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The anatomic approach to primary, revision and augmentation anterior cruciate ligament reconstruction

  • Knee
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

The anatomic approach is gaining popularity in anterior cruciate ligament (ACL) reconstruction. It is predominantly applied during primary ACL reconstruction. However, following the same principles as during primary surgery, the anatomic approach can also be applied during revision and augmentation surgery. This paper discusses the surgical technique for anatomic single- and double-bundle ACL reconstruction, for primary, revision and augmentation surgery. During primary reconstruction, the choice for single- or double-bundle reconstruction and graft size should be based on ACL insertion site and femoral intercondylar notch dimensions. When there is an isolated anteromedial (AM) or posterolateral (PL) bundle rupture, augmentation of a single-bundle can be performed while protecting the integrity of the intact bundle. Especially during revision surgery, there are many potential situations the surgeon may encounter when entering the knee. There are multiple possible solutions for all of these different situations leading to an anatomic end result. Three-dimensional computed tomography (CT) scanning should be used to evaluate the current tunnel positions and determine the operative strategy.

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References

  1. Aglietti P, Giron F, Losco M, Cuomo P, Ciardullo A, Mondanelli N (2010) Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial. Am J Sports Med 38:25–34

    Article  PubMed  Google Scholar 

  2. Arnold MP, Kooloos J, van Kampen A (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 9:194–199

    CAS  PubMed  Google Scholar 

  3. Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH (2006) Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am 88(Suppl 4):2–10

    Article  PubMed  Google Scholar 

  4. Cohen SB, Fu FH (2007) Three-portal technique for anterior cruciate ligament reconstruction: use of a central medial portal. Arthroscopy 23: 325, e321–325

    Google Scholar 

  5. Colvin AC, Shen W, Musahl V, Fu FH (2009) Avoiding pitfalls in anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 17:956–963

    Article  PubMed  Google Scholar 

  6. Dandy DJ (1996) Basic technique: the standard approach. In: McGinty JB (ed) Operative arthroscopy. Lippincott-Raven, Philadelphia, pp 252–253

    Google Scholar 

  7. Dustmann M, Schmidt T, Gangey I, Unterhauser FN, Weiler A, Scheffler SU (2008) The extracellular remodeling of free-soft-tissue autografts and allografts for reconstruction of the anterior cruciate ligament: a comparison study in a sheep model. Knee Surg Sports Traumatol Arthrosc 16:360–369

    Article  CAS  PubMed  Google Scholar 

  8. Edwards A, Bull AM, Amis AA (2007) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament: part 1: tibial attachment. Knee Surg Sports Traumatol Arthrosc 15:1414–1421

    Article  PubMed  Google Scholar 

  9. Ekdahl M, Wang JH, Ronga M, Fu FH (2008) Graft healing in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16:935–947

    Article  PubMed  Google Scholar 

  10. Ferretti M, Ekdahl M, Shen W, Fu FH (2007) Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy 23:1218–1225

    Article  PubMed  Google Scholar 

  11. Ferretti M, Levicoff EA, Macpherson TA, Moreland MS, Cohen M, Fu FH (2007) The fetal anterior cruciate ligament: an anatomic and histologic study. Arthroscopy 23:278–283

    Article  PubMed  Google Scholar 

  12. Fu FH (2008) The clock-face reference: simple but nonanatomic. Arthroscopy 24: 1433; author reply 1434

  13. Fu FH, Jordan SS (2007) The lateral intercondylar ridge—a key to anatomic anterior cruciate ligament reconstruction. J Bone Joint Surg Am 89:2103–2104

    Article  PubMed  Google Scholar 

  14. Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE (2004) Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res 22:85–89

    Article  PubMed  Google Scholar 

  15. George MS, Dunn WR, Spindler KP (2006) Current concepts review: revision anterior cruciate ligament reconstruction. Am J Sports Med 34:2026–2037

    Article  PubMed  Google Scholar 

  16. Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231

    Article  PubMed  Google Scholar 

  17. Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ (2001) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 50:463–474

    CAS  PubMed  Google Scholar 

  18. Harner CD, Honkamp NJ, Ranawat AS (2008) Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 24:113–115

    Article  PubMed  Google Scholar 

  19. Hefzy MS, Grood ES, Noyes FR (1989) Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med 17:208–216

    Article  CAS  PubMed  Google Scholar 

  20. Jagodzinski M, Richter GM, Passler HH (2000) Biomechanical analysis of knee hyperextension and of the impingement of the anterior cruciate ligament: a cinematographic MRI study with impact on tibial tunnel positioning in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 8:11–19

    Article  CAS  PubMed  Google Scholar 

  21. Jarvela T (2007) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc 15:500–507

    Article  PubMed  Google Scholar 

  22. Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD (1996) Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res 325:100–109

    Article  PubMed  Google Scholar 

  23. Kaz R, Starman JS, Fu FH (2007) Anatomic double-bundle anterior cruciate ligament reconstruction revision surgery. Arthroscopy 23: 1250, e1251–1253

    Google Scholar 

  24. Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T (2008) Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med 36:1675–1687

    Article  PubMed  Google Scholar 

  25. Markolf KL, Wascher DC, Finerman GA (1993) Direct in vitro measurement of forces in the cruciate ligaments. Part II: the effect of section of the posterolateral structures. J Bone Joint Surg Am 75:387–394

