Objectives

Our aim was to assess the use of intra-operative fluoroscopy in the assessment of the position of the tibial tunnel during reconstruction of the anterior cruciate ligament (ACL).

Abstract. The radiographic or bony landmark techniques are the two most common methods to determine Medial patellofemoral ligament (MPFL) femoral tunnel placement. Their intra/inter-observer reliability is widely debated. The palpation technique relies on identifying the medial epicondyle (ME) and adductor Tubercle (AT). The central longitudinal artery and associated vessels (CLV) are consistently seen in the surgical dissection during MPFL reconstruction. The aim of this study was to investigate the anatomic relationship of CLV to ME-AT and thereby use CLV as an important vascular landmark during MPFL reconstruction. A retrospective review of MRI scans in skeletally mature patients presenting to a tertiary referral knee clinic was undertaken. Group-N consisted of any presentation without patellofemoral instability or malalignment (PFI). Group-P with PFI. MRI's were reviewed and measured by two Consultant Radiologists for the CLV-ME-AT anatomy and relationship. Following exclusions 50 patients were identified in each group. The CLV passed anterior to the AT and ME in all patients. ME morphology did not differ greatly between the groups except in the tubercle height, where there was a statically but not clinically significant difference (larger in the non-PFI group, 2.95mm vs 2.52mm, p=0.002). The CLV to ME Tip distance was consistent between the groups (Group PFI group 3.8mm & ‘normal’ non-PFI Group 3.9mm). The CLV-ME-AT relationship remained consistent despite patients presenting pathology. The CLV consistently courses anterior to ME and AT. The CLV could be used as a vascular landmark assisting femoral tunnel placement during MPFL reconstruction

The outcome following arthroscopic anterior cruciate (ACL) reconstruction is dependant on a combination of surgical and non-surgical factors. Technical error is the commonest cause for graft failure, with poor tunnel placement accounting for over 80% of those errors. A routine audit of femoral and tibial tunnel positions following single bundle hamstring arthroscopic ACL reconstruction identified apparent inconsistent positioning of the tibial tunnel in the sagittal plane. Intra-operative fluoroscopy was therefore introduced (when available) to verify tibial guide wire position prior to tunnel reaming. This paper reports a comparison of tibial interference screw position measured on post-operative radiographs with known tunnel position as shown on intra-operative fluoroscopic images in 20 patients undergoing routine primary ACL reconstruction between January and June 2009. Surgery took a mean of 5 minutes longer when intra-operative fluoroscopy was used. In 3/20 patients, fluoroscopy led to re-positioning of the tibial guide wire prior to tunnel reaming. The mean tibial tunnel position as indicated by the tunnel reamer was 41 +/− 2.7 % of the total plateau depth (range 37% to 47%). The mean position projected from the tibial screw on post operative radiographs was 46 +/− 9.2% (range 38% to 76%). A paired t-test showed a significant difference (p = 0.022) between true tunnel position and tibial screw position. 6/20 patients had post operative screw positions that were > 5% more posterior than the known position of the tibial tunnel. The position of the tunnel should be measured at its mid-point where this is evident. On most early radiographic images, the margins of the tunnel are not clear and therefore a line projected from the centre of the screw is used. This audit demonstrates the potential inaccuracy associated with this

Purpose. The purpose of this study was to determine whether intra-operative identification of osseous ridge anatomy (lateral intercondylar “residents” ridge and lateral bifurcate ridge) could be used to reliably define and reconstruct individuals' native femoral ACL attachments in both single-bundle (SB) and double-bundle (DB) cases. Methods. Pre-and Post-operative 3D, surface rendered, CT reconstructions of the lateral intercondylar notch were obtained for 15 patients undergoing ACL reconstruction (11 Single bundle, 4 Double-bundle or Isolated bundle augmentations). Morphology of native ACL femoral attachment was defined from ridge anatomy on the pre-operative scans. Centre's of the ACL attachment, AM and PL bundles were recorded using the Bernard grid and Amis' circle methods. During reconstruction soft tissue was carefully removed from the lateral notch wall with RF coblation to preserve and visualise osseous ridge anatomy. For SB reconstructions the femoral tunnel was sited centrally on the lateral bifurcate ridge, equidistant between the lateral intercondylar ridge and posterior cartilage margin. For DB reconstructions tunnels were located either side of the bifurcate ridge, leaving a 2mm bony bridge. Post-operative 3D CTs were obtained within 6 weeks post-op to correlate tunnel positions with pre-op native morphology. Results. Pre-op native ACL attachment site morphology was very similar to previous in-vitro studies: the mean centre was found at 27% along Blumensaat's line (range 19-33%) and 38% the width of the lateral femoral condyle (range 31-43%). Despite the variability between individuals there was close correlation between pre-operative localization of the femoral attachment centre and position of single bundle ACL reconstructions tunnels on the post-op CT (R=0.92). Similar results were observed for double-bundle and isolated bundle augment reconstructions. Conclusion. ACL attachment site morphology varies between individuals. Intra-operative localization of the osseous landmarks (lateral intercondylar and bifurcate ridges) appears to lead to accurate, individualised anatomical tunnel placement whether using single or double-bundle reconstruction techniques

