Clin Orthop Surg.  2018 Dec;10(4):407-412. 10.4055/cios.2018.10.4.407.

How to Avoid Graft-Tunnel Length Mismatch in Modified Transtibial Technique for Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft

• Ko D
• Kim HJ
• Oh SH
• Kim BJ
• Kim SJ

• KMID: 2426524
• DOI: http://doi.org/10.4055/cios.2018.10.4.407

Abstract

BACKGROUND
We conducted this study to determine the optimal length of patellar and tibial bone blocks for the modified transtibial (TT) technique in anterior cruciate ligament (ACL) reconstruction using the bone-patellar tendon-bone (BPTB) graft.
METHODS
The current single-center, retrospective study was conducted in a total of 64 patients with an ACL tear who underwent surgery at our medical institution between March 2015 and February 2016. After harvesting the BPTB graft, we measured its length and that of the patellar tendon, patellar bone block, and tibial bone block using the arthroscopic ruler and double-checked measurements using a length gauge. Outcome measures included the length of tibial and femoral tunnels, inter-tunnel distance, length of the BPTB graft, patellar tendon, patellar bone block, and tibial bone block and graft-tunnel length mismatch. The total length of tunnels was defined as the sum of the length of the tibial tunnel, inter-tunnel distance and length of the femoral tunnel. Furthermore, the optimal length of the bone block was calculated as (the total length of tunnels − the length of the patellar tendon) / 2. We analyzed correlations of outcome measures with the height and body mass index of the patients.
RESULTS
There were 44 males (68.7%) and 20 females (31.3%) with a mean age of 31.8 years (range, 17 to 65 years). ACL reconstruction was performed on the left knee in 34 patients (53%) and on the right knee in 30 patients (47%). The optimal length of bone block was 21.7 mm (range, 19.5 to 23.5 mm). When the length of femoral tunnel was assumed as 25 mm and 30 mm, the optimal length of bone block was calculated as 19.6 mm (range, 17 to 21.5 mm) and 22.1 mm (range, 19.5 to 24 mm), respectively. On linear regression analysis, patients' height had a significant correlation with the length of tibial tunnel (p = 0.003), inter-tunnel distance (p = 0.014), and length of patellar tendon (p < 0.001).
CONCLUSIONS
Our results indicate that it would be mandatory to determine the optimal length of tibial tunnel in the modified TT technique for ACL reconstruction using the BPTB graft. Further large-scale, multi-center studies are warranted to establish our results.

Keyword

Anterior cruciate ligament reconstruction; Modified transtibial technique; Bone-patellar tendon-bone grafts; Graft-tunnel length mismatch; Bone block length

MeSH Terms

Anterior Cruciate Ligament Reconstruction*
Anterior Cruciate Ligament*
Body Mass Index
Bone-Patellar Tendon-Bone Grafts
Female
Humans
Knee
Linear Models
Male
Outcome Assessment (Health Care)
Patellar Ligament
Retrospective Studies
Tears
Transplants*

Figure

• 

  Fig. 1 A) Measurement of femoral tunnel (FT) length, inter-tunnel distance (IT), tibial tunnel (TT) length, and the total length (FT + IT + TT). (B) Tunnel length measurement was done using an arthroscopic ruler. (C) The tunnel length gauge was used to double-check the tunnel length.

• 

  Fig. 2 Ideal length of patellar bone block and tibial bone block of bone-patellar tendon-bone graft in anterior cruciate ligament reconstruction: [total tunnel length (femoral tunnel + inter-tunnel distance + tibial tunnel) − patellar tendon length] / 2.

Reference

1. Getelman MH, Friedman MJ. Revision anterior cruciate ligament reconstruction surgery. J Am Acad Orthop Surg. 1999; 7(3):189–198. PMID: 10346827.

2. Fineberg MS, Zarins B, Sherman OH. Practical considerations in anterior cruciate ligament replacement surgery. Arthroscopy. 2000; 16(7):715–724. PMID: 11027755.

3. Sommer C, Friederich NF, Muller W. Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc. 2000; 8(4):207–213. PMID: 10975260.

4. Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy. 2008; 24(1):113–115. PMID: 18188873.

