Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 4, pp 1110–1116 | Cite as

Sagittal femoral condyle morphology correlates with femoral tunnel length in anatomical single bundle ACL reconstruction

  • Takanori Iriuchishima
  • Freddie H. Fu
  • Keinosuke Ryu
  • Makoto Suruga
  • Yoshiyuki Yahagi
  • Shin Aizawa
Knee
  • 218 Downloads

Abstract

Purpose

The purpose of this study was to reveal the correlation between femoral tunnel length and the morphology of the femoral intercondylar notch in anatomical single bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT).

Methods

Thirty subjects undergoing anatomical single bundle ACL reconstruction were included in this study (23 female, 7 male: average age 45.5 ± 16.7). In the anatomical single bundle ACL reconstruction, the femoral and tibial tunnels were created close to the antero-medial bundle insertion site with trans-portal technique. Using post-operative three-dimensional computed tomography (3D-CT), accurate axial and lateral views of the femoral condyle were evaluated. The correlation of femoral tunnel length, which was measured intra-operatively, with the transepicondylar length (TEL), notch width index, notch outlet length, the notch area (axial), length of Blumensaat’s line, and the height and area of the lateral wall of the femoral intercondylar notch was statistically analyzed. Tunnel placement was also evaluated using a Quadrant method.

Results

The average femoral tunnel length was 35.4 ± 4.4 mm. The average TEL, NWI, notch outlet length, and the axial notch area, were 76.9 ± 5.1 mm, 29.1 ± 3.8%, 19.5 ± 3.9 mm, and 257.4 ± 77.4 mm2, respectively. The length of Blumensaat’s line and the height and area of the lateral wall of the femoral intercondylar notch were 33.8 ± 3.2 mm, 22.8 ± 2.3 mm, and 738.7 ± 129 mm2, respectively. The length of Blumensaat’s line, the height, and the area of the lateral wall of the femoral intercondylar notch were significantly correlated with femoral tunnel length. Femoral tunnel placement was 23.4 ± 4.5% in a shallow-deep direction and 35.4 ± 8.8% in a high-low direction.

Conclusion

The length of Blumensaat’s line, height, and area of the lateral wall of the femoral intercondylar notch are correlated with femoral tunnel length in anatomical single bundle ACL reconstruction. For clinical relevance, these parameters are useful in predicting the length of the femoral tunnel in anatomical single bundle ACL reconstruction for the prevention of extremely short femoral tunnel creation.

Level of evidence

Case controlled study, Level III.

Keywords

Anterior cruciate ligament Anatomy Tunnel length Femoral condyle 3D-CT 

Abbreviations

ACL

Anterior cruciate ligament

AM

Anteromedial bundle

PL

Posterolateral bundle

Introduction

The concept of anatomical anterior cruciate ligament (ACL) reconstruction is becoming more popular due to numerous studies reporting its superior ability to restore normal knee function when compared to non-anatomical reconstruction [3, 5, 7, 8, 9, 10, 11, 12, 17, 18, 20, 21, 22, 23, 27, 28, 29, 30, 33, 34, 35, 36, 37]. With the rising frequency of anatomical ACL reconstruction, the anatomy of the ACL has been studied in greater detail [5, 8, 9, 10, 11, 12, 15, 17, 28, 29]. However, reports vary as to the exact anatomy of the ACL, and the optimal placement of anatomical tunnels in anatomical ACL reconstruction remains unclear.

Although tunnel placement and kinematics of anatomical double bundle ACL reconstruction have been studied in great detail [6, 7, 16, 28, 29], they have not been well investigated in anatomical single bundle ACL reconstruction. Tunnel placement in particular remains controversial [1, 4, 13, 14, 15, 23, 24, 39]. Compared with isometric, non-anatomical ACL reconstruction, the femoral tunnel in anatomical ACL reconstruction is placed deeper and lower in the intercondylar notch [11, 16, 25]. To make this deep and low femoral tunnel, several authors have reported that the traditional trans-tibial technique is not suitable, and the superiority of the trans-portal technique has been suggested [19, 25, 26, 31]. In the trans-portal technique, the femoral tunnel is created from the medial or far-medial portal. Using this technique, surgeons are able to drill deep and low tunnels in the femoral intercondylar notch. However, there exist some characteristic risks in the trans-portal technique [19, 25, 26, 31]. A femoral tunnel of insufficient length and iatrogenic chondral tear is the most feared surgical complications [26]. To prevent a femoral tunnel of insufficient length, deep knee bending is required, while the tunnel is being drilled [25, 26]. Moreover, it is likely that the morphology of the knee bony structure can be influential in determining femoral tunnel length. If surgeons can predict the femoral tunnel length before surgery, the risk of creating an extremely short femoral tunnel would be greatly reduced. To the best of our knowledge, no study has investigated this subject.