Anterior cruciate ligament (ACL) reconstruction is commonly performed and has been for many years. Despite this, the technical details related to ACL anatomy, such as tunnel placement, are still a topic for debate. In this paper, we introduce the flat ribbon concept of the anatomy of the ACL, and its relevance to clinical practice. Cite this article: Bone Joint J 2016;98-B:1020–6

The Oxford unicompartmental knee replacement (UKR) is an established treatment option in the management of symptomatic end-stage medial compartmental osteoarthritis (MCOA), which works well in the young and active patient. However, previous studies have shown that it is reliable only in the presence of a functionally intact anterior cruciate ligament (ACL). This review reports the outcomes, at a mean of five years and a maximum of ten years, of 52 consecutive patients with a mean age of 51 years (36 to 57) who underwent staged or simultaneous ACL reconstruction and Oxford UKR. At the last follow-up (with one patient lost to follow-up), the mean Oxford knee score was 41 (. sd. 6.3; 17 to 48). Two patients required conversion to TKR: one for progression of lateral compartment osteoarthritis and one for infection. Implant survival at five years was 93% (95% CI 83 to 100). All but one patient reported being satisfied with the procedure. The outcome was not significantly influenced by age, gender, femoral or tibial tunnel placement, or whether the procedure was undertaken at one- or two-stages. In summary, ACL reconstruction and Oxford UKR gives good results in patients with end-stage MCOA secondary to ACL deficiency

Animal studies have shown that implanted anterior cruciate ligament (ACL) grafts initially undergo a process of revascularisation prior to remodelling, ultimately increasing mechanical strength. We investigated whether minimal debridement of the intercondylar notch and the residual stump of the ruptured ACL leads to earlier revascularisation in ACL reconstruction in humans. We undertook a randomised controlled clinical trial in which 49 patients underwent ACL reconstruction using autologous four-strand hamstring tendon grafts. Randomised by the use of sealed envelopes, 25 patients had a conventional clearance of the intercondylar notch and 24 had a minimal debridement method. Three patients were excluded from the study. All patients underwent MR scanning postoperatively at 2, 6 and 12 months, together with clinical assessment using a KT-1000 arthrometer and International Knee Documentation Committee (IKDC) evaluation. All observations were made by investigators blinded to the surgical technique. Signal intensity was measured in 4 mm diameter regions of interest along the ACL graft and the mid-substance of the posterior cruciate ligament. Our results indicate that minimal debridement leads to earlier revascularisation within the mid-substance of the ACL graft at two months (paired t-test, p = 0.002). There was a significant reduction of mid-substance signal six months after the minimal debridement technique (paired t-test, p = 0.00007). No statistically significant differences were found in tunnel placement, incidence of Cyclops lesions, blood loss, IKDC scores, range of movement or Lachman test between the two groups

The aim of this study was to determine current practice in anterior cruciate ligament reconstruction amongst BASK members. This was an internet-based survey where members were invited to complete a questionnaire on ACL reconstruction. Of the 365 BASK surgeons performing ACL reconstruction, 241 completed the questionnaire (response rate 66%). 147(61%) of surgeons used both hamstring and patellar tendon grafts, 71(29%) used only hamstrings and 21(9%) used patellar tendon only. All surgeons used ipsilateral autograft. 157 (65%) used the transtibial technique for femoral tunnel placement with 80(33%) using the anteromedial portal technique. Of those using the anteromedial portal, the most common femoral fixation devices were the Endobutton (34%) and RCI screw (34%). Interference screw fixation (81%) was the most common tibial fixation in the same group of surgeons with the RCI screw being the most common (63%). 19% (45/241) of surgeons were performing double bundle ACL reconstructions in select cases. Hamstring femoral fixation was with a suspension device in 79% and interference screw in 18%. Of those using a suspension device the Endobutton was most common (48%) followed by Transfix (26%) and Rigidfix (19%). Tibial fixation was most commonly achieved by interference screw (57%) followed by Intrafix (30%). With patellar tendon graft the most popular femoral fixation was with an interference screw (66%) followed by suspension (34%). All surgeons used interference screw for tibial fixation. 90% of surgeons (217) allow immediate full weight-bearing as tolerated irrespective of fixation type with 8% delaying full weight bearing between 1 and 3 weeks. The results show the wide spread of variation in practice of ACL reconstruction. With recent renewed interest in a more anatomic placement of tunnels, the use of the anteromedial portal may continue to increase. With such a wide variation in techniques, grafts and fixation implants used, a register may help assess outcomes

The purpose of this study was to report the outcome of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with ‘isolated’ ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time.

