An Analysis of the Femoral Drilling Angle to Avoid Tunnel Collision during Double-Bundle Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction on the Knee

Yusuke Kawanishi; Makoto Kobayashi; Sanshiro Yasuma; Hiroaki Fukushima; Jiro Kato; Atsunori Murase; Tetsuya Takenaga; Masahito Yoshida; Gen Kuroyanagi; Yohei Kawaguchi; Yuko Nagaya; Hideki Murakami; Masahiro Nozaki

doi:10.1055/s-0041-1736196

The Journal of Knee Surgery, Table of Contents

J Knee Surg 2023; 36(05): 483-490
DOI: 10.1055/s-0041-1736196

Original Article

An Analysis of the Femoral Drilling Angle to Avoid Tunnel Collision during Double-Bundle Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction on the Knee

Yusuke Kawanishi

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Makoto Kobayashi

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Sanshiro Yasuma

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Hiroaki Fukushima

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Jiro Kato

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Atsunori Murase

²Department of Orthopedic Surgery, Kasugai Joint & Sports Orthopedic Clinic, Kasugai, Aichi, Japan

,

Tetsuya Takenaga

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Masahito Yoshida

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Gen Kuroyanagi

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Yohei Kawaguchi

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Yuko Nagaya

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Hideki Murakami

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

,

Masahiro Nozaki

¹Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan

› Author Affiliations

Abstract

Concomitant anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has been reported as an effective technique for providing rotational control of the knee. However, the intraoperative risk of collision with an ACL tunnel during the drilling for the femoral ALL tunnel has been described. The purpose of this study was to investigate the various femoral drilling procedures to avoid tunnel collisions during combined double-bundle ACL and ALL reconstruction. Nine cadaveric knees were used in this study. ACL drilling was performed through the anteromedial portal to footprints of the posterolateral bundle at 120° (PL120) and 135° (PL135) knee flexion and the anteromedial bundle at 120° (AM120) and 135° (AM135) knee flexion. ALL drilling was performed at 0° (Cor0-ALL) and 30° (Cor30-ALL) coronal angles using a Kirschner wire (K-wire). The distance between the ALL footprint and ACL K-wire outlets, axial angles of ALL K-wires colliding with ACL K-wires, and distances from the ALL footprint to the collision point were measured. From these values, the safe zone, defined as the range of axial angles in which no collisions or penetrations occurred, was identified by simulation of tunnels utilized for reconstruction grafts in each drilling procedure. The point-to-point distance from the ALL footprint to the K-wire outlet was significantly greater in the AM120 than the AM135 (13.5 ± 3.1, 10.8 ± 3.2 mm; p = 0.048) and in the PL135 than the PL120 (18.3 ± 5.5, 16.1 ± 6.5 mm; p = 0.005) conditions, respectively. During an ACL drilling combination of PL135/AM120, a safe zone of > 45° in Cor30-ALL was identified. With a narrow safe zone during the PL135/AM120 combination only, the risk of femoral tunnel collisions in combined double-bundle ACL and ALL reconstruction is high. AM drilling at 120° and PL drilling at > 135° knee flexion, combined with ALL drilling at 30° coronal angle and > 45° axial angle, may reduce this risk.

Keywords

anterior cruciate ligament - anterolateral ligament reconstruction - tunnel collision - knee

