Abstract
Introduction
Since tunnel positioning is one of the key factors in anterior cruciate ligament (ACL) reconstruction and the variability of tunnel positioning in ACL reconstruction has so far never been analyzed, the objective of this study was to determine the inter- and intra-observer variability of tibial and femoral tunnel positioning in ACL reconstruction.
Materials and methods
In an operating room setup, 13 surgeons were asked to identify the tunnel positions in one and the same ACL-deficient cadaver knee. Using a fluoroscopic based ACL navigation system, tunnel positions were digitally measured in a test/re-test scenario. For variability analysis mean positions, standard deviations and range were calculated as well as differences between test/re-test positions.
Results
The intraobserver analysis showed a tibial variability of 3.3 mm (SD 2.1, range 7.5 mm) and a femoral variability of 2.0 mm (SD 1.6 mm, range 6.8 mm). The interobserver variability of the tibial tunnel positions was 3.2 mm (SD) with a range of 18.3 mm and a femoral variability of 3.7 mm (SD) with a range of 13.2 mm.
Conclusions
This study demonstrates that a reasonable inter- and intra-observer variability in ACL tunnel positioning exists even among experienced surgeons. Although deviations of 2–3 mm may seem to be acceptable at first sight, a range of up to 18.3 mm indicates that outliers exist, which can cause graft failure. More reliable reconstruction techniques should be developed to reduce the variability in tunnel positioning.
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References
Amis AA, Dawkins GP (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 73(2):260–267
Bedi A, Maak T, Musahl V, Citak M, O’Loughlin PF, Choi D, Pearle AD (2011) Effect of tibial tunnel position on stability of the knee after anterior cruciate ligament reconstruction: is the tibial tunnel position most important? Am J Sports Med 39(2):366–373
Bernard M, Hertel P (1996) Intraoperative and postoperative insertion control of anterior cruciate ligament-plasty. A radiologic measuring method (quadrant method). Unfallchirurg 99(5):332–340
Goble EM, Downey DJ, Wilcox TR (1995) Positioning of the tibial tunnel for anterior cruciate ligament reconstruction. Arthroscopy 11(6):688–695
Harner CD, Baek GH, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL (1999) Quantitative analysis of human cruciate ligament insertions. Arthroscopy 15(7):741–749
Hefzy MS, Grood ES (1986) Sensitivity of insertion locations on length patterns of anterior cruciate ligament fibers. J Biomech Eng 108(1):73–82
Hohmann E et al (2010) Tunnel positioning in anterior cruciate ligament reconstruction: how long is the learning curve? Knee Surg Sports Traumatol Arthrosc 18(11):1576–1582
Howell SM (1998) Principles for placing the tibial tunnel and avoiding roof impingement during reconstruction of a torn anterior cruciate ligament. Knee Surg, Sports Araumatology, Arthrosc 6(Suppl 1):S49–S55
Jalliard R, Lavallee S, Dessenne V (1998) Computer assisted reconstruction of the anterior cruciate ligament. Clin Orthop Relat Res 354:57–64
Jaureguito JW, Paulos LE (1996) Why grafts fail. Clin Orthop Relat Res 325:25–41
Kasten P, Szczodry M, Irrgang J, Kropf E, Costello J, Fu FH (2010) What is the role of intra-operative fluoroscopic measurements to determine tibial tunnel placement in anatomical anterior cruciate ligament reconstruction? Knee Surg Sports Traumatol Arthrosc 18(9):1169–1175. doi:10.1007/s00167-010-1082-8
Kato Y, Ingham SJ, Kramer S, Smolinski P, Saito A, Fu FH (2010) Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surg, Sports Traumatology, Arthrosc 18(1):2–10. doi:10.1007/s00167-009-0916-8
Kato Y, Maeyama A, Lertwanich P, Wang JH, Ingham SJ, Kramer S, Martins CQ, Smolinski P, Fu FH (2012) Biomechanical comparison of different graft positions for single-bundle anterior cruciate ligament reconstruction. Knee Surg, Sports Traumatology, Arthrosc. doi:10.1007/s00167-012-1951-4
Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum EB (1996) The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med 24(3):335–341
Klos TV, Habets RJ, Banks AZ, Banks SA, Devilee RJ, Cook FF (1998) Computer assistance in arthroscopic anterior cruciate ligament reconstruction. Clin Orthop Relat Res 354:65–69
Koh J, Koo SS, Leonard J, Kodali P (2006) Anterior cruciate ligament (ACL) tunnel placement: a radiographic comparison between navigated versus manual ACL reconstruction. Orthopedics 29(10 Suppl):S122–S124
Kohn D, Busche T, Carls J (1998) Drill hole position in endoscopic anterior cruciate ligament reconstruction. Results of an advanced arthroscopy course. Knee Surg Sports Traumatol Arthrosc 6(Suppl 1):S13–S15
