Clin Orthop Surg.  2013 Mar;5(1):26-35. 10.4055/cios.2013.5.1.26.

Three-Dimensional Reconstruction Computed Tomography Evaluation of Tunnel Location during Single-Bundle Anterior Cruciate Ligament Reconstruction: A Comparison of Transtibial and 2-Incision Tibial Tunnel-Independent Techniques

• Ahn JH
• Jeong HJ
• Ko CS
• Ko TS
• Kim JH

• KMID: 1402323
• DOI: http://doi.org/10.4055/cios.2013.5.1.26

Abstract

BACKGROUND
Anatomic tunnel positioning is important in anterior cruciate ligament (ACL) reconstructive surgery. Recent studies have suggested the limitations of a traditional transtibial technique to place the ACL graft within the anatomic tunnel position of the ACL on the femur. The purpose of this study is to determine if the 2-incision tibial tunnel-independent technique can place femoral tunnel to native ACL center when compared with the transtibial technique, as the placement with the tibial tunnel-independent technique is unconstrained by tibial tunnel.
METHODS
In sixty-nine patients, single-bundle ACL reconstruction with preservation of remnant bundle using hamstring tendon autograft was performed. Femoral tunnel locations were measured with quadrant methods on the medial to lateral view of the lateral femoral condyle. Tibial tunnel locations were measured in the anatomical coordinates axis on the top view of the proximal tibia. These measurements were compared with reference data on anatomical tunnel position.
RESULTS
With the quadrant method, the femoral tunnel centers of the transtibial technique and tibial tunnel-independent technique were located. The mean (+/- standard deviation) was 36.49% +/- 7.65% and 24.71% +/- 4.90%, respectively, from the over-the-top, along the notch roof (parallel to the Blumensaat line); and at 7.71% +/- 7.25% and 27.08% +/- 7.05%, from the notch roof (perpendicular to the Blumensaat line). The tibial tunnel centers of the transtibial technique and tibial tunnel-independent technique were located at 39.83% +/- 8.20% and 36.32% +/- 8.10%, respectively, of the anterior to posterior tibial plateau depth; and at 49.13% +/- 4.02% and 47.75% +/- 4.04%, of the medial to lateral tibial plateau width. There was no statistical difference between the two techniques in tibial tunnel position. The tibial tunnel-independent technique used in this study placed femoral tunnel closer to the anatomical ACL anteromedial bundle center. In contrast, the transtibial technique placed the femoral tunnel more shallow and higher from the anatomical position, resulting in more vertical grafts.
CONCLUSIONS
After single-bundle ACL reconstruction, three-dimensional computed tomography showed that the tibial tunnel-independent technique allows for the placement of the graft closer to the anatomical femoral tunnel position when compared with the traditional transtibial technique.

Keyword

Anterior cruciate ligament; Three-dimensional computed tomography; Transtibial technique; 2-Incision tibial tunnel-independent technique

MeSH Terms

Adolescent
Adult
Anterior Cruciate Ligament Reconstruction/*methods
Female
Femur/radiography/surgery
Humans
Imaging, Three-Dimensional
Male
Retrospective Studies
Tibia/*radiography/surgery
Tomography, X-Ray Computed
Young Adult

Figure

• 

  Fig. 1 Femoral tunnel made by the transtibial technique. (A) The femoral tunnel was made 1 to 2 mm before the posterior cortex. (B) Three-dimensional computed tomography shows the femoral tunnel made by the transtibial technique.

• 

  Fig. 2 Femoral tunnel made by the tibial tunnel-independent technique. (A) The marking hole was located at 5 to 6 mm shallow from the most proximal high deep point on the cartilage-bone border of lateral condyle (over-the-top), and from this point, 2 to 3 mm low. (B) Through a stab incision at the distal midlateral femoral metaphyseal flare, 3.5 mm outside-in minimally invasive drilling pin (Flipcutter) was introduced. (C) The cutter chosen to match the diameter of the graft; 10 mm drilled to create an outside-in femoral tunnel. (D) Three-dimensional computed tomography shows the femoral tunnel made by the tibial tunnel-independent technique.

• 

  Fig. 3 On the lateral femoral side of three-dimensional computed tomography, the location of the transtibial and tibial independent femoral tunnel are shown. The location of tunnel was quantified from center of the tunnel to the deepest subchondral bone contour (distance FA) and the intercondylar notch roof (distance FB). ACL: anterior cruciate ligament, AM: anteromedial, PL: posterolateral, TT: transtibial, TI: tibial tunnel-independent, DS: distance deep to shallow, HL: distance high to low, FA: femur 'A' line, FB: femur 'B' line.

• 

  Fig. 4 4 × 4 grid of quadrant method, by tibial tunnel-independent technique: 9 (25.7%) and 14 (40.0%) of 35 femoral tunnels located in 2a and 2b grid, respectively. On the other hand, by transtibial technique, 28 (82.4%) of 34 femoral tunnels were located in 1b grid; furthermore, 3 of 34 were located over the Blumensaat line (red line).

• 

  Fig. 5 On the top view of the proximal tibia, the location of the transtibial and tibial independent tibial tunnel are shown. The location of tunnel was measured from the anterior border (distance TA) and medial border (distance TB). AP: distance anterior to posterior, ML: distance medial to lateral, AM: anteromedial, PL: posterolateral, TT: transtibial, TI: tibial tunnel-independent, TA: tibia 'A' line, TB: tibia 'B' line.

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