Download PDF
J Knee Surg 2014; 27(04): 309-318
DOI: 10.1055/s-0033-1364101
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Anterior Cruciate Ligament Tunnel Placement

Brian R. Wolf
1   Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
,
Austin J. Ramme
2   Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa
,
Carla L. Britton
1   Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
,
Annunziato Amendola
1   Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
,
MOON Knee Group › Author Affiliations
Further Information

Publication History

06 September 2013

19 November 2013

Publication Date:
10 January 2014 (online)

    Permissions and Reprints

Abstract

The purpose of this cadaveric study was to analyze variation in anterior cruciate ligament (ACL) tunnel placement between surgeons and the influence of preferred surgical technique and surgeon experience level using three-dimensional (3D) computed tomography (CT). In this study, 12 surgeons drilled ACL tunnels on six cadaveric knees each. Surgeons were divided by experience level and preferred surgical technique (two-incision [TI], medial portal [MP], and transtibial [TT]). ACL tunnel aperture locations were analyzed using 3D CT scans and compared with radiographic ACL footprint criteria. The femoral tunnel location from front to back within the notch demonstrated a range of means of 16% with the TI tunnels the furthest back. A range of means of only 5% was found for femoral tunnel low to high positions by technique. The anterior to posterior tibial tunnel measure demonstrated wider variation than the medial to lateral position. The mean tibial tunnel location drilled by TT surgeons was more posterior than surgeons using the other techniques. Overall, 82% of femoral tunnels and 78% of tibial tunnels met all radiographic measurement criteria. Slight (1–7%) differences in mean tunnel placement on the femur and tibia were found between experienced and new surgeons. The location of the femoral tunnel aperture in the front to back plane relative to the notch roof and the anterior to posterior position on the tibia were the most variable measures. Surgeon experience level did not appear to significantly affect tunnel location. This study provides background information that may be beneficial when evaluating multisurgeon and multicenter collaborative ACL studies.

Keywords

anterior cruciate ligament reconstruction - femoral drilling technique - tunnel placement variability - CT imaging - ACL - surgeon experience
 

