Watch Your Footprint: Anatomic ACL Reconstruction

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Watch your step.

We better stay in line.

Precisely watching our footprints, we could walk on a beach, in the sand, in a line, and a detective examining the prints would not be able to tell if it were one of us, or just the two of us, or all of us who had gone by.

This may be a metaphor for anatomic ACL surgery. We believe that anatomic footprint reconstruction of ACL grafts is a critical key to successful outcome. This isn't unique to ACL reconstruction; shoulder surgeons continue their discussion1, 2, 3, 4, 5, 6, 7 of footprint reconstruction in the current issue.8 But the emphasis of October's issue is the ACL.

Jon Karlsson's group9 presents Level II evidence that graft type is not a significant determinant of ACL outcome. But this is controversial, and the authors do note a possible association of osteoarthritis with bone–patellar tendon–bone grafts and clinically insignificant tunnel widening with hamstring grafts. Adding to the controversy, Dargel et al.10 report that graft substance is the weak link in ACL biomechanical testing.

In addition, Samuelsson et al.9 present Level II evidence that fixation doesn't matter with regard to ACL reconstruction outcome. This finding is supported in the current issue by the study of Shen et al.11 Yet, Shen et al. do note an exception with regard to interference fixation screw insertion torque, where excessively high torque may result in cutting an ACL graft when too large screws are inserted. Dargel et al. also dispute that “fixation doesn't matter” by showing that fixation significantly influences graft tension during biomechanical testing.

Again, we believe footprint reconstruction positively effects outcome, and this is supported by Bedi et al. who emphasize footprint reconstruction in a technical note.12 But technical notes may be classified as Level V evidence, expert opinion, and thus the lowest level of evidence in the hierarchy. Basdekis et al.13 study double-bundle ACL reconstruction, and these authors now, and previously,14, 15 have also emphasized footprint anatomy in their publications.

Again, however, Samuelsson et al. in their Level II systematic review conclude that the objective decrease in knee anteroposterior16 and rotational9, 16 laxity that can occur after anatomic double-bundle ACL reconstruction seems clinically insignificant.

And the latest Level I evidence? Endele et al. show that with regard to ACL outcomes, computer navigation does not seem to be a significant determinant of outcome.17

In the context of controversy, we continue to contend that anatomic placement of ACL reconstruction grafts is the critical key to successful outcome. Yet, the difficulty in reaching clinically relevant conclusions, as we learn in this issue,9 is that “In the quality assessment [of current ACL clinical trials] … weaknesses in the study design of the randomized controlled trials were found.”

In the future, improved research methods may clarify clinical controversy; in the meantime, we're going to watch our footprints and step precisely.

References

1. 1Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The insertional footprint of the rotator cuff: An anatomic study. Arthroscopy. 2006;22:603–609. Abstract | Full Text | Full-Text PDF (1725 KB) | CrossRef

2. 2Richards DP, Burkhart SS, Tehrany AM, Wirth MA. The subscapularis footprint: An anatomic description of its insertion site. Arthroscopy. 2007;23:251–254. Abstract | Full Text | Full-Text PDF (94 KB) | CrossRef

3. 3Burkhart SS, Adams CR, Burkhart SS, Schoolfield JD. A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: The swivelock-fiberchain construct versus standard double-row repair. Arthroscopy. 2009;25:274–281. Abstract | Full Text | Full-Text PDF (1875 KB) | CrossRef

4. 4Ide J, Tokiyoshi A, Hirose J, Mizuta H. An anatomic study of the subscapularis insertion to the humerus: The subscapularis footprint. Arthroscopy. 2008;24:749–753. Abstract | Full Text | Full-Text PDF (427 KB) | CrossRef

5. 5D'Addesi LL, Anbari A, Reish MW, Brahmabhatt S, Kelly JD. The subscapularis footprint: An anatomic study of the subscapularis tendon insertion. Arthroscopy. 2006;22:937–940. Abstract | Full Text | Full-Text PDF (133 KB) | CrossRef

6. 6Lafosse L, Baier GP, Jost B. Footprint fixation for arthroscopic reconstruction in anterior shoulder instability: The Cassiopeia double-row technique. Arthroscopy. 2006;22:231.e1–231.e6. Abstract | Full Text | Full-Text PDF (461 KB) | CrossRef

7. 7Park M, Cadet E, Levine W, Bigliani L, Ahmad C. Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques. Arthroscopy. 2005;21:e22;(Abstr SS-45). Full-Text PDF (38 KB) | CrossRef

8. 8Yoo JC, Ahn JH, Koh KH, Lim KS. Rotator cuff integrity after arthroscopic repair of large tears with less-than-optimal footprint coverage. Arthroscopy. 2009;25:1093–1100. Abstract | Full Text | Full-Text PDF (1189 KB) | CrossRef

9. 9Samuelsson K, Andersson D, Karlsson J. Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique (An assessment of randomized controlled trials). Arthroscopy. 2009;25:1139–1174. Abstract | Full Text | Full-Text PDF (1119 KB) | CrossRef

10. 10Dargel J, Koebke J, Brüggemann G-P, Pennig D, Schmidt-Wiethoff R. Tension degradation of anterior cruciate ligament grafts with dynamic flexion-extension loading: A biomechanical model in porcine knees. Arthroscopy. 2009;25:1115–1125. Abstract | Full Text | Full-Text PDF (873 KB) | CrossRef

11. 11Shen P-H, Lien S-B, Shen H-C, et al. Comparison of different sizes of bioabsorbable interference screws for anterior cruciate ligament reconstruction using bioabsorbable bead augmentation in a porcine model. Arthroscopy. 2009;25:1101–1107. Abstract | Full Text | Full-Text PDF (967 KB) | CrossRef

12. 12Bedi A, Altchek DW. The “footprint” anterior cruciate ligament technique: An anatomic approach to anterior cruciate ligament reconstruction. Arthroscopy. 2009;25:1128–1138. Abstract | Full Text | Full-Text PDF (2862 KB) | CrossRef

13. 13Basdekis 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;25:1108–1114. Abstract | Full Text | Full-Text PDF (1094 KB) | CrossRef

14. 14Christel P, Sahasrabudhe A, Basdekis G. Anatomic double-bundle anterior cruciate ligament reconstruction with anatomic aimers. Arthroscopy. 2008;24:1146–1151. Abstract | Full Text | Full-Text PDF (1013 KB) | CrossRef

15. 15Basdekis G, Abisafi C, Christel P. Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy. 2008;24:459–464. Abstract | Full Text | Full-Text PDF (563 KB) | CrossRef

16. 16Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H. Clinical evaluation of anatomic double bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: Comparisons among 3 different procedures. Arthroscopy. 2006;22:240–2513. Abstract | Full Text | Full-Text PDF (438 KB) | CrossRef

17. 17Endele D, Jung C, Becker U, Bauer G, Mauch F. Anterior cruciate ligament reconstruction with and without computer navigation: A clinical and magnetic resonance imaging evaluation 2 years after surgery. Arthroscopy. 2009;25:1067–1074. Abstract | Full Text | Full-Text PDF (958 KB) | CrossRef

PII: S0749-8063(09)00693-8

doi:10.1016/j.arthro.2009.08.001

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