arthroscopic technique for anterior cruciate ligament replacement. A study of tibial tunnel placement, intraoperative graft tension, and stability. Am J Sports Med 27:284–293

    CAS  PubMed  Google Scholar 

  15. Hwang MD, Piefer JW, Lubowitz JH (2012) Anterior cruciate ligament tibial footprint anatomy: systematic review of the 21st century literature. Arthroscopy 28:728–734

    Article  PubMed  Google Scholar 

  16. Inderhaug E, Larsen A, Strand T, Waaler PA, Solheim E (2014) The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3858-3

    Google Scholar 

  17. Inderhaug E, Strand T, Fischer-Bredenbeck C, Solheim E (2013) Effect of a too posterior placement of the tibial tunnel on the outcome 10–12 years after anterior cruciate ligament reconstruction using the 70-degree tibial guide. Knee Surg Sports Traumatol Arthrosc 22:1182–1189

    Article  PubMed  Google Scholar 

  18. Iriuchishima T, Horaguchi T, Kubomura T, Morimoto Y, Fu FH (2011) Evaluation of the intercondylar roof impingement after anatomical double-bundle anterior cruciate ligament reconstruction using 3D-CT. Knee Surg Sports Traumatol Arthrosc 19:674–679

    Article  PubMed  Google Scholar 

  19. Jagodzinski M, Richter GM, Pässler HH (2014) 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  Google Scholar 

  20. Leiter JRS, de Korompay N, Macdonald L, McRae S, Froese W, Macdonald PB (2011) Reliability of tunnel angle in ACL reconstruction: two-dimensional versus three-dimensional guide technique. Knee Surg Sports Traumatol Arthrosc 19:1258–1264

    Article  PubMed  Google Scholar 

  21. Margier J, Tchouda SD, Banihachemi J-J, Bosson J-L, Plaweski S (2014) Computer-assisted navigation in ACL reconstruction is attractive but not yet cost efficient. Knee Surg Sports Traumatol Arthrosc 23:1026–1034

    Article  PubMed  Google Scholar 

  22. 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 41:1794–1800

    Article  PubMed  Google Scholar 

  23. Morgan J, Dahm D, Levy B, Stuart M, The MARS Study Group (2012) Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg 25:361–368

    Article  PubMed  PubMed Central  Google Scholar 

  24. Owens BD (2013) Location, location, location. Am J Sports Med 41:2481–2483

    Article  PubMed  Google Scholar 

  25. Pinczewski LA, Salmon LJ, Jackson WFM, von Bormann RBP, 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 90:172–179

    Article  CAS  PubMed  Google Scholar 

  26. Scheffel PT, Henninger HB, Burks RT (2013) Relationship of the intercondylar roof and the tibial footprint of the ACL: implications for ACL reconstruction. Am J Sports Med 41:396–401

    Article  PubMed  Google Scholar 

  27. Silva A, Sampaio R, Pinto E (2011) ACL reconstruction: comparison between transtibial and anteromedial portal techniques. Knee Surg Sports Traumatol Arthrosc 20:896–903

    Article  PubMed  Google Scholar 

  28. Stäubli 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 2:138–146

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Surgical Department, Haraldsplass Deaconess Hospital, PB 6165, 5152, Bergen, Norway

    Eivind Inderhaug, Eirik Solheim & Torbjørn Strand

  2. Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway

    Sveinung Raknes, Thomas Østvold & Eirik Solheim

Authors
  1. Eivind Inderhaug
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  2. Sveinung Raknes
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  3. Thomas Østvold
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  4. Eirik Solheim
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  5. Torbjørn Strand
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Corresponding author

Correspondence to Eivind Inderhaug.

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The authors declare that they have no conflict of interest.

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There is no funding source.

Ethical approval

The regional ethical committee reviewed and approved the study (REK Helse Vest, REK ID:3366)

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Informed consent has been collected from the patients.

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Inderhaug, E., Raknes, S., Østvold, T. et al. Increased revision rate with posterior tibial tunnel placement after using the 70-degree tibial guide in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 25, 152–158 (2017). https://doi.org/10.1007/s00167-016-4341-5

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  • DOI: https://doi.org/10.1007/s00167-016-4341-5

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