High risk of tunnel convergence during combined anterior cruciate ligament and anterolateral ligament reconstruction
To assess the risk of femoral tunnel convergence in combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstructions. The hypothesis was that a more proximal and anterior orientation of the ALL femoral tunnel should reduce the risk of convergence with the ACL femoral tunnel.
15 fresh-frozen cadaver knees were examined. An anatomic ACL femoral tunnel was drilled arthroscopically in each specimen and ALL tunnels were made in two directions: (1) 0° coronal angulation and 20° axial angulation, (2) 30° coronal angulation and 30° axial angulation. Computed tomography scans were performed to investigate tunnel convergence and to measure the minimal distance between tunnels, tunnel length and the LFC width.
Tunnel convergence occurred in 20 of 30 cases (67%). Convergence was significantly reduced when tunnels were drilled at 30° coronal and 30° axial angulation (p < 0.05). The mean length of the ALL tunnel was 15.9 mm [95% CI (13.6; 18.1)] and was independent of ALL tunnel angulation. The mean minimal distance between the ALL and ACL tunnel was 3.1 mm [95% CI (2.1; 4.1)]. The odds ratio for tunnel convergence was 3.5 for small LFC, relative to large LFC (n.s.)
A high risk of tunnel convergence was observed when performing combined ACL and ALL reconstructions. The clinical relevance of this work is that the occurrence of tunnel conflicts can be reduced by aiming the ALL tunnel in a more proximal and anterior direction. Surgeons should be aware of this, since tunnel convergence could jeopardize the ACL reconstruction and fixation.
KeywordsKnee Anterior cruciate ligament Anterolateral ligament Reconstruction Tunnel convergence
The authors thank Senne Van de Bempt and Maarten Verheyden for their help with the drilling of femoral tunnels on human cadavers.
No funding was received.
Compliance with ethical standards
Conflict of interest
All authors declare that they have no conflict of interest.
The study was approved by the Institutional Review Board.
- 12.Gelber PE, Erquicia J, Abat F, Torres R, Pelfort X, Rodriguez-Baeza A, Alomar X, Monllau JC (2011) Effectiveness of a footprint guide to establish an anatomic femoral tunnel in anterior cruciate ligament reconstruction: computed tomography evaluation in a cadaveric model. Arthroscopy 27:817–824CrossRefPubMedGoogle Scholar
- 13.Gelber PE, Erquicia JI, Sosa G, Ferrer G, Abat F, Rodriguez-Baeza A, Segura-Cros C, Monllau JC (2013) Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model. Arthroscopy 29:257–265CrossRefPubMedGoogle Scholar
- 18.Karikis I, Desai N, Sernert N, Rostgard-Christensen L, Kartus J (2016) Comparison of anatomic double- and single-bundle techniques for anterior cruciate ligament reconstruction using hamstring tendon autografts: a prospective randomized study with 5-year clinical and radiographic follow-up. Am J Sports Med 44:1225–1236CrossRefPubMedGoogle Scholar
- 22.Kraeutler MJ, Welton KL, Chahla J, LaPrade RF, McCarty EC (2017) Current concepts of the anterolateral ligament of the knee: anatomy, biomechanics, and reconstruction. Am J Sports Med. https://doi.org/10.1177/0363546517701920:363546517701920 Google Scholar
- 24.Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. 2002 Richard O’Connor Award paper. Arthroscopy 19:297–304CrossRefPubMedGoogle Scholar
- 30.Nitri M, Rasmussen MT, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, LaPrade RF (2016) An in vitro robotic assessment of the anterolateral ligament, part 2: anterolateral ligament reconstruction combined with anterior cruciate ligament reconstruction. Am J Sports Med 44:593–601CrossRefPubMedGoogle Scholar
- 37.Sonnery-Cottet B, Daggett M, Fayard JM, Ferretti A, Helito CP, Lind M, Monaco E, de Padua VB, Thaunat M, Wilson A, Zaffagnini S, Zijl J, Claes S (2017) Anterolateral ligament expert group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament—deficient knee. J Orthop Traumatol. https://doi.org/10.1007/s10195-017-0449-8 PubMedPubMedCentralGoogle Scholar
- 39.Sonnery-Cottet B, Saithna A, Blakeney WG, Ouanezar H, Borade A, Daggett M, Thaunat M, Fayard JM, Delaloye JR (2018) Anterolateral ligament reconstruction protects the repaired medial meniscus: a comparative study of 383 anterior cruciate ligament reconstructions from the SANTI study group with a minimum follow-up of 2 years. Am J Sports Med 46:1819–1826CrossRefPubMedGoogle Scholar
- 40.Sonnery-Cottet B, Saithna A, Cavalier M, Kajetanek C, Temponi EF, Daggett M, Helito CP, Thaunat M (2017) Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med 45:1547–1557CrossRefPubMedGoogle Scholar
- 45.Thompson SM, Salmon LJ, Waller A, Linklater J, Roe JP, Pinczewski LA (2016) Twenty-year outcome of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft. Am J Sports Med 44:3083–3094CrossRefPubMedGoogle Scholar