  • References

  • 1 Hardin GT, Bach Jr BR, Bush-Joseph CA, Farr J. Endoscopic single-incision anterior cruciate ligament reconstruction using patellar tendon autograft: surgical technique. 1992 [classical article]. J Knee Surg 2003; 16 (3) 135-144 , discussion 145–147
    PubMedGoogle Scholar
  • 2 Hewson Jr GF. Drill guides for improving accuracy in anterior cruciate ligament repair and reconstruction. Clin Orthop Relat Res 1983; (172) 119-124
    PubMedGoogle Scholar
  • 3 O'Donnell JB, Scerpella TA. Endoscopic anterior cruciate ligament reconstruction: modified technique and radiographic review. Arthroscopy 1995; 11 (5) 577-584
    CrossrefPubMedGoogle Scholar
  • 4 Dunn WR, Spindler KP ; MOON Consortium. Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): a Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study. Am J Sports Med 2010; 38 (10) 2040-2050
    CrossrefPubMedGoogle Scholar
  • 5 Howe JG, Johnson RJ, Kaplan MJ, Fleming B, Jarvinen M. Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I. Long-term followup. Am J Sports Med 1991; 19 (5) 447-457
    CrossrefPubMedGoogle Scholar
  • 6 Kaplan MJ, Howe JG, Fleming B, Johnson RJ, Jarvinen M. Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part II. A specific sport review. Am J Sports Med 1991; 19 (5) 458-462
    CrossrefPubMedGoogle Scholar
  • 7 Spindler KP, Huston LJ, Wright RW , et al; MOON Group. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. Am J Sports Med 2011; 39 (2) 348-359
    CrossrefPubMedGoogle Scholar
  • 8 Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum EB. The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med 1996; 24 (3) 335-341
    CrossrefPubMedGoogle Scholar
  • 9 Sommer C, Friederich NF, Müller W. Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 2000; 8 (4) 207-213
    Google Scholar
  • 10 Dunn WR, Spindler KP, Amendola A , et al; MOON ACL Investigation. Which preoperative factors, including bone bruise, are associated with knee pain/symptoms at index anterior cruciate ligament reconstruction (ACLR)? A Multicenter Orthopaedic Outcomes Network (MOON) ACLR Cohort Study. Am J Sports Med 2010; 38 (9) 1778-1787
    CrossrefPubMedGoogle Scholar
  • 11 Magnussen RA, Granan LP, Dunn WR , et al. Cross-cultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surg Sports Traumatol Arthrosc 2010; 18 (1) 98-105
    CrossrefPubMedGoogle Scholar
  • 12 Toman CV, Dunn WR, Spindler KP , et al. Success of meniscal repair at anterior cruciate ligament reconstruction. Am J Sports Med 2009; 37 (6) 1111-1115
    Google Scholar
  • 13 Wright RW, Dunn WR, Amendola A , et al. Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate ligament graft during the first 2 years after anterior cruciate ligament reconstruction: a prospective MOON cohort study. Am J Sports Med 2007; 35 (7) 1131-1134
    CrossrefPubMedGoogle Scholar
  • 14 Giron F, Buzzi R, Aglietti P. Femoral tunnel position in anterior cruciate ligament reconstruction using three techniques. A cadaver study. Arthroscopy 1999; 15 (7) 750-756
    CrossrefPubMedGoogle Scholar
  • 15 Magnotta VA, Harris G, Andreasen NC, O'Leary DS, Yuh WT, Heckel D. Structural MR image processing using the BRAINS2 toolbox. Comput Med Imaging Graph 2002; 26 (4) 251-264
    CrossrefPubMedGoogle Scholar
  • 16 Ramme AJ, Criswell AJ, Wolf BR, Magnotta VA, Grosland NM. EM segmentation of the distal femur and proximal tibia: a high-throughput approach to anatomic surface generation. Ann Biomed Eng 2011; 39 (5) 1555-1562
    CrossrefPubMedGoogle Scholar
  • 17 Tadepalli SC, Shivanna KH, Magnotta VA, Kallemeyn NA, Grosland NM. Toward the development of virtual surgical tools to aid orthopaedic FE analyses. EURASIP J Adv Signal Process 2010; 2010: 1902931-1902937
    PubMedGoogle Scholar
  • 18 Ramme AJ, Wolf BR, Warme BA , et al. Surgically oriented measurements for three-dimensional characterization of tunnel placement in anterior cruciate ligament reconstruction. Comput Aided Surg 2012; 17 (5) 221-231
    CrossrefPubMedGoogle Scholar
  • 19 McConkey MO, Amendola A, Ramme AJ , et al; MOON Knee Group. Arthroscopic agreement among surgeons on anterior cruciate ligament tunnel placement. Am J Sports Med 2012; 40 (12) 2737-2746
    CrossrefPubMedGoogle Scholar
  • 20 Bernard M, Hertel P, Hornung H, Cierpinski T. Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 1997; 10 (1) 14-21 , discussion 21–22