5. Fu FH, van Eck CF, Tashman S, Irrgang JJ, Moreland MS. Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc. 2015; 23(3):640–648. PMID: 25086574.

6. Chhabra A, Diduch DR, Blessey PB, Miller MD. Recreating an acceptable angle of the tibial tunnel in the coronal plane in anterior cruciate ligament reconstruction using external landmarks. Arthroscopy. 2004; 20(3):328–330. PMID: 15007325.

7. Howell SM, Hull ML. Checkpoints for judging tunnel and anterior cruciate ligament graft placement. J Knee Surg. 2009; 22(2):161–170. PMID: 19476184.

8. Heming JF, Rand J, Steiner ME. Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med. 2007; 35(10):1708–1715. PMID: 17664343.

9. Shaffer B, Gow W, Tibone JE. Graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction: a new technique of intraarticular measurement and modified graft harvesting. Arthroscopy. 1993; 9(6):633–646. PMID: 8305099.

10. Spindler KP, Bergfeld JA, Andrish JT. Intraoperative complications of ACL surgery: avoidance and management. Orthopedics. 1993; 16(4):425–430. PMID: 8493148.

11. L'Insalata JC, Klatt B, Fu FH, Harner CD. Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc. 1997; 5(4):234–238. PMID: 9430573.

12. Lorenz S, Elser F, Mitterer M, Obst T, Imhoff AB. Radiologic evaluation of the insertion sites of the 2 functional bundles of the anterior cruciate ligament using 3-dimensional computed tomography. Am J Sports Med. 2009; 37(12):2368–2376. PMID: 19687513.

13. Denti M, Bigoni M, Randelli P, et al. Graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction: intraoperative and cadaver measurement of the intra-articular graft length and the length of the patellar tendon. Knee Surg Sports Traumatol Arthrosc. 1998; 6(3):165–168. PMID: 9704323.

14. Miller MD, Olszewski AD. Cruciate ligament graft intra-articular distances. Arthroscopy. 1997; 13(3):291–295. PMID: 9195023.

15. Kenna B, Simon TM, Jackson DW, Kurzweil PR. Endoscopic ACL reconstruction: a technical note on tunnel length for interference fixation. Arthroscopy. 1993; 9(2):228–230. PMID: 8461089.

16. Miller MD, Hinkin DT. The “N + 7 rule” for tibial tunnel placement in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1996; 12(1):124–126. PMID: 8838744.

17. Taylor DE, Dervin GF, Keene GC. Femoral bone plug recession in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1996; 12(4):513–515. PMID: 8864015.

18. Fowler BL, DiStefano VJ. Tibial tunnel bone grafting: a new technique for dealing with graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1998; 14(2):224–228. PMID: 9531138.

19. Morgan CD, Kalman VR, Grawl DM. Definitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy. 1995; 11(3):275–288. PMID: 7632302.

20. Grawe B, Smerina A, Allen A. Avoiding graft-tunnel length mismatch in anterior cruciate ligament reconstruction: the single-bone plug technique. Arthrosc Tech. 2014; 3(3):e417–e420. PMID: 25126515.

21. Auge WK 2nd, Yifan K. A technique for resolution of graft-tunnel length mismatch in central third bone-patellar tendon-bone anterior cruciate ligament reconstruction. Arthroscopy. 1999; 15(8):877–881. PMID: 10564869.

22. Hogerle S, Letsch R, Sievers KW. ACL reconstruction by patellar tendon: a comparison of length by magnetic resonance imaging. Arch Orthop Trauma Surg. 1998; 117(1-2):58–61. PMID: 9457339.

23. Brown JA, Brophy RH, Franco J, et al. Avoiding allograft length mismatch during anterior cruciate ligament reconstruction: patient height as an indicator of appropriate graft length. Am J Sports Med. 2007; 35(6):986–989. PMID: 17337725.

24. McAllister DR, Bergfeld JA, Parker RD, Grooff PN, Valdevit AD. A comparison of preoperative imaging techniques for predicting patellar tendon graft length before cruciate ligament reconstruction. Am J Sports Med. 2001; 29(4):461–465. PMID: 11476387.

25. Kopf S, Forsythe B, Wong AK, et al. Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. J Bone Joint Surg Am. 2010; 92(6):1427–1431. PMID: 20516318.