Skip to main content

Advertisement

SpringerLink
Log in

The orientation of the ALL femoral tunnel to minimize collision with the ACL tunnel depends on the need or not of far-cortex drilling

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

Abstract

Purpose

To (1) evaluate the optimal drill orientation of the anterolateral ligament (ALL) femoral tunnel to minimize collision with the anterior cruciate ligament (ACL) femoral tunnel during anatomical ACL reconstruction according to the need for far-cortex drilling and (2) investigate the geometric factors that affect tunnel collision secondary to drill orientation of the ALL femoral tunnel.

Methods

A three-dimensional femoral model of patients who underwent anatomical single-bundle ACL reconstruction between 2015 and 2016 was constructed, and the geometric factors were evaluated. Virtual ALL femoral tunnels were created to simulate 45 drilling conditions. For each condition, whether the virtual ALL femoral tunnel and its trajectory violated the femoral cortex and the minimum distance between tunnels was investigated.

Results

Thirty-nine subjects were included. Overall violation rates of the femoral cortex by the ALL tunnels and its trajectories were 11.1% (195 of 1755 conditions) and 40.7% (714 of 1755 conditions), respectively. A drilling angle of axial 0° and coronal − 40° showed the longest minimum distance between tunnels without femoral cortex violation by the ALL tunnel (6.3 ± 4.0 mm; collision rate 2.6% [1 of 39 subjects]). With simultaneous consideration of the ALL tunnel’s trajectory representing far-cortex drilling, a drill angle of axial 40° and coronal 10° showed the longest minimum distance between tunnels without femoral cortex violation (0.6 ± 3.9 mm; collision rate 38.5% [15 of 39 subjects]). For surgical techniques requiring far-cortex drilling, regression analyses were performed on geometric factors that could affect tunnel collision, which revealed that the sagittal inclination angle of the ACL and the distance between the ACL femoral tunnel’s outlet and ALL’s femoral attachment were associated with tunnel collision.

Conclusion

The optimal drill orientations of the ALL femoral tunnel to minimize collision with the ACL femoral tunnel were axial 0° and coronal − 40° for surgical techniques not requiring far-cortex drilling and axial 40° and coronal 10° for techniques requiring far-cortex drilling. For techniques requiring far-cortex drilling, additional adjustment for orientation of the ACL femoral tunnel is required to reduce the risk of tunnel collision. Therefore, an individualized surgical strategy should be applied according to the graft fixation method of the ALL femoral tunnel.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1.
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Explore related subjects

Discover the latest articles, news and stories from top researchers in related subjects.

Abbreviations

ALL:

Anterolateral ligament

ACL:

Anterior cruciate ligament

FCD:

Far-cortex drilling

CT:

Computed tomography

3D:

Three dimensional

MDBT:

Minimum distance between tunnels

CI:

Confidence interval

References

  1. Ariel de Lima D, de Lima LL, de Souza NGR, de Moraes Perez RA, Sobrado MF, Guimarães TM et al (2021) Clinical outcomes of combined anterior cruciate ligament and anterolateral ligament reconstruction: a systematic review and meta-analysis. Knee Surg Relat Res 33:33

    Article  PubMed  PubMed Central  Google Scholar 

  2. Basdekis G, Abisafi C, Christel P (2008) Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy 24:459–464

    Article  PubMed  Google Scholar 

  3. Chahla J, Menge TJ, Mitchell JJ, Dean CS, LaPrade RF (2016) Anterolateral ligament reconstruction technique: an anatomic-based approach. Arthrosc Tech 5:e453-457

    Article  PubMed  PubMed Central  Google Scholar 

  4. Cho CH, Bae KC, Kim DH (2021) Biomaterials used for suture anchors in orthopedic surgery. Clin Orthop Surg 13:287–292

    Article  PubMed  PubMed Central  Google Scholar 

  5. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328

    Article  PubMed  PubMed Central  Google Scholar 

  6. Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA (2014) The anterolateral ligament: Anatomy, length changes and association with the Segond fracture. Bone Joint J 96-b:325–331