The purpose of this study was to reveal the correlation between femoral tunnel length and knee bony structures in anatomical single bundle ACL reconstruction using three-dimensional computed tomography (3D-CT). The hypothesis of this study was that femoral tunnel length would be correlated with knee bony morphology, and revealing that this issue would be useful for the prevention of extremely short femoral tunnel creation in the anatomical single bundle ACL reconstruction.

Materials and methods

Thirty subjects undergoing anatomical single bundle ACL reconstruction were included in this study (20 female, 10 male: average age 43.8 ± 16.5). Exclusion criteria were: knees with osteoarthritic changes and chondral treatment, revision ACL surgery, and surgical treatment in the contra lateral side.

Surgical treatment

All patients underwent anatomical single bundle ACL reconstruction using a hamstring or quadriceps auto graft. When the patients had recovered their full range of motion after the initial ACL injury, ACL reconstruction was performed. The surgery was arthroscopically assisted. At the beginning of the surgery, intra articular conditions were evaluated through the normal anteromedial and antero-lateral portals. All knees had complete ACL tear. Femoral and tibial insertions of the ACL were confirmed, and the remnant was removed with a shaver. The femoral tunnel was placed at the native ACL stumps close to the anteromedial (AM) bundle footprint using a trans-portal technique. While the femoral tunnel was being drilled, knees were bent to maximal flexion. Resident’s ridge and bifurcate ridge [5, 6, 27] were indicated to ensure the correct anatomical position of the tunnel. Intra operative femoral tunnel length measurement was performed using a depth gauge. The tibial tunnel was made using an ACL tip guide (Acufex, Smith and Nephew Inc, Andover, MA, USA). Tunnel size was selected based on the graft or knee size, and was 7–10 mm in diameter (Average femoral tunnel diameter: 7.6 ± 1.3 mm, tibial tunnel diameter: 7.8 ± 1.6 mm). After the graft was passed through the tunnels, femoral fixation was performed with a titanium button (Endobutton CL, Smith and Nephew Inc, Andover, MA, USA). After this, 20 cycles of passive flexion and extension for preconditioning were performed. The tibial fixation of the graft was accomplished by applying 30 N of initial tension [9], tethering the sutures (2.0 ETHILON sutures; Johnson and Johnson Co., Ltd, Piscataway, NJ, USA) to a Double spike plate (Meira, Co. Ltd., Nagoya, Japan), and fixing with a 6.5 mm screw.

3D-CT

Pre-operatively, using the slice of CT (Alexion; Toshiba, Co, Ltd., Tokyo, Japan) image which could evaluate the longest length between the medial and lateral epicondyle of the femur (Trans epicondylar length: TEL), the TEL, the length of the notch outlet, and the length of medial and lateral posterior condyle were measured. Notch width index (NWI) was calculated as the length of the notch outlet/the length of medial and lateral posterior condyle × 100. The axial notch area was evaluated using the same slice. The notch was outlined, and the posterior border of the notch was determined as the line between the inside medial and lateral femoral condyles with a sudden change of slope [33].

Eight-to-twelve weeks after ACL reconstruction and when the subjects could move their knees with the same full range of motion as the contra lateral side, a 3D-CT image of the operated knee was made. 3D reconstruction of the image was performed using ZIO STATION (Amin Co, Ltd., Tokyo, Japan).

At the femoral side, tunnel position measurement was performed using 3D-CT, with a complete lateral view of the femoral lateral condyle. Tunnel measurements were performed using the techniques of Bernald and Hertel [2] for the femoral side. In this technique, the total sagittal depth of the lateral femoral condyle and the height of the intercondylar surface are divided into four quadrants by which the ACL’s center is determined. With the same images used in the ACL tunnel evaluation, the height, area, and length of Blumensaat’s line of the lateral wall of the femoral intercondylar notch were measured (Fig. 1) [12]. All image evaluations were performed using a PACS system. The measurement accuracy of the PACS system was 0.01 mm and 0.1 mm2 [10]. This study has been approved by the ethics committee of Kamimoku hot springs hospital. The IRB number is KH27004.