    CAS  PubMed  Google Scholar 

  26. Martins CAQ, Kropf EJ, Shen W, van Eck CF, Fu FH (2008) The concept of anatomic anterior cruciate ligament reconstruction. Oper Tech Sports Med 16:104–115

    Article  Google Scholar 

  27. Muneta T, Koga H, Mochizuki T, Ju YJ, Hara K, Nimura A, Yagishita K, Sekiya I (2007) a prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy 23:618–628

    Article  PubMed  Google Scholar 

  28. Odensten M, Gillquist J (1985) Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 67:257–262

    CAS  PubMed  Google Scholar 

  29. Pombo MW, Shen W, Fu FH (2008) Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy 24:1168–1177

    Article  PubMed  Google Scholar 

  30. Purnell ML, Larson AI, Clancy W (2008) Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 36:2083–2090

    Article  PubMed  Google Scholar 

  31. Safran MR, Harner CD (1996) Technical considerations of revision anterior cruciate ligament surgery. Clin Orthop Relat Res 325:50–64

    Article  PubMed  Google Scholar 

  32. Samuelsson K, Andersson D, Karlsson J (2009) Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials. Arthroscopy 25:1139–1174

    Article  PubMed  Google Scholar 

  33. Scheffler SU, Schmidt T, Gangey I, Dustmann M, Unterhauser F, Weiler A (2008) Fresh-frozen free-tendon allografts versus autografts in anterior cruciate ligament reconstruction: delayed remodeling and inferior mechanical function during long-term healing in sheep. Arthroscopy 24:448–458

    Article  PubMed  Google Scholar 

  34. Shen W, Forsythe B, Ingham SM, Honkamp NJ, Fu FH (2008) Application of the anatomic double-bundle reconstruction concept to revision and augmentation anterior cruciate ligament surgeries. J Bone Joint Surg Am 90(Suppl 4):20–34

    Article  PubMed  Google Scholar 

  35. Siebold R, Dehler C, Ellert T (2008) Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy 24:137–145

    Article  PubMed  Google Scholar 

  36. Simmons R, Howell SM, Hull ML (2003) Effect of the angle of the femoral and tibial tunnels in the coronal plane and incremental excision of the posterior cruciate ligament on tension of an anterior cruciate ligament graft: an in vitro study. J Bone Joint Surg Am 85-A:1018–1029

    PubMed  Google Scholar 

  37. Tischer T, Ronga M, Tsai A, Ingham SJ, Ekdahl M, Smolinski P, Fu FH (2009) Biomechanics of the goat three bundle anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 17:935–940

    Article  CAS  PubMed  Google Scholar 

  38. van Eck CF, Lesniak BP, Schreiber VM, Fu FH (2010) Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy 26:258–268

    Article  PubMed  Google Scholar 

  39. van Eck CF, Morse KR, Lesniak BP, Kropf EJ, Tranovich MJ, van Dijk CN, Fu FH (2010) Does the lateral intercondylar ridge disappear in ACL deficient patients? Knee Surg Sports Traumatol Arthrosc. Epub ahead of print Jan 20. doi:10.1007/s00167-009-1038-z

  40. van Eck CF, Romanowski JR, Fu FH (2009) Anatomic single-bundle anterior cruciate ligament reconstruction. Arthroscopy 25:943–946

    Article  PubMed  Google Scholar 

  41. Wascher DC, Markolf KL, Shapiro MS, Finerman GA (1993) Direct in vitro measurement of forces in the cruciate ligaments. Part I: the effect of multiplane loading in the intact knee. J Bone Joint Surg Am 75:377–386

    CAS  PubMed  Google Scholar 

  42. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M (2007) Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res 454:100–107

    Article  PubMed  Google Scholar 

  43. Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H (2006) Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy 22:240–251

    Article  PubMed  Google Scholar 

  44. Zantop T, Brucker PU, Vidal A, Zelle BA, Fu FH (2007) Intraarticular rupture pattern of the ACL. Clin Orthop Relat Res 454:48–53

    Article  PubMed  Google Scholar 

  45. Zantop T, Kubo S, Petersen W, Musahl V, Fu FH (2007) Current techniques in anatomic anterior cruciate ligament reconstruction. Arthroscopy 23:938–947

    Article  PubMed  Google Scholar 

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Acknowledgments

Our department receives funding from Smith and Nephew to support research related to reconstruction of the ACL. The research that forms the basis for this manuscript was done at our institution.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA

    Carola F. van Eck, Verena M. Schreiber, T. Thomas Liu & Freddie H. Fu

  2. Orthopaedic Research Centre Amsterdam, Academic Medical Center, Amsterdam, The Netherlands

    Carola F. van Eck

Authors
  1. Carola F. van Eck
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  2. Verena M. Schreiber
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  3. T. Thomas Liu
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  4. Freddie H. Fu
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Correspondence to Freddie H. Fu.

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van Eck, C.F., Schreiber, V.M., Liu, T.T. et al. The anatomic approach to primary, revision and augmentation anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18, 1154–1163 (2010). https://doi.org/10.1007/s00167-010-1191-4

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  • DOI: https://doi.org/10.1007/s00167-010-1191-4

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