    Article  CAS  PubMed  Google Scholar 

  7. Guettler JH, Demetropoulos CK, Yang KH, Jurist KA (2004) Osteochondral defects in the human knee: influence of defect size on cartilage rim stress and load redistribution to surrounding cartilage. Am J Sports Med 32:1451–1458

    Article  PubMed  Google Scholar 

  8. Hamido F, Habiba AA, Marwan Y, Soliman ASI, Elkhadrawe TA, Morsi MG et al (2021) Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes. Knee Surg Sports Traumatol Arthrosc 29:1173–1180

    Article  PubMed  Google Scholar 

  9. Helito CP, Camargo DB, Sobrado MF, Bonadio MB, Giglio PN, Pécora JR et al (2018) Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 26:3652–3659

    Article  PubMed  Google Scholar 

  10. Hensler D, Working ZM, Illingworth KD, Thorhauer ED, Tashman S, Fu FH (2011) Medial portal drilling: effects on the femoral tunnel aperture morphology during anterior cruciate ligament reconstruction. J Bone Joint Surg Am 93:2063–2071

    Article  PubMed  Google Scholar 

  11. Hurley ET, Bloom DA, Hoberman A, Anil U, Gonzalez-Lomas G, Strauss EJ et al (2021) There are differences in knee stability based on lateral extra-articular augmentation technique alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 29:3854–3863

    Article  PubMed  Google Scholar 

  12. Hurley ET, Fried JW, Kingery MT, Strauss EJ, Alaia MJ (2021) Antero-lateral ligament reconstruction improves knee stability alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 29:764–771

    Article  PubMed  Google Scholar 

  13. Iacono F, Lo Presti M, Bruni D, Raspugli GF, Bignozzi S, Sharma B et al (2013) The adductor tubercle: a reliable landmark for analysing the level of the femorotibial joint line. Knee Surg Sports Traumatol Arthrosc 21:2725–2729

    Article  PubMed  Google Scholar 

  14. Ibrahim SA, Shohdy EM, Marwan Y, Ramadan SA, Almisfer AK, Mohammad MW et al (2017) Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: a randomized clinical trial. Am J Sports Med 45:1558–1566

    Article  PubMed  Google Scholar 

  15. Jaecker V, Ibe P, Endler CH, Pfeiffer TR, Herbort M, Shafizadeh S (2019) High risk of tunnel convergence in combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis. Am J Sports Med 47:2110–2115

    Article  PubMed  Google Scholar 

  16. Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Kim SH, Kim SJ, Choi CH, Kim D, Jung M (2018) Optimal condition to create femoral tunnel considering combined influence of knee flexion and transverse drill angle in anatomical single-bundle ACL reconstruction using medial portal technique: 3D simulation study. Biomed Res Int 2018:2643247

    Article  PubMed  PubMed Central  Google Scholar 

  18. Kurtoğlu A, Başar B, Başar G, Gezginaslan Ö, Başar H (2021) Small size autograft versus large size allograft in anterior cruciate ligament reconstruction. Clin Orthop Surg 13:47–52

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lee DW, Kim JG, Cho SI, Kim DH (2019) Clinical outcomes of isolated revision anterior cruciate ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction. Am J Sports Med 47:324–333

    Article  PubMed  Google Scholar 

  20. Lording T, Corbo G, Bryant D, Burkhart TA, Getgood A (2017) Rotational laxity control by the anterolateral ligament and the lateral meniscus is dependent on knee flexion angle: a cadaveric biomechanical study. Clin Orthop Relat Res 475:2401–2408

    Article  PubMed  PubMed Central  Google Scholar 

  21. Moatshe G, Brady AW, Slette EL, Chahla J, Turnbull TL, Engebretsen L et al (2017) Multiple ligament reconstruction femoral tunnels: intertunnel relationships and guidelines to avoid convergence. Am J Sports Med 45:563–569

