Advertisement

Height and Depth Guidelines for Anatomic Femoral Tunnels in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

Published:February 10, 2016DOI:https://doi.org/10.1016/j.arthro.2015.11.031

      Purpose

      To develop guidelines for femoral tunnel placement based on height and depth on the lateral wall of the notch and to apply these guidelines arthroscopically to show tunnel placements within the anterior cruciate ligament (ACL) femoral insertion site.

      Methods

      Twelve cadaveric knees were dissected to define the centers of the femoral ACL attachment and its anteromedial (AM) and posterolateral (PL) bundles. In 90° of flexion, the height and depth of each center were determined relative to the low point on the lateral intercondylar notch. Radiographic grid measurements were made to validate these measurements. Subsequently, the measurement guidelines were applied arthroscopically in 10 new cadaveric knees to evaluate their accuracy for an anatomic single-bundle femoral tunnel. Interobserver reliability analysis was evaluated with the intraclass correlation coefficient.

      Results

      In 90° of flexion, the height of the ACL center was 8.7 ± 0.6 mm from the low point of the lateral notch; PL center, 7.2 ± 1.2 mm; and AM center, 9.6 ± 1.1 mm. Relative to the low point, the ACL center was 1.7 ± 1.7 mm posterior, the PL center was 3.4 ± 1.5 mm anterior, and the AM center was 4.9 ± 1.7 mm posterior (intraclass correlation coefficient, 0.859). Radiographic grid measurements were consistent with the direct measurements. Application of the guidelines arthroscopically with or without the assistance of a 7-mm offset aimer placed all guide pins for tunnels within the femoral ACL footprint, with 90% within 4 mm of the ACL center.

      Conclusions

      This study showed in cadaveric knees in 90° of flexion that the center of the ACL can be located on the lateral notch at a height of 8.7 ± 0.6 mm from the lowest point and anterior 11.5 ± 1.3 mm from the deepest point. How anatomic tunnels can be placed using these measurements was also shown in cadaveric knees.

