J Korean Orthop Assoc.  2015 Jun;50(3):232-240. 10.4055/jkoa.2015.50.3.232.

Analysis of Femoral Tunnel Position Targeted at Bifurcate Ridge Using Anteromedial Portal Technique in Anatomic Anterior Cruciate Ligament Reconstruction

• Pak CH
• Kim DH
• Jung S
• Yang SH

• KMID: 1851957
• DOI: http://doi.org/10.4055/jkoa.2015.50.3.232

Abstract

PURPOSE
The purpose of this study is to analyze the position of the 10-mm-sized femur tunnel drilled aiming for the bifurcate ridge using anteromedial portal technique with 'Figure of 4 position' by 3-dimensional computed tomography (3D-CT) reconstruction images after anatomic anterior cruciate ligament (ACL) reconstruction and to evaluate it's propriety.
MATERIALS AND METHODS
Out of 35 patients who underwent anatomic ACL reconstruction from March 2012 to February 2013, 32 patients who undergone postoperative 3D-CT scans were included in this study retrospectively. Medial surface of the lateral femoral condyle was reconstructed using Mimics, and then the position of the femoral tunnel was evaluated using the Bernard quadrant method and the results were compared with those of published literatures. The mean age of the patients was 32.6 years old. There were 25 cases of double-bundle ACL reconstruction with one femoral-two tibial tunnel. There were 7 cases of single bundle ACL reconstruction with one femoral-one tibial tunnel.
RESULTS
The mean distance of the femoral tunnel center was 32.2%+/-2.9% (range, 27.4%-37.6%) along the line parallel to the Blumensaat's line from the posterior condylar surface and 46.7%+/-2.3% (range, 43.5%-51.1%) along the line perpendicular to the Blumensaat's line from the roof of the notch. In comparison with the results of published literature, although the center of the femoral tunnel was presented in the femoral footprint, it was located slightly more shallow and inferior than the center of the ACL footprints.
CONCLUSION
The bifurcate ridge may be a good anatomic landmark when making a 10-mm-sized single femoral tunnel in 'Figure of 4 position' using the anteromedial portal technique.

Keyword

anatomic ACL reconstruction; bifurcate ridge; 3D-CT analysis

MeSH Terms

Anatomic Landmarks
Anterior Cruciate Ligament
Anterior Cruciate Ligament Reconstruction*
Femur
Humans
Retrospective Studies

Figure

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  Figure 1 Fresh frozen allogenous Achilles tendon was split into 6-mm-diameter for posterolateral bundle, 8 mm diameter for anteromedial bundle with 20×10×10 mm bone block.

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  Figure 2 Operative technique during right knee anatomic anterior cruciate ligament (ACL) reconstruction. (A) 'Figure of 4 position' which was knee flexion to 100° to 120° and varus state. (B) Micro-fracture awl tip marked the midpoint of the bifurcate ridge and 5 mm superior to the articular margin. (C) A guide pin was placed at the marked position and drilled out to the lateral cortex of the lateral condyle taking care to enclose the guide pin on the cartilage of the medial condyle but to avoid damaging it. (D) A 10-mm Sentinel drill bit was used to confirm the location of the tunnel without articular cartilage damage. (E) A 20-mm-depth bone tunnel was made in the anatomical position. (F) ACL graft was viewed through the central portal.

• 

  Figure 3 Three-dimensional reconstruction image using the Mimics program and tunnel measurement of the right knee using Bernard's quadrant method. (A) Medial-lateral view of the femoral condyle in the strictly lateral position where both condyles were superimposed. (B) In the distal view, the medial femoral condyle was removed at the highest point of the intercondylar notch (white arrow). (C) Leaving lateral femoral condyle was rotated back to the 'strictly lateral position' which was confirmed by superimposing onto (A). (D) Measurement of femoral tunnel location using the quadrant method described by Bernard et al.16)

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  Figure 4 Distributed red dots of anterior cruciate ligament (ACL) femoral tunnels according to our anteromedial portal technique using the quadrant method described by Bernard et al.16) Each marker represents the geographic mean distribution of ACL femoral tunnel location (☆, Current study; ★, Lertwanich et al.18); *, Bird et al.17); ¤, Zantop et al.20)).

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