Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction
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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.
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.
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).
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.
KeywordsAnterolateral ligament Femoral tunnel drilling ACL reconstruction Anatomic reconstruction
Anterior cruciate ligament
Lateral collateral ligament
Analyses of variance
Lateral extra-articular tenodesis
Posterior femoral cortex
Institutional Review Board
Intraclass correlation coefficient
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.
The authors declare that no funding was received to perform this study.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This study was performed after ethical approval from the Institutional Review Board at the Univesity of Barcelona (IRB00003099).
Informed consent was obtained from all individual participants included in the study.
- 9.Geeslin AG, Moatshe G, Chahla J, Kruckeberg BM, Muckenhirn KJ, Dornan GJ, Coggins A, Brady AW, Getgood AM, Godin JA, LaPrade RF (2018) Anterolateral knee extra-articular stabilizers: a robotic study comparing anterolateral ligament reconstruction and modified Lemaire lateral extra-articular tenodesis. Am J Sports Med 46:607–616CrossRefGoogle Scholar
- 10.Gelber PE, Erquicia JI, Sosa G, Ferrer G, Abat F, Rodriguez-Baeza A, Segura-Cros C, Monllau JC (2013) Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model. Arthroscopy 29:257–265CrossRefGoogle Scholar
- 19.Smeets K, Bellemans J, Lamers G, Valgaeren B, Bruckers L, Gielen E, Vandevenne J, Vandenabeele F, Truijen J (2018) High risk of tunnel convergence during combined anterior cruciate ligament and anterolateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5200-3 Google Scholar
- 20.Sonnery-Cottet B, Daggett M, Fayard J-M, Ferretti A, Helito CP, Lind M, Monaco E, de Pádua VBC, Thaunat M, Wilson A, Zaffagnini S, Zijl J, Claes S (2017) Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. J Orthop Traumatol 18:91–106CrossRefGoogle Scholar
- 21.Zein AMN, Ali M, Ali H, Saleh Elsaid AN, Mahmoud AZ, Osman MK, Mohamed Soliman AM (2017) Combined anatomic reconstruction of the anterior cruciate and anterolateral ligaments using hamstring graft through a single femoral tunnel and with a single femoral fixation. Arthrosc Tech 6:e567–e577CrossRefGoogle Scholar