      Clinical Relevance

      An anatomic femoral tunnel for ACL reconstruction can be placed using height and depth guidelines.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ho J.Y.
        • Gardiner A.
        • Shah V.
        • Steiner M.E.
        Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions.
        Arthroscopy. 2009; 25: 464-472
        • Loh J.C.
        • Fukuda Y.
        • Tsuda E.
        • Steadman R.J.
        • Fu F.H.
        • Woo S.L.
        Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement. 2002 Richard O’Connor Award paper.
        Arthroscopy. 2003; 19: 297-304
        • Steiner M.E.
        • Battaglia T.C.
        • Heming J.F.
        • Rand J.D.
        • Festa A.
        • Baria M.
        Independent drilling outperforms conventional transtibial drilling in anterior cruciate ligament reconstruction.
        Am J Sports Med. 2009; 37: 1912-1919
        • Yamamoto Y.
        • Hsu W.H.
        • Woo S.L.
        • Van Scyoc A.H.
        • Takakura Y.
        • Debski R.E.
        Knee stability and graft function after anterior cruciate ligament reconstruction: A comparison of a lateral and an anatomical femoral tunnel placement.
        Am J Sports Med. 2004; 32: 1825-1832
        • Kamath G.V.
        • Redfern J.C.
        • Greis P.E.
        • Burks R.T.
        Revision anterior cruciate ligament reconstruction.
        Am J Sports Med. 2011; 39: 199-217
        • Marchant B.G.
        • Noyes F.R.
        • Barber-Westin S.D.
        • Fleckenstein C.
        Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions.
        Am J Sports Med. 2010; 38: 1987-1996
        • Lubowitz J.H.
        Anteromedial portal technique for the anterior cruciate ligament femoral socket: Pitfalls and solutions.
        Arthroscopy. 2009; 25: 95-101
        • Forsythe B.
        • Kopf S.
        • Wong A.K.
        • et al.
        The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models.
        J Bone Joint Surg Am. 2010; 92: 1418-1426
        • Heming J.F.
        • Rand J.
        • Steiner M.E.
        Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction.
        Am J Sports Med. 2007; 35: 1708-1715
        • Pansard E.
        • Klouche S.
        • Vardi G.
        • Greeff E.
        • Hardy P.
        • Ferguson M.
        How accurate are anatomic landmarks for femoral tunnel positioning in anterior cruciate ligament reconstruction? An in vivo imaging analysis comparing both anteromedial portal and outside-in techniques.
        Arthroscopy. 2015; 31: 882-889
        • Edwards A.
        • Bull A.M.
        • Amis A.A.
        The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament. Part 2: Femoral attachment.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 29-36
        • Scopp J.M.
        • Jasper L.E.
        • Belkoff S.M.
        • Moorman III, C.T.
        The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts.
        Arthroscopy. 2004; 20: 294-299
        • Fu F.H.
        The clock-face reference: Simple but nonanatomic.
        Arthroscopy. 2008; 24 (letter): 1433
        • Ziegler C.G.
        • Pietrini S.D.
        • Westerhaus B.D.
        • et al.
        Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions.
        Am J Sports Med. 2011; 39: 743-752
        • Bernard M.
        • Hertel P.
        • Hornung H.
        • Cierpinski T.
        Femoral insertion of the ACL. Radiographic quadrant method.
        Am J Knee Surg. 1997; 10: 14-21
        • Colombet P.
        • Robinson J.
        • Christel P.
        • et al.
        Morphology of anterior cruciate ligament attachments for anatomic reconstruction: A cadaveric dissection and radiographic study.
        Arthroscopy. 2006; 22: 984-992
        • Kaseta M.K.
        • DeFrate L.E.
        • Charnock B.L.
        • Sullivan R.T.
        • Garrett Jr., W.E.
        Reconstruction technique affects femoral tunnel placement in ACL reconstruction.
        Clin Orthop Relat Res. 2008; 466: 1467-1474
        • Bird J.H.
        • Carmont M.R.
        • Dhillon M.
        • et al.
        Validation of a new technique to determine midbundle femoral tunnel position in anterior cruciate ligament reconstruction using 3-dimensional computed tomography analysis.
        Arthroscopy. 2011; 27: 1259-1267
        • Sasaki N.
        • Ishibashi Y.
        • Tsuda E.
        • et al.
        The femoral insertion of the anterior cruciate ligament: Discrepancy between macroscopic and histological observations.
        Arthroscopy. 2012; 28: 1135-1146
        • Iriuchishima T.
        • Ryu K.
        • Aizawa S.
        • Fu F.H.
        The difference in centre position in the ACL femoral footprint inclusive and exclusive of the fan-like extension fibres.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 254-259
        • Amis A.A.
        • Jakob R.P.
        Anterior cruciate ligament graft positioning, tensioning and twisting.
        Knee Surg Sports Traumatol Arthrosc. 1998; 6: S2-S12
        • Piefer J.W.
        • Pflugner T.R.
        • Hwang M.D.
        • Lubowitz J.H.
        Anterior cruciate ligament femoral footprint anatomy: Systematic review of the 21st century literature.
        Arthroscopy. 2012; 28: 872-881
        • Oakley S.P.
        • Portek I.
        • Szomor Z.
        • et al.
        Poor accuracy and interobserver reliability of knee arthroscopy measurements are improved by the use of variable angle elongated probes.
        Ann Rheum Dis. 2002; 61: 540-543
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Iriuchishima T.
        • Ingham S.J.
        • Tajima G.
        • et al.
        Evaluation of the tunnel placement in the anatomical double-bundle ACL reconstruction: A cadaver study.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1226-1231
        • Lorenz S.
        • Elser F.
        • Mitterer M.
        • Obst T.
        • Imhoff A.B.
        Radiologic evaluation of the insertion sites of the 2 functional bundles of the anterior cruciate ligament using 3-dimensional computed tomography.
        Am J Sports Med. 2009; 37: 2368-2376
        • Pietrini S.D.
        • Ziegler C.G.
        • Anderson C.J.
        • et al.
        Radiographic landmarks for tunnel positioning in double-bundle ACL reconstructions.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 792-800
        • Tsukada H.
        • Ishibashi Y.
        • Tsuda E.
        • Fukuda A.
        • Toh S.
        Anatomical analysis of the anterior cruciate ligament femoral and tibial footprints.
        J Orthop Sci. 2008; 13: 122-129
        • Zantop T.
        • Wellmann M.
        • Fu F.H.
        • Petersen W.
        Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: Anatomic and radiographic findings.
        Am J Sports Med. 2008; 36: 65-72
        • Wu E.
        • Chen M.
        • Cooperman D.
        • Victoroff B.
        • Goodfellow D.
        • Farrow L.D.
        No correlation of height or gender with anterior cruciate ligament footprint size.
        J Knee Surg. 2011; 24: 39-43