    Article  PubMed  Google Scholar 

  22. Moon DK, Jo HS, Lee DY, Kang DG, Won HC, Seo MS et al (2021) Anterior cruciate ligament femoral-tunnel drilling through an anteromedial portal: 3-dimensional plane drilling angle affects tunnel length relative to notchplasty. Knee Surg Relat Res 33:13. https://doi.org/10.1186/s43019-021-00092-5

    Article  PubMed  PubMed Central  Google Scholar 

  23. Moon HS, Choi CH, Jung M, Lee DY, Chang H, Kim SH (2019) Do Rotation and measurement methods affect reliability of anterior cruciate ligament tunnel position on 3D reconstructed computed tomography? Orthop J Sports Med 7:2325967119885882

    Article  PubMed  PubMed Central  Google Scholar 

  24. Musahl V, Engler ID, Nazzal EM, Dalton JF, Lucidi GA, Hughes JD et al (2022) Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation. Knee Surg Sports Traumatol Arthrosc 30:34–51

    Article  PubMed  Google Scholar 

  25. Parsons EM, Gee AO, Spiekerman C, Cavanagh PR (2015) The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med 43:669–674

    Article  PubMed  PubMed Central  Google Scholar 

  26. Perelli S, Erquicia JI, Ibañez M, Daesino G, Gelber PE, Pelfort X et al (2020) Evaluating for tunnel convergence in anterior cruciate ligament reconstruction with modified lemaire tenodesis: what is the best tunnel angle to decrease risk? Arthroscopy 36:776–784

    Article  PubMed  Google Scholar 

  27. Ra HJ, Kim JH, Lee DH (2020) Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis. Arch Orthop Trauma Surg 140:923–931

    Article  PubMed  Google Scholar 

  28. Rasmussen MT, Nitri M, Williams BT, Moulton SG, Cruz RS, Dornan GJ et al (2016) An in vitro robotic assessment of the anterolateral ligament, part 1: secondary role of the anterolateral ligament in the setting of an anterior cruciate ligament injury. Am J Sports Med 44:585–592

    Article  PubMed  Google Scholar 

  29. Robin BN, Jani SS, Marvil SC, Reid JB, Schillhammer CK, Lubowitz JH (2015) Advantages and disadvantages of transtibial, anteromedial portal, and outside-in femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 31:1412–1417

    Article  PubMed  Google Scholar 

  30. Roessler PP, Schüttler KF, Heyse TJ, Wirtz DC, Efe T (2016) The anterolateral ligament (ALL) and its role in rotational extra-articular stability of the knee joint: a review of anatomy and surgical concepts. Arch Orthop Trauma Surg 136:305–313

    Article  PubMed  Google Scholar 

  31. Santoso A, Anwar IB, Sibarani T, Soetjahjo B, Utomo DN, Mustamsir E et al (2020) Research on the anterolateral ligament of the knee: an evaluation of PubMed articles from 2010 to 2019. Orthop J Sports Med 8:2325967120973645

    Article  PubMed  PubMed Central  Google Scholar 

  32. Shuler MS, Jasper LE, Rauh PB, Mulligan ME, Moorman CT 3rd (2006) Tunnel convergence in combined anterior cruciate ligament and posterolateral corner reconstruction. Arthroscopy 22:193–198

    Article  PubMed  Google Scholar 

  33. Smeets K, Bellemans J, Lamers G, Valgaeren B, Bruckers L, Gielen E et al (2019) High risk of tunnel convergence during combined anterior cruciate ligament and anterolateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 27:611–617

    Article  PubMed  Google Scholar 

  34. Smeets K, Van Haver A, Van den Bempt S, Verheyden M, Bruckers L, Verdonk P et al (2019) Risk analysis of tunnel collision in combined anterior cruciate ligament and anterolateral ligament reconstructions. Knee 26:962–968

    Article  CAS  PubMed  Google Scholar 

  35. Smith JO, Yasen SK, Lord B, Wilson AJ (2015) Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee. Knee Surg Sports Traumatol Arthrosc 23:3151–3156