    PubMedGoogle Scholar
  • 21 Forsythe B, Kopf S, Wong AK , et al. The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models. J Bone Joint Surg Am 2010; 92 (6) 1418-1426
    CrossrefPubMedGoogle Scholar
  • 22 Howell SM, Barad SJ. 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 1995; 23 (3) 288-294
    CrossrefPubMedGoogle Scholar
  • 23 Colombet P, Robinson J, Christel P , et al. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 2006; 22 (9) 984-992
    CrossrefPubMedGoogle Scholar
  • 24 Doi M, Takahashi M, Abe M, Suzuki D, Nagano A. Lateral radiographic study of the tibial sagital insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2009; 17 (4) 347-351
    CrossrefPubMedGoogle Scholar
  • 25 Edwards A, Bull AM, Amis AA. The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament: Part 1: tibial attachment. Knee Surg Sports Traumatol Arthrosc 2007; 15 (12) 1414-1421
    Google Scholar
  • 26 Lintner DM, Dewitt SE, Moseley JB. Radiographic evaluation of native anterior cruciate ligament attachments and graft placement for reconstruction. A cadaveric study. Am J Sports Med 1996; 24 (1) 72-78
    CrossrefPubMedGoogle Scholar
  • 27 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
    CrossrefPubMedGoogle Scholar
  • 28 Morgan JA, Dahm D, Levy B, Stuart MJ ; MARS Study Group. Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg 2012; 25 (5) 361-368
    Google Scholar
  • 29 Spindler KP, Parker RD, Andrish JT , et al; MOON Group. Prognosis and predictors of ACL reconstructions using the MOON cohort: a model for comparative effectiveness studies. J Orthop Res 2013; 31 (1) 2-9
    CrossrefPubMedGoogle Scholar
  • 30 Ahldén M, Samuelsson K, Sernert N, Forssblad M, Karlsson J, Kartus J. The Swedish National Anterior Cruciate Ligament Register: a report on baseline variables and outcomes of surgery for almost 18,000 patients. Am J Sports Med 2012; 40 (10) 2230-2235
    CrossrefPubMedGoogle Scholar
  • 31 Granan LP, Bahr R, Steindal K, Furnes O, Engebretsen L. Development of a national cruciate ligament surgery registry: the Norwegian National Knee Ligament Registry. Am J Sports Med 2008; 36 (2) 308-315
    CrossrefPubMedGoogle Scholar
  • 32 Røtterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Arøen A. Effect of meniscal and focal cartilage lesions on patient-reported outcome after anterior cruciate ligament reconstruction: a nationwide cohort study from Norway and Sweden of 8476 patients with 2-year follow-up. Am J Sports Med 2013; 41 (3) 535-543
    CrossrefPubMedGoogle Scholar
  • 33 Bedi A, Raphael B, Maderazo A, Pavlov H, Williams III RJ. Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy 2010; 26 (3) 342-350
    CrossrefPubMedGoogle Scholar
  • 34 Burkart A, Debski RE, McMahon PJ , et al. Precision of ACL tunnel placement using traditional and robotic techniques. Comput Aided Surg 2001; 6 (5) 270-278
    CrossrefPubMedGoogle Scholar
  • 35 Behrend H, Stutz G, Kessler MA, Rukavina A, Giesinger K, Kuster MS. Tunnel placement in anterior cruciate ligament (ACL) reconstruction: quality control in a teaching hospital. Knee Surg Sports Traumatol Arthrosc 2006; 14 (11) 1159-1165
    CrossrefPubMedGoogle Scholar
  • 36 Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG. Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 2009; 91 (10) 2321-2328
    CrossrefPubMedGoogle Scholar
  • 37 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
    CrossrefPubMedGoogle Scholar
  • 38 Lopez-Vidriero E, Hugh Johnson D. Evolving concepts in tunnel placement. Sports Med Arthrosc 2009; 17 (4) 210-216
    CrossrefPubMedGoogle Scholar
  • 39 Purnell ML, Larson AI, Clancy W. Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 2008; 36 (11) 2083-2090
    CrossrefPubMedGoogle Scholar
  • 40 Siebold R, Ellert T, Metz S, Metz J. Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for double-bundle bone tunnel placement—a cadaver study. Arthroscopy 2008; 24 (5) 585-592
    CrossrefPubMedGoogle Scholar
  • 41 Siebold R, Ellert T, Metz S, Metz J. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy 2008; 24 (2) 154-161
    CrossrefPubMedGoogle Scholar
  • 42 Zantop T, Wellmann M, Fu FH, Petersen W. Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 2008; 36 (1) 65-72
    PubMedGoogle Scholar
  • 43 Amis AA, Jakob RP. Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 1998; 6 (Suppl. 01) S2-S12