Fig. 1

3D-CT measurement. As the sagittal parameters of the femoral condyle, length of Blumensaat’s line, height and area of the medial wall of the lateral femoral condyle were measured. As the axial parameters of the femoral condyle, transepicondylar length (TEL), notch outlet length, notch width index (notch outlet length/length of posterior condyle), and the axial notch area were measured

Statistical analysis

Data are presented as mean ± standard deviations. The Pearson’s product movement correlation was calculated to reveal the correlation between femoral tunnel length and:

  • the TEL;

  • the notch outlet length;

  • the NWI;

  • the axial notch area;

  • the length of Blumensaat’s line;

  • the height of the lateral wall of the femoral intercondylar notch;

  • the area of the lateral wall of the femoral intercondylar notch;

  • tunnel placement in shallow-deep and high-low directions.

It was assumed that there was statistical significance when P < 0.05. All statistical data were calculated with SPSS 19.0 (SPSS Inc., Chicago, IL, USA).

Considering the mean and standard deviations of the notch height, the calculated sample size was 27.4 (G*Power 3 software).

Results

Femoral tunnel length and placement

The measured length of the femoral tunnel was 35.4 ± 4.4 mm. Femoral tunnel placement was 23.4 ± 4.5% in a shallow-deep direction and 35.3 ± 8.7% in a high-low direction.

Femur and femoral condyle morphology

The average TEL, notch outlet length, NWI, and the axial notch area were 76.9 ± 5.1 mm, 19.5 ± 3.9 mm, 29.1 ± 3.8%, and 257.4 ± 77.4 mm2, respectively.

The height of the lateral femoral condyle was 22.8 ± 2.3 mm. The area of the lateral femoral condyle was 738 ± 129 mm2. The length of Blumensaat’s line was 33.8 ± 3.2 mm.

Correlation of femoral tunnel length with knee bony morphology and tunnel placement

The height (Pearson’s correlation coefficient = 0.566, P = 0.001), area of the lateral wall of the femoral intercondylar notch (Pearson’s correlation coefficient = 0.580, P = 0.001), and the length of Blumensaat’s line (Pearson’s correlation coefficient = 0.460, P = 0.011) were significantly correlated with the length of the femoral ACL tunnel (Figs. 2, 3, 4). The TEL, notch outlet length, NWI, notch axial area, and the femoral tunnel placement (both shallow-deep and high-low) were not correlated with the length of the femoral tunnel (Table 1).

Fig. 2

Correlation between femoral ACL tunnel length and the height of the medial wall of the lateral femoral condyle. Significant correlation was observed between the femoral ACL tunnel length in anatomical single bundle ACL reconstruction and the length of Blumensaat’s line

Fig. 3

Correlation between femoral ACL tunnel length and the area of the medial wall of the lateral femoral condyle. Significant correlation was observed between the femoral ACL tunnel length in anatomical single bundle ACL reconstruction and the height of the medial wall of the lateral femoral condyle

Fig. 4

Correlation between femoral ACL tunnel length and the length of the Blumensaat's line. Significant correlation was observed between the femoral ACL tunnel length in anatomical single bundle ACL reconstruction and the area of the medial wall of the lateral femoral condyle

Table 1

Correlation between femoral ACL tunnel length and the axial parameters of the femoral intercondylar notch and tunnel placement

  

Correlation

Tunnel placement

 Shallow-deep

23.4 ± 4.5%

NS

 High-low

35.3 ± 8.7%

NS

Axial parameters

 TEL

76.9 ± 5.1 mm

NS

 Notch outlet length

19.5 ± 3.9 mm

NS

 NWI

29.1 ± 3.8%

NS

 Axial notch area

257.4 ± 77 mm2

NS

TEL trans epicondylar length, NWI notch width index

No significant correlation was observed between femoral ACL tunnel length and the axial parameters of the femoral intercondylar notch (TEL, notch outlet length, NWI, and notch axial area), or femoral tunnel placement (both shallow-deep, and high-low)

Discussion

The most important finding of this study was that the height and the area of the lateral wall of the femoral intercondylar notch, and the length of Blumensaat’s line showed significant correlation with femoral ACL tunnel length. However, the axial parameters (TEL, NWI, notch outlet length, and the axial notch area) and femoral tunnel placement showed no significant correlation with the length of the femoral tunnel. These results suggest that the length of the femoral ACL tunnel created using a trans-portal technique can be estimated before surgery by measuring the size of the lateral wall of the femoral intercondylar notch using a lateral knee radiograph, CT, or magnetic resonance imaging (MRI). In knees in which the medial wall of the lateral femoral condyle is small in size, there is a risk of creating a femoral tunnel which is insufficient in length when performing anatomical single bundle ACL reconstruction using a trans-portal technique. The results of this study may suggest a means of reducing that risk.