Full Text

References

References
1 Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 2011; 45 (07) 596-606
2 Rasmussen MT, Nitri M, Williams BT. et al. An in vitro robotic assessment of the anterolateral ligament, part 1: secondary role of the anterolateral ligament in the setting of an anterior cruciate ligament injury. Am J Sports Med 2016; 44 (03) 585-592
3 Tavlo M, Eljaja S, Jensen JT, Siersma VD, Krogsgaard MR. The role of the anterolateral ligament in ACL insufficient and reconstructed knees on rotatory stability: A biomechanical study on human cadavers. Scand J Med Sci Sports 2016; 26 (08) 960-966
4 Thein R, Boorman-Padgett J, Stone K, Wickiewicz TL, Imhauser CW, Pearle AD. biomechanical assessment of the anterolateral ligament of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability. J Bone Joint Surg Am 2016; 98 (11) 937-943
5 Sobrado MF, Giglio PN, Bonadio MB. et al. Outcomes after isolated acute anterior cruciate ligament reconstruction are inferior in patients with an associated anterolateral ligament injury. Am J Sports Med 2020; 48 (13) 3177-3182
6 Nitri M, Rasmussen MT, Williams BT. et al. An in vitro robotic assessment of the anterolateral ligament, part 2: anterolateral ligament reconstruction combined with anterior cruciate ligament reconstruction. Am J Sports Med 2016; 44 (03) 593-601
7 Chen J, Xu C, Cho E, Huangfu X, Zhao J. Reconstruction for chronic ACL tears with or without anterolateral structure augmentation in patients at high risk for clinical failure: a randomized clinical trial. J Bone Joint Surg Am 2021; 103 (16) 1482-1490
8 Saithna A, Daggett M, Helito CP. et al. Clinical results of combined ACL and anterolateral ligament reconstruction: a narrative review from the SANTI study group. J Knee Surg 2021; 34 (09) 962-970
9 Sonnery-Cottet B, Saithna A, Cavalier M. et al. anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med 2017; 45 (07) 1547-1557
10 Helito CP, Sobrado MF, Giglio PN. et al. Combined reconstruction of the anterolateral ligament in patients with anterior cruciate ligament injury and ligamentous hyperlaxity leads to better clinical stability and a lower failure rate than isolated anterior cruciate ligament reconstruction. Arthroscopy 2019; 35 (09) 2648-2654
11 Chahla J, Menge TJ, Mitchell JJ, Dean CS, LaPrade RF. Anterolateral ligament reconstruction technique: an anatomic-based approach. Arthrosc Tech 2016; 5 (03) e453-e457
12 Smith JO, Yasen SK, Lord B, Wilson AJ. Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee. Knee Surg Sports Traumatol Arthrosc 2015; 23 (11) 3151-3156
13 Wagih AM, Elguindy AM. Percutaneous reconstruction of the anterolateral ligament of the knee with a polyester tape. Arthrosc Tech 2016; 5 (04) e691-e697
14 Smeets K, Bellemans J, Lamers G. et al. High risk of tunnel convergence during combined anterior cruciate ligament and anterolateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27 (02) 611-617
15 Gali JC, Bernardes AdeP, dos Santos LC, Ferreira TC, Almagro MA, da Silva PA. Tunnel collision during simultaneous anterior cruciate ligament and posterolateral corner reconstruction. Knee Surg Sports Traumatol Arthrosc 2016; 24 (01) 195-200
16 Gelber PE, Erquicia JI, Sosa G. et al. Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model. Arthroscopy 2013; 29 (02) 257-265
17 Osaki K, Okazaki K, Tashiro Y, Matsubara H, Iwamoto Y. Influences of knee flexion angle and portal position on the location of femoral tunnel outlet in anterior cruciate ligament reconstruction with anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc 2015; 23 (03) 777-784
18 Jette C, Pomés J, Sastre S, Gutierrez D, Llusa M, Combalia A. Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27 (11) 3411-3417
19 Järvelä S, Kiekara T, Suomalainen P, Järvelä T. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 10-year results. Am J Sports Med 2017; 45 (11) 2578-2585
20 El-Sherief FAH, Aldahshan WA, Wahd YE. et al. Double-bundle anterior cruciate ligament reconstruction is better than single-bundle reconstruction in terms of objective assessment but not in terms of subjective score. Knee Surg Sports Traumatol Arthrosc 2018; 26 (08) 2395-2400
21 Maeyama A, Hoshino Y, Kato Y. et al. Anatomic double bundle ACL reconstruction outperforms any types of single bundle ACL reconstructions in controlling dynamic rotational laxity. Knee Surg Sports Traumatol Arthrosc 2018; 26 (05) 1414-1419
22 Piefer JW, Pflugner TR, Hwang MD, Lubowitz JH. Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature. Arthroscopy 2012; 28 (06) 872-881
23 Nakamura M, Deie M, Shibuya H. et al. Potential risks of femoral tunnel drilling through the far anteromedial portal: a cadaveric study. Arthroscopy 2009; 25 (05) 481-487
24 Otani M, Nozaki M, Kobayashi M. et al. Comparative risk of common peroneal nerve injury in far anteromedial portal drilling and transtibial drilling in anatomical double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2012; 20 (05) 838-843
25 Basdekis G, Abisafi C, Christel P. Effect of knee flexion angle on length and orientation of posterolateral femoral tunnel drilled through anteromedial portal during anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 2009; 25 (10) 1108-1114
26 Farrow LD, Parker RD. The relationship of lateral anatomic structures to exiting guide pins during femoral tunnel preparation utilizing an accessory medial portal. Knee Surg Sports Traumatol Arthrosc 2010; 18 (06) 747-753
27 Kennedy MI, Claes S, Fuso FA. et al. The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med 2015; 43 (07) 1606-1615
28 LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med 2003; 31 (06) 854-860
29 Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant 2013; 48 (03) 452-458
30 Jaecker V, Ibe P, Endler CH, Pfeiffer TR, Herbort M, Shafizadeh S. High risk of tunnel convergence in combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis. Am J Sports Med 2019; 47 (09) 2110-2115
31 Angelini FJ, Helito CP, Tozi MR. et al. Combined reconstruction of the anterior cruciate ligament and posterolateral corner with a single femoral tunnel. Arthrosc Tech 2013; 2 (03) e285-e288
32 Bonadio MB, Helito CP, Foni NO. et al. Combined reconstruction of the posterior cruciate ligament and medial collateral ligament using a single femoral tunnel. Knee Surg Sports Traumatol Arthrosc 2017; 25 (10) 3024-3030
33 Sonnery-Cottet B, Daggett M, Helito CP, Fayard JM, Thaunat M. Combined anterior cruciate ligament and anterolateral ligament reconstruction. Arthrosc Tech 2016; 5 (06) e1253-e1259
34 Mediavilla I, Aramberri M, Tiso G, Murillo-González JA. Combined double bundle anterior cruciate ligament reconstruction and anterolateral ligament reconstruction. Arthrosc Tech 2018; 7 (08) e881-e886
35 Ahn JH, Jeong HJ, Lee YS, Park JH, Lee JH, Ko TS. Graft bending angle is correlated with femoral intraosseous graft signal intensity in anterior cruciate ligament reconstruction using the outside-in technique. Knee 2016; 23 (04) 666-673
36 Wang JH, Lee DK, Chung ST, Lee BH. Influence of change of tunnel axis angle on tunnel length during double-bundle ACL reconstruction via the transportal technique. BMC Musculoskelet Disord 2017; 18 (01) 237
37 Wein F, Osemont B, Goetzmann T. et al. Anteversion and length of the femoral tunnel in ACL reconstruction: in-vivo comparison between rigid and flexible instrumentation. J Exp Orthop 2019; 6 (01) 26