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More anatomic tunnel placement for anterior cruciate ligament reconstruction by surgeons with high volume compared to low volume

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Correct placement of the femoral and tibial tunnels in the anatomic footprint during anterior cruciate ligament reconstruction (ACLR) is paramount for restoring rotatory knee stability. Recent studies have looked at surgeon volume and its outcomes on procedures such as total knee arthroplasty and infection rates, but only few studies have specifically examined tunnel placement after ACLR based on surgeon volume. The purpose of this study was to compare the placement of femoral and tibial tunnels during ACLR between high-volume and low-volume surgeons. It was hypothesized that high-volume surgeons would have more anatomic tunnel placement compared with low-volume surgeons.

Methods

A retrospective review of all ACLR performed between 2015 and 2019 at an integrated health care system consisting of both academic and community hospitals with 68 orthopaedic surgeons was conducted. Surgeon volume was categorized as less than 35 ACLR per year (low volume) and 35 or more ACLR per year (high volume). Femoral tunnel placement for each patient was determined using an exact strict lateral radiograph (less than 6 mm of offset between the posterior halves of the medial and lateral condyles) taken after the primary ACLR using the quadrant method. The centre of the femoral tunnel was measured in relation to the posterior–anterior (PA) and proximal–distal (PD) dimensions (normal centre of anatomic footprint: PA 25% and PD 29%). Tibial tunnel placement for each patient was determined on the same lateral radiographs by measuring the mid-sagittal tibial diameter and the centre of the tibial attachment area of the ACL from the anterior tibial margin (normal centre of anatomic footprint: 43%). Each lateral radiograph was reviewed by one of two blinded reviewers.

Results

A total of 4500 patients were reviewed, of which 645 patients met all the inclusion/exclusion criteria and were included in the final analysis. There were 228 patients in the low-volume group and 417 patients in the high-volume group. Low-volume surgeons performed a mean of 5 ACLRs per year, whereas surgeons in the high-volume group performed a mean of 40 ACLRs per year. In the PA dimension, the low-volume group had significantly more anterior femoral tunnel placement compared with the high-volume group (32 ± 10% vs 28 ± 9%, p < 0.01). In the PD dimension, the low-volume group had statistically significant more proximal femoral tunnel placement compared to the high-volume group (32 ± 9% vs 35 ± 9%, p < 0.01). For the tibial tunnel, the low-volume group had significantly more posterior tibial tunnel placement compared with the high-volume group (41 ± 10% vs 38 ± 7%, p < 0.01).

Conclusion

Low-volume surgeons placed their femoral tunnels significantly more anterior and proximal (high) during ACLR, and placed their tibial tunnels significantly more posterior, compared with high-volume surgeons. Prior research has indicated that anatomic placement of the femoral and tibial tunnels during ACLR leads to improved rotatory knee stability. The findings of this study demonstrate the importance of surgical volume and experience during ACLR.

Level of evidence

III.

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Funding

No outside funding was used during this study.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, USA

    Jonathan D. Hughes, Christopher M. Gibbs, Akere Atte & Volker Musahl

  2. Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Jonathan D. Hughes, Mikael Sansone & Jon Karlsson

  3. University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Anmol Almast

Authors
  1. Jonathan D. Hughes
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  6. Jon Karlsson
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  7. Volker Musahl
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Contributions

All the listed authors have contributed substantially to this work: JDH, CMG, and AA were involved with drafting and revising the manuscript, tables and figures, as well as data analysis, statistics, and data interpretation. MS, JK, and VM were involved in the study design, clinical analysis, editing, and revision of the manuscript, tables, and figures.

Corresponding author

Correspondence to Jonathan D. Hughes.

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Conflict of interest

VM reports educational grants, consulting fees, and speaking fees from Smith & Nephew plc, educational grants from Arthrex, is a board member of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), and deputy editor-in-chief of Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA). In addition, VM has a patent Quantified injury diagnostics-U.S. Patent No. 9,949,684, Issued on April 24, 2018, issued to University of Pittsburgh.

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Approved by the Institutional Review Board at University of Pittsburgh (STUDY1903019).

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Informed consent was waived by the IRB at the University of Pittsburgh.

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Hughes, J.D., Gibbs, C.M., Almast, A. et al. More anatomic tunnel placement for anterior cruciate ligament reconstruction by surgeons with high volume compared to low volume. Knee Surg Sports Traumatol Arthrosc 30, 2014–2019 (2022). https://doi.org/10.1007/s00167-022-06875-x

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  • DOI: https://doi.org/10.1007/s00167-022-06875-x

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