Following the theory of anatomical double bundle ACL reconstruction, the method of single bundle ACL reconstruction has also shifted from isometric to anatomical [32, 38]. In anatomical single bundle ACL reconstruction, the femoral and tibial tunnels are created within the ACL footprint [1, 4, 13, 14, 15, 23, 24, 34, 39]. Some authors have reported that the tunnels in anatomical single bundle ACL reconstruction should be placed at the center of ACL footprint to reproduce both AM and posterolateral (PL) bundle function [4, 13, 23, 24], while others have suggested that the tunnels be made to reproduce only the AM bundle function and should be placed close to the AM bundle native footprint [1, 14, 15, 39]. Recently, Kawaguchi et al. reported that among ACL fibers, those attached close to the AM bundle footprint resisted 66–84% of anterior tibial drawer force [15]. In the present study, tunnels were placed to best reproduce AM bundle morphology. A longer follow-up is needed to evaluate the efficacy of this approach as it relates to knee stability.

The trans-portal technique has been reported as a suitable method to create anatomical femoral tunnels in ACL reconstruction [19, 25, 26, 31]. The advantage of the trans-portal technique is that femoral tunnel placement is not restricted by the tibial tunnel position, and it can be performed with a single incision and without a special device [19, 25, 26, 31]. However, there is a risk of iatrogenic chondral tear and the creation of a femoral tunnel of insufficient length [26]. An extremely short femoral tunnel is likely to result in the delay of graft maturation and should be avoided [6]. The results of this study suggest that femoral ACL tunnel length is affected by the sagittal parameters (length of Blumensaat’s line, height, and area of the medial wall of the lateral femoral condyle), and not by the axial parameters (TEL, NWI, notch outlet length, and axial notch area). It was hypothesized that the axial parameters would affect tunnel length, because the intercondylar notch space is important when using a trans-portal technique. However, this hypothesis was refuted. The results of this study suggest that, to prevent the creation of an extremely short femoral tunnel, and to estimate tunnel length before surgery, preoperative measurement of the sagittal parameters of the femoral condyle is more important than preoperative measurement of the axial parameters.

In this study, tunnel placement was not correlated with femoral tunnel length. If there had been a wider variation in tunnel placement, tunnel placement likely would have shown correlation with tunnel length. However, since femoral tunnel placement was relatively consistent in this study, and the sample size was small, no correlation was detected. Such correlation might be revealed in future studies.

The main limitations of this study were (1) the sample size was not large (n = 30) but was similar to a previous study [9, 12]. However, due to anatomical variation and to accurately define the ACL anatomy, a study with a larger sample size is needed. (2) Only Japanese subjects were included in this study. Ethnicity might be a potential influence and should be taken into consideration in future studies.

For clinical relevance, as shown by the results of this study, surgeons should be careful to create femoral tunnels of sufficient length when performing anatomical single bundle ACL reconstruction using a trans-portal technique, especially in knees in which the sagittal parameters of the intercondylar notch are small in size.

Conclusion

In conclusion, the sagittal parameters (length of Blumensaat’s line, height, and area of the medial wall of the lateral femoral condyle) of the femoral intercondylar notch showed significant correlation with the length of the femoral ACL tunnel in anatomical single bundle ACL reconstruction. Measuring these parameters pre-operatively might be an effective means of preventing a femoral tunnel of insufficient length and of predicting tunnel length.

Notes

Compliance with ethical standards

Conflict of interest

Takanori Iriuchishima, Fu FH, Keinosuke Ryu, Makoto Suruga, Yoshiyuki Yahagi, and Sin Aizawa declare that they have no conflict of interest.

Ethical approval

This study was performed in accordance with the ethics principles of the Declaration of Helsinki and was conducted with the approval of the institutional review boards of the Kamimoku Hot springs Hospital.

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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryKamimoku Hot Springs HospitalMinakamiJapan
  2. 2.Department of Orthopaedic SurgeryNihon University HospitalTokyoJapan
  3. 3.Departments of Functional MorphologyNihon University School of MedicineTokyoJapan
  4. 4.Department of Orthopaedic SurgeryUniversity of PittsburghPittsburgUSA

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