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Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction

  • Knee
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To determine graft bending angle (GBA) during knee motion after anatomic anterior cruciate ligament (ACL) reconstruction and to clarify whether surgical techniques affect GBA. Our hypotheses were that the graft bending angle would be highest at knee extension and the difference of surgical techniques would affect the bending steepness.

Methods

Eight healthy volunteers with a mean age of 29.3 ± 3.0 years were recruited and 3D MRI knee models were created at three flexion angles (0°, 90° and 130°). Surgical simulation of the tunnel drilling was performed with anatomic tunnel position using each outside-in (OI), trans-portal (TP) and trans-tibial (TT) techniques on the identical cases. The models were matched to other knee positions and the GBA in 3D was measured using computational software. Double-bundle ACL reconstruction was analysed first, and single-bundle reconstruction was also analysed to evaluate its effect to reduce GBA. A repeated-measures ANOVA was used to compare GBA difference at three flexion angles, by three techniques or of three bundles.

Results

GBA changed substantially with knee motion, and it was highest at full extension (p < 0.001) in each surgical technique. OI technique exhibited highest GBA for anteromedial bundle (94.3° ± 5.2°) at extension, followed by TP (83.1° ± 6.5°) and TT (70.0° ± 5.2°) techniques (p < 0.01). GBA for posterolateral bundle at extension were also high in OI (84.6° ± 7.4°), TP (83.0° ± 6.3°) and TT (77.2° ± 7.0°) techniques (n.s.). Single-bundle grafts did not decrease GBA compared with double-bundle grafts. In OI technique, a more proximal location of the femoral exit reduced GBA of each bundle at extension and 90° flexion.

Conclusion

A significant GBA change with knee motion and considerably steep bending at full extension, especially with OI and TP techniques, were simulated. Although single-bundle technique did not reduce GBA as seen in double-bundle technique, proximal location of femoral exits by OI technique, with tunnels kept in anatomic position, was effective in decreasing GBA at knee extension and flexion. For clinical relevance, high stress on graft and bone interface has been suggested by steep GBA at full extension after anatomic ACL reconstruction.

Level of evidence

Therapeutic study (prospective comparative study), Level II.

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Abbreviations

GBA:

Graft bending angle

ACL:

Anterior cruciate ligament

OI:

Outside-in

TP:

Trans-portal

TT:

Trans-tibial

AM:

Anteromedial

PL:

Posterolateral

MRI:

Magnetic resonance imaging

ICC:

Intraclass/interclass correlation coefficients

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Acknowledgments

This study was supported by JSPS Fellowships for Research Abroad and International Research Fund for Subsidy of Kyushu University School of Medicine Alumni. We thank Dr. Tracye J. Lawyer (University of Pittsburgh) for her assistance in editing the manuscript and Dr. Shinya Kawahara (Kyushu University) for his assistance in data collection.

Authors’ contributions

YT designed the study, performed data collection and analysis. He drafted the manuscript. SI assisted in data collection and evaluation. He revised the manuscript. KO carried out examining the materials and created the 3D knee models. He helped drafting the manuscript. YI assisted in designing the study, grant acquisition and co-supervised the entire research. FF advised the study design and directed all clinical aspects. He examined the validity of data analysis and supervised the entire research.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA

    Yasutaka Tashiro, Sebastián Irarrázaval & Freddie H. Fu

  2. Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan

    Yasutaka Tashiro, Kanji Osaki & Yukihide Iwamoto

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  1. Yasutaka Tashiro
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  2. Sebastián Irarrázaval
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Correspondence to Yasutaka Tashiro.

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Tashiro, Y., Irarrázaval, S., Osaki, K. et al. Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25, 129–137 (2017). https://doi.org/10.1007/s00167-016-4191-1

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