Tunnel placement in anterior cruciate ligament (ACL) reconstruction: quality control in a teaching hospital

Correct placement of the femoral and tibial bone tunnels is decisive for a successful anterior cruciate ligament (ACL) reconstruction. Our method of tunnel placement was evaluated as part of quality control at a teaching hospital. The emphasis was placed mainly on investigating the influence of surgical experience on tunnel placement, and the effect of tunnel position on the clinical outcome. Seventeen surgeons with different levels of experience (between 0 and >150 ACL reconstructions) performed endoscopic ACL repair in uniform technique from August 2000 to August 2003 on 50 patients (18 women, 32 men, age range 18–43 years). The patients were available to clinical and radiological follow-up after an average of 19 months. The clinical outcome was classified according to the International Knee Documentation Committee (IKDC) standard evaluation form. The femoral tunnel was evaluated according to the quadrant method of Bernard and Hertel; the position of the tibial bone tunnel was assessed according to the criteria of Stäubli and Rauschnig. The IKDC score revealed 47 (94%) patients with a normal (A) or nearly normal (B) knee joint at follow-up. According to the quadrant method, the femoral canal was situated on average at 29% in the saggital plane. The tibial tunnel was situated on average at 43% of the a.p. diameter of the tibial condyle. Statistical analysis of our data showed no significant correlation between tunnel placement and surgical expertise. However, a highly significant correlation was found (α<0.01) between the femoral position of the tunnel in the sagittal plane and the IKDC score. The more anterior the femoral canal, the poorer the IKDC score. The method of tunnel placement in ACL reconstruction being investigated here only showed slight dependence on surgical experience, whereby good short-term clinical outcomes were achieved. Therefore, the method is suitable for application at a teaching hospital. A far too anterior femoral tunnel placement will probably lead to a decline in the clinical result.

[1]  Jacques Menetrey,et al.  Current Trends in Anterior Cruciate Ligament Reconstruction , 2000, The American journal of sports medicine.

[2]  W. Müller,et al.  Das Knie : Form, Funktion und ligamentäre Wiederherstellungschirurgie , 1982 .

[3]  E S Grood,et al.  Factors affecting the region of most isometric femoral attachments , 1989, The American journal of sports medicine.

[4]  C. Topliss,et al.  An audit of tunnel position in anterior cruciate ligament reconstruction. , 2001, The Knee.

[5]  V. Musahl,et al.  ACL reconstruction using bone-patellar tendon-bone press-fit fixation: 10-year clinical results , 2005, Knee Surgery, Sports Traumatology, Arthroscopy.

[6]  L. Pinczewski,et al.  Arthroscopic reconstruction of the anterior cruciate ligament with patellar-tendon autograft and interference screw fixation. The results at seven years. , 1999, The Journal of bone and joint surgery. British volume.

[7]  C. Fink,et al.  VKB-Plastik: Positionierung des Transplantats , 2005, Arthroskopie.

[8]  M. Bernard,et al.  Femoral insertion of the ACL. Radiographic quadrant method. , 1997, The American journal of knee surgery.

[9]  L. Blankevoort,et al.  Proceedings of the ESSKA Scientific Workshop on Reconstruction of the Anterior and Posterior Cruciate Ligaments , 2005, Knee Surgery, Sports Traumatology, Arthroscopy.

[10]  Hans H. Pässler,et al.  Intraoperative Qualitätskontrolle bei der Bohrkanalplatzierung zum vorderen Kreuzbandersatz , 2004, Der Unfallchirurg.

[11]  J. Carls,et al.  Drill hole position in endoscopic anterior cruciate ligament reconstruction Results of an advanced arthroscopy course , 1998, Knee Surgery, Sports Traumatology, Arthroscopy.

[12]  K. Markolf,et al.  Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft , 2002, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[13]  K. Benedetto,et al.  Langzeitergebnisse nach konservativer oder operativer Therapie der vorderen Kreuzbandruptur , 1996, Der Unfallchirurg.

[15]  Freddie H. Fu,et al.  Use of the International Knee Documentation Committee guidelines to assess outcome following anterior cruciate ligament reconstruction , 1998, Knee Surgery, Sports Traumatology, Arthroscopy.

[16]  P. Aglietti,et al.  Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon A 5–8-year follow-up , 1997, Knee Surgery, Sports Traumatology, Arthroscopy.

[17]  Freddie H. Fu,et al.  Varying Femoral Tunnels between the Anatomical Footprint and Isometric Positions , 2005, The American journal of sports medicine.

[18]  Freddie H. Fu,et al.  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. , 2003, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

[19]  Niklaus F. Friederich,et al.  Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results , 2000, Knee Surgery, Sports Traumatology, Arthroscopy.

[20]  H. Stäubli,et al.  Tibial attachment area of the anterior cruciate ligament in the extended knee position , 1994, Knee Surgery, Sports Traumatology, Arthroscopy.

[21]  J. Agneskirchner,et al.  Qualitätssicherung in der Kreuzbandchirurgie , 2003, Arthroskopie.

[22]  J. Eichhorn,et al.  Computerassistierte Rekonstruktion des vorderen Kreuzbandes mit dem Navigationssystem , 2005, Arthroskopie.

[23]  Freddie H. Fu,et al.  In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads , 1997, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[24]  J. Gillquist,et al.  Arthroscopic reconstruction of the anterior cruciate ligament. , 1988, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

[25]  J. Höher,et al.  [Intraoperative quality control of the placement of bone tunnels for the anterior cruciate ligament]. , 2004, Der Unfallchirurg.

[26]  M. L. Hull,et al.  Effect of the Angle of the Femoral and Tibial Tunnels in the Coronal Plane and Incremental Excision of the Posterior Cruciate Ligament on Tension of an Anterior Cruciate Ligament Graft: An in Vitro Study , 2003, The Journal of bone and joint surgery. American volume.

[27]  A. A. Amis,et al.  Anterior cruciate ligament graft positioning, tensioning and twisting , 1998, Knee Surgery, Sports Traumatology, Arthroscopy.

[28]  D. Deehan,et al.  Endoscopic reconstruction of the anterior cruciate ligament with an ipsilateral patellar tendon autograft. A prospective longitudinal five-year study. , 2000, The Journal of bone and joint surgery. British volume.