Kopf S, Musahl V, Tashman S, Szczodry M, Shen W, Fu FH (2009) A systematic review of the femoral origin and tibial insertion morphology of the ACL. Knee Surg Sports Traumatol Arthrosc 17(3):213–219. doi:10.1007/s00167-008-0709-5
Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement. 2002 Richard O’Connor Award paper. Arthroscopy 19(3):297–304. doi:10.1053/jars.2003.50084
Markolf KL, Jackson SR, McAllister DR (2010) A comparison of 11 o’clock versus oblique femoral tunnels in the anterior cruciate ligament-reconstructed knee: knee kinematics during a simulated pivot test. Am J of Sports Med 38(5):912–917. doi:10.1177/0363546509358321
McConkey MO, Amendola A, Ramme AJ, Dunn WR, Flanigan DC, Britton CL, Group MK, Wolf BR, Spindler KP, Carey JL, Cox CL, Kaeding CC, Wright RW, Matava MJ, Brophy RH, Smith MV, McCarty EC, Vida AF, Wolcott M, Marx RG, Parker RD, Andrish JF, Jones MH (2012) Arthroscopic agreement among surgeons on anterior cruciate ligament tunnel placement. Am J Sports Med 40(12):2737–2746. doi:10.1177/0363546512461740
Mehta VM, Paxton EW, Fithian DC (2009) Does the use of fluoroscopy and isometry during anterior cruciate ligament reconstruction affect surgical decision making? Clin J Sport Med 19(1):46–48. doi:10.1097/JSM.0b013e3181915bd7
Musahl V, Plakseychuk A, VanScyoc A, Sasaki T, Debski RE, McMahon PJ, Fu FH (2005) Varying femoral tunnels between the anatomical footprint and isometric positions: effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med 33(5):712–718. doi:10.1177/0363546504271747
Nakauchi M, Kurosawa H, Kawakami A (2000) Abnormal lateral notch in knees with anterior cruciate ligament injury. J Orthop Sci 5(2):92–95
Oettl GM, Imhoff AB (1998) Revision surgery in failed anterior cruciate ligament-plasty. Zentralbl Chir 123(9):1033–1039
Picard F, DiGioia AM, Moody J, Martinek V, Fu FH, Rytel M, Nikou C, LaBarca RS, Jaramaz B (2001) Accuracy in tunnel placement for ACL reconstruction. comparison of traditional arthroscopic and computer-assisted navigation techniques. Comput Aided Surg 6(5):279–289
Piefer JW, Pflugner TR, Hwang MD, Lubowitz JH (2012) Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature. Arthroscopy 28(6):872–881. doi:10.1016/j.arthro.2011.11.026
Plaweski S, Cazal J, Rosell P, Merloz P (2006) Anterior cruciate ligament reconstruction using navigation: a comparative study on 60 patients. Am J Sports Med 34(4):542–552
Sati M, Staubli H, Bourquin Y, Kunz M, Nolte LP (2002) Real-time computerized in situ guidance system for ACL graft placement. Comput Aided Surg 7(1):25–40
Shafizadeh S, Balke M, Wegener S, Tjardes T, Bouillon B, Hoeher J, Baethis H (2011) Precision of tunnel positioning in navigated anterior cruciate ligament reconstruction. Arthroscopy 27(9):1268–1274
Shafizadeh S, Huber HJ, Grote S, Hoeher J, Paffrath T, Tiling T, Bouillon B (2005) Principles of fluoroscopic-based navigation in anterior cruciate ligament reconstruction. Oper Tech Orthop 15:70–75
Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo MS (1995) Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program. Am J Sports Med 23(5):575–579
Siebold R (2011) The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(5):699–706
Siebold R, Axe J, Irrgang JJ, Li K, Tashman S, Fu FH (2010) A computerized analysis of femoral condyle radii in ACL intact and contralateral ACL reconstructed knees using 3D CT. Knee Surg, Sports Traumatology, Arthrosc 18(1):26–31. doi:10.1007/s00167-009-0969-8
Siebold R, Ellert T, Metz S, Metz J (2008) Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for double-bundle bone tunnel placement–a cadaver study. Arthroscopy 24(5):585–592. doi:10.1016/j.arthro.2007.12.008
Sommer C, Friederich NF, Muller W (2000) Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 8(4):207–213
Staubli HU, Rauschning W (1994) Tibial attachment area of the anterior cruciate ligament in the extended knee position. Anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo. Knee Surg Sports Traumatol Arthrosc 2(3):138–146
Tsuda E, Ishibashi Y, Fukuda A, Yamamoto Y, Tsukada H, Ono S (2010) Tunnel position and relationship to postoperative knee laxity after double-bundle anterior cruciate ligament reconstruction with a transtibial technique. Am J of Sports Med 38(4):698–706. doi:10.1177/0363546509351561
Zantop T, Wellmann M, Fu FH, Petersen W (2008) Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 36(1):65–72
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Shafizadeh, S., Balke, M., Hagn, U. et al. Variability of tunnel positioning in ACL reconstruction. Arch Orthop Trauma Surg 134, 1429–1436 (2014). https://doi.org/10.1007/s00402-014-2039-z
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DOI: https://doi.org/10.1007/s00402-014-2039-z