Radiographic Landmarks for Tunnel Positioning in Posterior Cruciate Ligament Reconstructions

Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado.
The American Journal of Sports Medicine (Impact Factor: 4.36). 11/2012; 41(1). DOI: 10.1177/0363546512465072
Source: PubMed


BACKGROUND:Consistent radiographic guidelines for tunnel placement in single- or double-bundle posterior cruciate ligament (PCL) reconstructions are not well defined. Quantitative guidelines reporting the location of the individual PCL bundle attachments would aid in intraoperative tunnel placement and postoperative assessment of a PCL reconstruction. HYPOTHESIS:Consistent and reproducible measurements in relation to radiographic landmarks for the entire PCL and its individual bundle attachments are achievable. STUDY DESIGN:Controlled laboratory study. METHODS:The femoral and tibial PCL bundle attachment centers of 20 nonpaired fresh-frozen cadaveric knees were labeled using radio-opaque spheres and the attachment areas were labeled using barium sulfate. Anteroposterior (AP) and lateral radiographs of the femur and tibia were obtained, and measurements of the distances between the PCL bundle centers and landmarks were acquired. RESULTS:On the AP femur view, the anterolateral bundle (ALB) and posteromedial bundle (PMB) centers were 34.1 ± 3.0 mm and 29.2 ± 3.0 mm lateral to the most medial border of the medial femoral condyle, respectively. The lateral femur images revealed that the ALB center was 17.4 ± 1.7 mm and the PMB center was 23.9 ± 2.7 mm posteroproximal to a line perpendicular to the Blumensaat line that intersected the anterior margin of the medial femoral condyle cortex. Anteroposterior tibia images revealed that the ALB and PMB centers were located 0.2 ± 2.1 mm proximal and 4.9 ± 2.9 mm distal to the proximal joint line, respectively. The PCL attachment center was 1.6 ± 2.5 mm distal to the proximal joint line. On the lateral tibia view, the ALB center was 8.4 ± 1.8 mm, the PCL attachment center was 5.5 ± 1.7 mm, and the PMB center was 2.5 ± 1.5 mm superior to the champagne glass drop-off of the posterior tibia. CONCLUSION:Radiographic measurements from several clinically relevant views of the femur and tibia were reproducible with regard to the anatomic locations of the ALB and PMB centers. The measurements from the lateral femur and tibia views provided the most clinically pertinent radiographic measurements intraoperatively. CLINICAL RELEVANCE:This study established a set of clinically relevant radiographic guidelines for anatomic reconstruction of the PCL. The parameters set forth in this study can be used in both the intraoperative and postoperative settings for both single- and double-bundle PCL reconstructions.

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Available from: Robert F LaPrade, May 09, 2015
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    • "Only the Danish register includes this type of evaluation during the monitoring of operated patients. A radiological evaluation could provide information about the tunnel positioning (main cause of failure) or the appearance of osteoarthritis secondary to ACL rupture [30] [31]. Joint laxity measurements could be used to quantitatively measure the knee joint's stability and determine if the procedure was successful or not [32]. "
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    ABSTRACT: The purpose of this work was to report the main characteristics and results of all active anterior cruciate ligament (ACL) reconstruction registers along with the differences between them. We systematically searched on Google and Medline via PubMed to identify ACL registers. National or regional registers were included if they were active and took into account ACL reconstructions. The main results and characteristics, namely the number of inclusions, exhaustivity, data collection methods and results dissemination methods were determined. The collected information was then submitted to each register for validation. Four registers (3 national, 1 regional) were identified that routinely included every ACL reconstruction procedure. Register data were collected either through dedicated websites or on paper forms. All the registers used the same two outcome measures, namely the revision rate and a subjective patient score (KOOS score). Register results were made available through scientific publications or annual reports. The main differences between registers were in the graft choice and presence of associated meniscus and cartilage injuries. Although there are only a few ACL reconstruction-specific registers, their scientific contribution is undeniable thanks to the quality of the collected data and the organization and collaboration between registers. Their impact on health care and science should grow in the future. Copyright © 2014. Published by Elsevier Masson SAS.
    Orthopaedics & Traumatology Surgery & Research 10/2014; 100(8). DOI:10.1016/j.otsr.2014.07.020 · 1.26 Impact Factor
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    • "Osti et al. [30] correlated radiography and descriptive anatomy and observed that the cross-sectional areas and femoral and tibial insertions for the anterolateral and posteromedial bundles were similar to, but smaller in area than those observed anatomically by Takahashi et al. [38], and the intercondylar depth of the two bundles was smaller than that observed radiologically by Lorenz et al. [24], with the insertion areas deeper into the intercondylar wall. Johannsen et al. [17] characterized the anterolateral and posteromedial bundles of the PCL radiologically and recommended that a single tibial tunnel should be located between 1 and 2 mm distal to the joint line on the anteroposterior view. It is not yet known whether this location is consistently reproducible during arthroscopic PCL reconstruction surgery and leads to effective maintenance of joint stability. "
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    ABSTRACT: Purpose: Reconstruction of the posterior cruciate ligament (PCL) yields less satisfying results than anterior cruciate ligament reconstruction with respect to laxity control. Accurate tibial tunnel placement is crucial for successful PCL reconstruction using arthroscopic tibial tunnel techniques. A discrepancy between anatomical studies of the tibial PCL insertion site and surgical recommendations for tibial tunnel placement remains. The objective of this study was to identify the optimal placement of the tibial tunnel in PCL reconstruction based on clinical studies. Methods: In a systematic review of the literature, MEDLINE, EMBASE, Cochrane Review, and Cochrane Central Register of Controlled Trials were screened for articles about PCL reconstruction from January 1990 to September 2011. Clinical trials comparing at least two PCL reconstruction techniques were extracted and independently analysed by each author. Only studies comparing different tibial tunnel placements in the retrospinal area were included. Results: This systematic review found no comparative clinical trial for tibial tunnel placement in PCL reconstruction. Several anatomical, radiological, and biomechanical studies have described the tibial insertion sites of the native PCL and have led to recommendations for placement of the tibial tunnel outlet in the retrospinal area. However, surgical recommendations and the results of morphological studies are often contradictory. Conclusions: Reliable anatomical landmarks for tunnel placement are lacking. Future randomized controlled trials could compare precisely defined tibial tunnel placements in PCL reconstruction, which would require an established mapping of the retrospinal area of the tibial plateau with defined anatomical and radiological landmarks.
    Knee Surgery Sports Traumatology Arthroscopy 06/2013; 22(7). DOI:10.1007/s00167-013-2563-3 · 3.05 Impact Factor
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    Instructional course lectures 02/2002; 51:347-51.
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