ACL reconstructive surgery in patients with an ‘isolated’ rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis.

There is little evidence examining the relationship between anatomical landmarks, radiological placement of the tunnels and long-term clinical outcomes following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to investigate the reproducibility of intra-operative landmarks for placement of the tunnels in single-bundle reconstruction of the ACL using four-strand hamstring tendon autografts.

Isolated reconstruction of the ACL was performed in 200 patients, who were followed prospectively for seven years with use of the International Knee Documentation Committee forms and radiographs. Taking 0% as the anterior and 100% as the posterior extent, the femoral tunnel was a mean of 86% (sd 5) along Blumensaat’s line and the tibial tunnel was 48% (sd 5) along the tibial plateau. Taking 0% as the medial and 100% as the lateral extent, the tibial tunnel was 46% (sd 3) across the tibial plateau and the mean inclination of the graft in the coronal plane was 19° (sd 5.5).

The use of intra-operative landmarks resulted in reproducible placement of the tunnels and an excellent clinical outcome seven years after operation. Vertical inclination was associated with increased rotational instability and degenerative radiological changes, while rupture of the graft was associated with posterior placement of the tibial tunnel. If the osseous tunnels are correctly placed, single-bundle reconstruction of the ACL adequately controls both anteroposterior and rotational instability.

Graft-tunnel mismatch of the bone-patellar tendon-bone (BPTB) graft is a major concern during anatomical anterior cruciate ligament (ACL) reconstruction if the femoral tunnel is positioned using a far medial portal technique, as the femoral tunnel tends to be shorter compared with that positioned using a transtibial portal technique. This study describes an accurate method of calculating the ideal length of bone plugs of a BPTB graft required to avoid graft–tunnel mismatch during anatomical ACL reconstruction using a far medial portal technique of femoral tunnel positioning.

Based on data obtained intra-operatively from 60 anatomical ACL reconstruction procedures, we calculated the length of bone plugs required in the BPTB graft to avoid graft–tunnel mismatch. When this was prevented in all the 60 cases, we found that the mean length of femoral bone plug that remained in contact with the interference screw within the femoral tunnel was 14 mm (12 to 22) and the mean length of tibial bone plug that remained in contact with the interference screw within the tibial tunnel was 23 mm (18 to 28). These results were used to validate theoretical formulae developed to predict the required length of bone plugs in BPTB graft during anatomical ACL reconstruction using a far medial portal technique.

Cite this article: Bone Joint J 2015;97-B:324–8.

We reviewed 87 patients who underwent revision reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the interval between failure of the primary graft and revision reconstruction. Patients were divided into two groups: early revision surgery within six months of graft failure, and delayed revision. Degenerative change was scored using the French Society of Arthroscopy system.

There was a significantly higher incidence of articular cartilage degeneration in the delayed group (Mann-Whitney U-test, 53.2% vs 24%, p < 0.01). No patient in the early group had advanced degenerative change, compared to 9.2% of patients in the delayed group. There was no significant difference (Mann-Whitney U-test, p = 0.3) in the incidence of meniscal tears between the two groups.

We conclude that revision reconstruction should be carried out within six months of primary graft failure, in order to minimise the risk of degenerative change.

The potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally-immature patients is well documented, but we are not aware of literature on the subject of the fate of the graft itself. We have reviewed five adolescent males who underwent reconstruction of the ligament with four-strand hamstring grafts using MR images taken at a mean of 34.6 months (18 to 58) from the time of operation. The changes in dimension of the graft were measured and compared with those taken at the original operation. No growth arrest was seen on radiological or clinical measurement of leg-length discrepancy, nor was there any soft-tissue contracture. All the patients regained their pre-injury level of activity, including elite-level sport in three. The patients grew by a mean of 17.3 cm (14 to 24). The diameter of the grafts did not change despite large increases in length (mean 42%; 33% to 57%). Most of the gain in length was on the femoral side. Large changes in the length of the grafts were seen.

There is a considerable increase in the size of the graft, so some neogenesis must occur; the graft must grow.