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Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To determine the best angle to drill the femoral tunnels of an anterolateral ligament (ALL) anatomic reconstruction combined with a single-bundle anterior cruciate ligament (ACL) reconstruction to avoid tunnel collisions and cortical disruption.

Methods

Ten cadaveric knees were studied. Single-bundle anatomic ACL femoral tunnels were arthroscopically drilled. The starting point of the ALL femoral tunnel was located posterior and superior to the lateral epicondyle. ALL tunnels were drilled at four different angulations: (1) 0° axial/0° coronal, (2) 0° axial/30° coronal superior, (3) 30° axial anterior/0° coronal, and (4) 30° axial anterior 30° coronal superior. Specimens were scanned by computed tomography to measure the relations of each trajectory with the ACL socket and the nearest cortical bone.

Results

None of the four trajectories studied presented risk of collision with the ACL. The tunnel at 30° anterior/30° proximal presented the safest distance to the ACL socket (P = 0.01) [mean distance 18.6 mm (SD ± 6.7)]. However, both tunnels angled at 0° in the axial plane presented a high risk of posterior femoral cortex disruption (P = 0.01), either by close proximity or direct contact in some specimens (mean distance 3.1 mm (SD ± 2.8) at 0° axial/0° coronal and 3.7 mm (SD ± 2.2) at 0° axial/30° coronal).

Conclusions

When performing simultaneous ACL and ALL ligament reconstruction, the ALL femoral tunnel should be drilled with an angle of 30° anterior in the axial plane and 30° proximal in the coronal plane. Tunnels with an angle of 0° in the axial plane showed high risk of contact and disruption of the posterior femoral cortex; thus, these angles should be avoided. The clinical relevance of this work is that an ALL anatomical reconstruction does not represent a risk when performing a simultaneous ACL reconstruction as long as the ALL tunnel is reamed with a proximal and anterior angulation.

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Abbreviations

ACL:

Anterior cruciate ligament

ALL:

Anterolateral ligament

LCL:

Lateral collateral ligament

AL:

Anterolateral

AM:

Anteromedial

AAM:

Accessory anteromedial

CT:

Computed tomography

ANOVA:

Analyses of variance

LET:

Lateral extra-articular tenodesis

IC:

Intercondylar notch

PC:

Posterior femoral cortex

IRB:

Institutional Review Board

ICC:

Intraclass correlation coefficient

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Funding

The authors declare that no funding was received to perform this study.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery and Traumatology, Hospital Clinic, 170 Villarroel Street, 08036, Barcelona, Spain

    Cristian Jette, Sergi Sastre, David Gutierrez, Manuel Llusa & Andrés Combalia

  2. Division of Musculoskeletal Radiology, Department of Radiology, Hospital Clinic, Barcelona, Spain

    Jaume Pomés

  3. Department of Human Anatomy, University of Barcelona Medical School, Barcelona, Spain

    Manuel Llusa & Andrés Combalia

Authors
  1. Cristian Jette
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  2. Jaume Pomés
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  3. Sergi Sastre
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  4. David Gutierrez
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  5. Manuel Llusa
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  6. Andrés Combalia
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Contributions

CJ designed the study, carried out the anatomic dissection, arthroscopy procedures, and femoral tunnel placement and drafted the manuscript. JP carried out the image analysis and CT measurements. SS participated in the study design and coordination between departments. DG participated in the anatomic dissection, data gathering and performed the statistical analysis. ML participated in the coordination with the university and helped with the arthroscopy procedures. AC participated in the coordination and helped to draft the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Cristian Jette.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was performed after ethical approval from the Institutional Review Board at the Univesity of Barcelona (IRB00003099).

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Jette, C., Pomés, J., Sastre, S. et al. Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 27, 3411–3417 (2019). https://doi.org/10.1007/s00167-019-05388-4

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  • DOI: https://doi.org/10.1007/s00167-019-05388-4

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