Impingement Pressure in the Anatomical and Nonanatomical Anterior Cruciate Ligament Reconstruction: A Cadaver Study
Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA. The American Journal of Sports Medicine
(Impact Factor: 4.36).
08/2010; 38(8):1611-7. DOI: 10.1177/0363546510363461
Although the literature has extensively discussed impingement after anterior cruciate ligament (ACL) reconstruction, the definition of impingement is vague, and impingement pressure has not been well investigated as a function of tunnel position.
To determine the amount of impingement pressure between the ACL and posterior cruciate ligament (PCL) and between the ACL and notch roof in the native ACL, the single-bundle ACL reconstruction with different tunnel placements, and the anatomical double-bundle ACL reconstruction.
Controlled laboratory study.
Fifteen fresh-frozen nonpaired human cadaver knees were used. In each knee, different femoral and tibial tunnels were created, which allowed different graft placements. A single graft was placed in 3 positions: tibial anteromedial (AM) to femoral AM (anatomical), tibial posterolateral (PL) to femoral high AM (nonanatomical/mismatch), and tibial AM to femoral high AM. Double grafts were placed in an anatomical fashion (AM to AM and PL to PL). In each case, pressure-measuring films were inserted between the ACL and roof, the ACL and PCL, and the AM and PL bundles (for double-bundle group only). Knees were then moved with 40 N of force and from full flexion to full extension, and the pressure pattern on the film was analyzed.
Compared with other groups, only the AM-high AM group showed significantly higher roof impingement pressure (P < .05). There was no significant difference in PCL impingement pressure between the intact ACL group and any of the reconstructed groups. No impingement pressure was observed between the grafts in the anatomical double-bundle ACL reconstruction.
This study evaluated the effect of different tunnel placements on the impingement pressure after ACL reconstruction. Anatomical single- or double-bundle ACL reconstruction and nonanatomical tibial PL-femoral high AM ACL reconstruction do not cause roof, PCL, and interbundle impingement.
Surgeons can perform the anatomical double-bundle ACL, anatomical single-bundle, and nonanatomical tibial PL-femoral high AM reconstructions as impingement-free reconstructions.
Available from: PubMed Central
- "The causes of graft damage are multifactorial and can be related the type of graft, graft fixation and tensioning, as well as impingement of the graft against the surrounding structures.19 Another factor responsible for graft damage is repetitive bending stress on the graft at the intra-articular tunnel aperture.2,19-23 "
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The purpose of this study was to compare four graft-tunnel angles (GTA), the femoral GTA formed by three different femoral tunneling techniques (the outside-in, a modified inside-out technique in the posterior sag position with knee hyperflexion, and the conventional inside-out technique) and the tibia GTA in 3-dimensional (3D) knee flexion models, as well as to examine the influence of femoral tunneling techniques on the contact pressure between the intra-articular aperture of the femoral tunnel and the graft.
Materials and Methods
Twelve cadaveric knees were tested. Computed tomography scans were performed at different knee flexion angles (0°, 45°, 90°, and 120°). Femoral and tibial GTAs were measured at different knee flexion angles on the 3D knee models. Using pressure sensitive films, stress on the graft of the angulation of the femoral tunnel aperture was measured in posterior cruciate ligament reconstructed cadaveric knees.
Between 45° and 120° of knee flexion, there were no significant differences between the outside-in and modified inside-out techniques. However, the femoral GTA for the conventional inside-out technique was significantly less than that for the other two techniques (p<0.001). In cadaveric experiments using pressure-sensitive film, the maximum contact pressure for the modified inside-out and outside-in technique was significantly lower than that for the conventional inside-out technique (p=0.024 and p=0.017).
The conventional inside-out technique results in a significantly lesser GTA and higher stress at the intra-articular aperture of the femoral tunnel than the outside-in technique. However, the results for the modified inside-out technique are similar to those for the outside-in technique.
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ABSTRACT: The concepts of "weakness factor", w, and defect density, D(w), are introduced for thin oxide study. The defect density is sensitive to silicon material qualities and process conditions and can be characterized by simple time-to-breakdown or ramp-breakdown field measurements (see Figure 1). We present an experimentally verified method of predicting the time-dependent dielectric breakdown (TDDB) behavior for different oxide area and field using D(w). We also demonstrate a method for determining the stress time and stress field required for screening to meet a given failure rate for any oxide area and operating field, and the yield loss due to screening. Based on this study, there appears to be a large window between adequate screen and over-screen.
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ABSTRACT: To reveal the relationship between anatomically placed anterior cruciate ligament (ACL) graft and the intercondylar roof using three-dimensional computed tomography (3D-CT).
Twenty-four patients undergoing anatomical double-bundle ACL reconstruction were included in this study. Anatomical double-bundle ACL reconstruction was performed with two femoral tunnels (antero-medial; AM and postero-lateral; PL) and two tibial tunnels. Hamstring autograft was used in all cases. Six to eight weeks after operation and when the subjects had obtained full extension of the knee, 3D-CT was performed with full knee extension. In the 3D-CT, the ACL graft was also reconstructed and visualized three dimensionally. Tunnel placement was evaluated with 3D-CT and intra-operative radiographs. The extension angle of the knee was also evaluated with 3D-CT.
No intercondylar roof impingement was observed. In 12 subjects, the ACL graft touched the roof (Touch group) but no graft deformation was observed. In 12 subjects, no roof-graft contact was observed (Non-touch group). No significant difference in femoral and tibial tunnel placement was observed between the Touch and Non-touch groups. All subjects attained full knee extension.
We believe that 3D-CT is an effective means of evaluating impingement after ACL reconstruction. For the clinical relevance, when the grafts are positioned in an anatomical fashion, there is no risk of impingement, and surgeons can perform anatomical double-bundle ACL as an impingement-free reconstruction. Level of evidence: III (Case control study).
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