    CrossrefPubMedGoogle Scholar
  • 44 Giron F, Cuomo P, Edwards A, Bull AM, Amis AA, Aglietti P. Double-bundle “anatomic” anterior cruciate ligament reconstruction: a cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy 2007; 23 (1) 7-13
    CrossrefPubMedGoogle Scholar
  • 45 Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett Jr WE. Reconstruction technique affects femoral tunnel placement in ACL reconstruction. Clin Orthop Relat Res 2008; 466 (6) 1467-1474
    CrossrefPubMedGoogle Scholar
  • 46 Kopf S, Musahl V, Tashman S, Szczodry M, Shen W, Fu FH. A systematic review of the femoral origin and tibial insertion morphology of the ACL. Knee Surg Sports Traumatol Arthrosc 2009; 17 (3) 213-219
    CrossrefPubMedGoogle Scholar
  • 47 Dargel J, Pohl P, Tzikaras P, Koebke J. Morphometric side-to-side differences in human cruciate ligament insertions. Surg Radiol Anat 2006; 28 (4) 398-402
    CrossrefPubMedGoogle Scholar
  • 48 Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T. Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 2009; 17 (3) 220-227
    CrossrefPubMedGoogle Scholar
  • 49 Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 1975; (106) 216-231
    PubMedGoogle Scholar
  • 50 Hefzy MS, Grood ES, Noyes FR. Factors affecting the region of most isometric femoral attachments. Part II: The anterior cruciate ligament. Am J Sports Med 1989; 17 (2) 208-216
    CrossrefPubMedGoogle Scholar
  • 51 Hoogland T, Hillen B. Intra-articular reconstruction of the anterior cruciate ligament. An experimental study of length changes in different ligament reconstructions. Clin Orthop Relat Res 1984; (185) 197-202
    PubMedGoogle Scholar
  • 52 Shelbourne KD, Whitaker HJ, McCarroll JR, Rettig AC, Hirschman LD. Anterior cruciate ligament injury: evaluation of intraarticular reconstruction of acute tears without repair. Two to seven year followup of 155 athletes. Am J Sports Med 1990; 18 (5) 484-488 , discussion 488–489
    CrossrefPubMedGoogle Scholar
  • 53 Clancy Jr WG, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am 1982; 64 (3) 352-359
    CrossrefPubMedGoogle Scholar
  • 54 Garofalo R, Mouhsine E, Chambat P, Siegrist O. Anatomic anterior cruciate ligament reconstruction: the two-incision technique. Knee Surg Sports Traumatol Arthrosc 2006; 14 (6) 510-516
    CrossrefPubMedGoogle Scholar
  • 55 Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. 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 2003; 19 (3) 297-304
    CrossrefPubMedGoogle Scholar
  • 56 Muneta T, Yamamoto H, Sakai H, Ishibashi T, Furuya K. Relationship between changes in length and force in in vitro reconstructed anterior cruciate ligament. Am J Sports Med 1993; 21 (2) 299-304
    CrossrefPubMedGoogle Scholar
  • 57 Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 1985; 67 (2) 257-262
    CrossrefPubMedGoogle Scholar
  • 58 Goble EM, Downey DJ, Wilcox TR. Positioning of the tibial tunnel for anterior cruciate ligament reconstruction. Arthroscopy 1995; 11 (6) 688-695
    Google Scholar
  • 59 Good L, Odensten M, Gillquist J. Precision in reconstruction of the anterior cruciate ligament. A new positioning device compared with hand drilling. Acta Orthop Scand 1987; 58 (6) 658-661
    CrossrefPubMedGoogle Scholar
  • 60 Howell SM. Principles for placing the tibial tunnel and avoiding roof impingement during reconstruction of a torn anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 1998; 6 (Suppl. 01) S49-S55
    CrossrefPubMedGoogle Scholar
  • 61 Howell SM, Taylor MA. Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. J Bone Joint Surg Am 1993; 75 (7) 1044-1055
    CrossrefPubMedGoogle Scholar
  • 62 Musahl V, Burkart A, Debski RE, Van Scyoc A, Fu FH, Woo SL. Anterior cruciate ligament tunnel placement: Comparison of insertion site anatomy with the guidelines of a computer-assisted surgical system. Arthroscopy 2003; 19 (2) 154-160
    PubMedGoogle Scholar
  • 63 Wolf BR, Ramme AJ, Wright RW , et al. Variability in ACL tunnel placement: observational clinical study of surgeon ACL tunnel variability. Am J Sports Med 2013; 41 (6) 1265-1273
    CrossrefPubMedGoogle Scholar
  • 64 Westermann R, Sybrowsky C, Ramme A, Amendola A, Wolf BR. Three-dimensional characterization of the anterior cruciate ligament's femoral footprint. J Knee Surg 2014; 27 (1) 53-58
    PubMedGoogle Scholar