To map knee morphology radiographically in a population with a torn ACL and to investigate whether anatomic factors could be related to outcomes after ACL reconstruction at mid- to long-term follow-up. Further, we wanted to assess tibial tunnel placement after using the 70-degree “anti-impingement” tibial tunnel guide and investigate any relation between tunnel placement and revision surgery.
Patients undergoing ACL reconstruction involving the 70-degree tibial guide from 2003 to 2008 were included. Two independent investigators analysed pre- and post-operative radiographs. Demographic data and information on revision surgery were collected from an internal database. Anatomic factors and post-operative tibial tunnel placements were investigated as predictors of revision.
Three-hundred and seventy-seven patients were included in the study. A large anatomic variation with significant differences between men and women was seen. None of the anatomic factors could be related to a significant increase in revision rate. Patients with a posterior tibial tunnel placement, defined as 50 % or more posterior on the Amis and Jakob line, did, however, have a higher risk of revision surgery compared to patients with an anterior tunnel placement (P = 0.03).
Use of the 70-degree tibial guide did result in a high incidence (47 %) of posterior tibial tunnel placements associated with an increased rate of revision surgery. The current study was, however, not able to identify any anatomic variation that could be related to a higher risk of revision surgery. Avoiding graft impingement from the femoral roof in anterior tibial tunnel placements is important, but the insight that overly posterior tunnel placement can lead to inferior outcome should also be kept in mind when performing ACL surgery.
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Aglietti P, Buzzi R, Giron F, Simeone AJ, Zaccherotti G (1997) Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon. A 5–8-year follow-up. Knee Surg Sports Traumatol Arthrosc 5:138–144
Amis AA, Jakob RP (1998) Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 6:S2–12
Benjaminse A, Gokeler A, van der Schans CP (2006) Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 36:267–288
Berg EE (1992) Tibial bone plug nonunion: a cause of anterior cruciate ligament reconstructive failure. Arthroscopy 8:380–384
Bird JH, Carmont MR, Dhillon M, Smith N, Brown C, Thompson P, Spalding T (2011) Validation of a new technique to determine midbundle femoral tunnel position in anterior cruciate ligament reconstruction using 3-dimensional computed tomography analysis. Arthroscopy 27:1259–1267
Bracht H, Verhelst L, Stuyts B, Page B, Bellemans J, Verdonk P (2013) Anatomic single-bundle ACL surgery: consequences of tibial tunnel diameter and drill-guide angle on tibial footprint coverage. Knee Surg Sports Traumatol Arthrosc 22:1030–1039
Buzzi R, Zaccherotti G, Giron F, Aglietti P (1999) The relationship between the intercondylar roof and the tibial plateau with the knee in extension: relevance for tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy 15:625–631
Cuomo P, Edwards A, Giron F, Bull AMJ, Amis AA, Aglietti P (2006) Validation of the 65° Howell guide for anterior cruciate ligament reconstruction. Arthroscopy 22:70–75
Crawford NS, Waterman BR, Lubowitz JH (2013) Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy 29:1566–1571
Haasper C, Kopf S, Lorenz S, Middleton KK, Tashman S, Fu FH (2013) Influence of tibial rotation on tibial tunnel position measurements using lateral fluoroscopy in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23:649–654
Howell SM (1998) Principles for placing the tibial tunnel and avoiding roof impingement during reconstruction of a torn anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 6(Suppl 1):S49–S55
Howell SM, Barad SJ (1995) Knee extension and its relationship to the slope of the intercondylar roof. Implications for positioning the tibial tunnel in anterior cruciate ligament reconstructions. Am J Sports Med 23:288–294
Howell SM, Taylor MA (1993) Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. J Bone Joint Surg Am 75:1044–1055
Howell SM, Wallace MP, Hull ML, Deutsch ML (1999) Evaluation of the single-incision arthroscopic technique for anterior cruciate ligament replacement. A study of tibial tunnel placement, intraoperative graft tension, and stability. Am J Sports Med 27:284–293
Hwang MD, Piefer JW, Lubowitz JH (2012) Anterior cruciate ligament tibial footprint anatomy: systematic review of the 21st century literature. Arthroscopy 28:728–734
Inderhaug E, Larsen A, Strand T, Waaler PA, Solheim E (2014) The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3858-3
Inderhaug E, Strand T, Fischer-Bredenbeck C, Solheim E (2013) Effect of a too posterior placement of the tibial tunnel on the outcome 10–12 years after anterior cruciate ligament reconstruction using the 70-degree tibial guide. Knee Surg Sports Traumatol Arthrosc 22:1182–1189
Iriuchishima T, Horaguchi T, Kubomura T, Morimoto Y, Fu FH (2011) Evaluation of the intercondylar roof impingement after anatomical double-bundle anterior cruciate ligament reconstruction using 3D-CT. Knee Surg Sports Traumatol Arthrosc 19:674–679
Jagodzinski M, Richter GM, Pässler HH (2014) 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
Leiter JRS, de Korompay N, Macdonald L, McRae S, Froese W, Macdonald PB (2011) Reliability of tunnel angle in ACL reconstruction: two-dimensional versus three-dimensional guide technique. Knee Surg Sports Traumatol Arthrosc 19:1258–1264
Margier J, Tchouda SD, Banihachemi J-J, Bosson J-L, Plaweski S (2014) Computer-assisted navigation in ACL reconstruction is attractive but not yet cost efficient. Knee Surg Sports Traumatol Arthrosc 23:1026–1034
Moloney G, Araujo P, Rabuck S, Carey R, Rincon G, Zhang X, Harner C (2013) Use of a fluoroscopic overlay to assist arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med 41:1794–1800
Morgan J, Dahm D, Levy B, Stuart M, The MARS Study Group (2012) Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg 25:361–368
Owens BD (2013) Location, location, location. Am J Sports Med 41:2481–2483
Pinczewski LA, Salmon LJ, Jackson WFM, von Bormann RBP, Haslam PG, Tashiro S (2008) Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 90:172–179
Scheffel PT, Henninger HB, Burks RT (2013) Relationship of the intercondylar roof and the tibial footprint of the ACL: implications for ACL reconstruction. Am J Sports Med 41:396–401
Silva A, Sampaio R, Pinto E (2011) ACL reconstruction: comparison between transtibial and anteromedial portal techniques. Knee Surg Sports Traumatol Arthrosc 20:896–903
Stäubli 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 2:138–146
Conflict of interest
The authors declare that they have no conflict of interest.
There is no funding source.
The regional ethical committee reviewed and approved the study (REK Helse Vest, REK ID:3366)
Informed consent has been collected from the patients.
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Inderhaug, E., Raknes, S., Østvold, T. et al. Increased revision rate with posterior tibial tunnel placement after using the 70-degree tibial guide in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 25, 152–158 (2017). https://doi.org/10.1007/s00167-016-4341-5
- Anterior cruciate ligament reconstruction
- 70-Degree tibial guide