    Article  PubMed  Google Scholar 

  36. Sonnery-Cottet B, Barbosa NC, Tuteja S, Daggett M, Kajetanek C, Thaunat M (2016) Minimally invasive anterolateral ligament reconstruction in the setting of anterior cruciate ligament injury. Arthrosc Tech 5:e211-215

    Article  PubMed  PubMed Central  Google Scholar 

  37. Sonnery-Cottet B, Daggett M, Fayard JM, Ferretti A, Helito CP, Lind M et al (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 18:91–106

    Article  PubMed  PubMed Central  Google Scholar 

  38. Sonnery-Cottet B, Saithna A, Cavalier M, Kajetanek C, Temponi EF, Daggett M et al (2017) Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med 45:1547–1557

    Article  PubMed  Google Scholar 

  39. Sood M, Kulshrestha V, Sachdeva J, Ghai A, Sud A, Singh S (2020) Poor functional outcome in patients with voluntary knee instability after anterior cruciate ligament reconstruction. Clin Orthop Surg 12:312–317

    Article  PubMed  PubMed Central  Google Scholar 

  40. Tramer JS, Fidai MS, Kadri O, Jildeh TR, Hooda Z, Makhni EC et al (2018) Anterolateral ligament reconstruction practice patterns across the United States. Orthop J Sports Med 6:2325967118811063

    Article  PubMed  PubMed Central  Google Scholar 

  41. Xu H, Zhang C, Zhang Q, Du T, Ding M, Wang Y et al (2016) A Systematic review of anterior cruciate ligament femoral footprint location evaluated by quadrant method for single-bundle and double-bundle anatomic reconstruction. Arthroscopy 32:1724–1734

    Article  PubMed  Google Scholar 

  42. Zeng C, Lei G, Gao S, Luo W (2018) Methods and devices for graft fixation in anterior cruciate ligament reconstruction. Cochrane Database Syst Rev 2018:CD010730

    PubMed Central  Google Scholar 

  43. Zhu M, Han Lee DY, Williams A (2021) Safe femoral fixation depth and orientation for lateral extra-articular tenodesis in anterior cruciate ligament reconstruction. Orthop J Sports Med 9:2325967120976591

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, and patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article. There were no external sources of funding and none of the authors had any conflicts of interest.

Author information

Authors and Affiliations

  1. Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea

    Hyun-Soo Moon, Chong-Hyuk Choi, Young-Jin Seo, Min Jung & Sung-Hwan Kim

  2. Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea

    Hyun-Soo Moon & Jung-Hun Park

  3. Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Chong-Hyuk Choi & Min Jung

  4. Department of Orthopedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea

    Young-Jin Seo

  5. Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Younghan Lee

  6. Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 20 Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, Republic of Korea

    Sung-Hwan Kim

Authors
  1. Hyun-Soo Moon
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chong-Hyuk Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Young-Jin Seo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Younghan Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Min Jung
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jung-Hun Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sung-Hwan Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The project was coordinated by HS Moon, CH Choi, and SH Kim. HS Moon drafted the manuscript, together with YJ Seo, YH Lee, and M Jung. HS Moon and SH Kim generated the concept of the study. The acquisition of data and analysis was done by HS Moon and JH Park. The design of the study and interpretation of data were all done jointly by all authors. HS Moon and SH Kim revised the final draft critically for important intellectual content and approved the version to be submitted. We have read and understood your journal’s policies, and we believe that neither the manuscript nor the study violates any of these.

Corresponding author

Correspondence to Sung-Hwan Kim.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This study was ethically approved by the institutional review board from Gangnam Severance hospital (ID Number: 3-2021-0092).

Informed consent

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Flowchart of patient inclusion in the study (TIF 72 KB)

Supplementary file2 (DOCX 26 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Moon, HS., Choi, CH., Seo, YJ. et al. The orientation of the ALL femoral tunnel to minimize collision with the ACL tunnel depends on the need or not of far-cortex drilling. Knee Surg Sports Traumatol Arthrosc 30, 3805–3817 (2022). https://doi.org/10.1007/s00167-022-07007-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-022-07007-1

Keywords

Search

Navigation