Comparison of Knee Kinematics After Single-Bundle Anterior Cruciate Ligament Reconstruction via the Medial Portal Technique With a Central Femoral Tunnel and an Eccentric Femoral Tunnel and After Anatomic Double-Bundle Reconstruction
Restricted accessResearch articleFirst published online January, 2016
Comparison of Knee Kinematics After Single-Bundle Anterior Cruciate Ligament Reconstruction via the Medial Portal Technique With a Central Femoral Tunnel and an Eccentric Femoral Tunnel and After Anatomic Double-Bundle Reconstruction
Anatomic femoral tunnel placement in anterior cruciate ligament (ACL) reconstruction is considered to be a key to good primary stability of the knee. There is still no consensus on whether a centrally placed single bundle in the anatomical femoral footprint can compare with anatomic double-bundle (DB) reconstruction.
Purpose/Hypothesis:
The purpose of this study was to determine knee kinematics after single-bundle ACL reconstruction via the medial portal technique using 2 different femoral tunnel positions and to compare results with those of the anatomic DB technique. The hypotheses were that (1) single-bundle reconstruction using the medial portal technique with a centrally placed femoral tunnel relative to the native footprint (SB-central technique) would more closely restore intact knee kinematics compared with the same reconstruction technique with an eccentric femoral tunnel drilled in the anteromedial bundle footprint (SB-AM technique) and (2) DB reconstruction would result in superior kinematics compared with the SB-central technique.
Study Design:
Controlled laboratory study.
Methods:
Knee kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force-moment sensor system. Kinematics in simulated pivot-shift and 134-N anterior tibial loading tests were determined in different conditions within the same specimen: (1) intact ACL, (2) deficient ACL, (3) SB-AM, (4) SB-central, and (5) DB.
Results:
All reconstruction techniques significantly reduced anterior tibial translation (ATT) compared with a deficient ACL at 0°, 15°, 30°, 60°, and 90° in the anterior tibial loading test (P < .01, repeated-measures analysis of variance) and at 0°, 15°, and 30° in the simulated pivot-shift test (P < .001). There were no significant differences in the SB-central group and the DB group compared with the intact ACL. Reconstruction in the SB-AM group resulted in significantly increased ATT compared with the intact ACL in near-to-extension angles in both tests (0°, 15°, and 30°; P < .01). SB-central and DB reconstructions both resulted in significantly reduced ATT, in some tests at ≤30°, compared with SB-AM reconstruction (P < .05). No significant differences between the SB-central and DB groups were found (P > .05).
Conclusion:
The SB-central technique restored intact knee kinematics more closely than did SB-AM reconstruction at time zero. There were no differences in knee kinematics between the DB and SB-central techniques.
Clinical Relevance:
Anatomic single-bundle ACL reconstruction provides similar knee kinematics as anatomic double-bundle reconstruction.
AhldenMSernertNKarlssonJKartusJ. A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(11):2484-2491.
2.
AjuiedAWongFSmithC. Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med. 2014;42(9):2242-2252.
3.
AndersenHNDyhre-PoulsenP. The anterior cruciate ligament does play a role in controlling axial rotation in the knee. Knee Surg Sports Traumatol Arthrosc. 1997;5(3):145-149.
4.
AyeniORChahalMTranMNSpragueS. Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012;20(4):767-777.
5.
BareniusBPonzerSShalabiABujakRNorlenLErikssonK. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year follow-up study of a randomized controlled trial. Am J Sports Med. 2014;42(5):1049-1057.
6.
BediAMaakTMusahlV. Effect of tunnel position and graft size in single-bundle anterior cruciate ligament reconstruction: an evaluation of time-zero knee stability. Arthroscopy. 2011;27(11):1543-1551.
7.
BediAMusahlVO’LoughlinP. A comparison of the effect of central anatomical single-bundle anterior cruciate ligament reconstruction and double-bundle anterior cruciate ligament reconstruction on pivot-shift kinematics. Am J Sports Med. 2010;38(9):1788-1794.
8.
BediAMusahlVSteuberV. Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy. 2011;27(3):380-390.
9.
CelentanoUCardosoMPMartinsCA. Use of transtibial aimer via the accessory anteromedial portal to identify the center of the ACL footprint. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):69-74.
10.
ChhabraAKlineAJNillesKMHarnerCD. Tunnel expansion after anterior cruciate ligament reconstruction with autogenous hamstrings: a comparison of the medial portal and transtibial techniques. Arthroscopy. 2006;22(10):1107-1112.
11.
CrawfordCNylandJLandesS. Anatomic double bundle ACL reconstruction: a literature review. Knee Surg Sports Traumatol Arthrosc. 2007;15(8):946-964, discussion 945.
12.
DriscollMDIsabellGPJrCondittMA. Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy. 2012;28(10):1481-1489.
13.
FaulFErdfelderELangAGBuchnerA. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175-191.
14.
GalwayHRMacIntoshDL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res. 1980;147:45-50.
15.
GoldsmithMTJanssonKSSmithSDEngebretsenLLaPradeRFWijdicksCA. Biomechanical comparison of anatomic single- and double-bundle anterior cruciate ligament reconstructions: an in vitro study. Am J Sports Med. 2013;41(7):1595-1604.
16.
GriffithTBAllenBJLevyBAStuartMJDahmDL. Outcomes of repeat revision anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(6):1296-1301.
17.
HerbortMLenschowSFuFHPetersenWZantopT. ACL mismatch reconstructions: influence of different tunnel placement strategies in single-bundle ACL reconstructions on the knee kinematics. Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1551-1558.
18.
HoJYGardinerAShahVSteinerME. Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy. 2009;25(5):464-472.
19.
HofbauerMMullerBMurawskiCDBaragaMvan EckCFFuFH. Strategies for revision surgery after primary double-bundle anterior cruciate ligament (ACL) reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013;21(9):2072-2080.
20.
HusseinMvan EckCFCretnikADinevskiDFuFH. Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med. 2012;40(3):512-520.
21.
JepsenCFLundberg-JensenAKFaunoeP. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? A clinical, prospective, randomized, double-blind study. Arthroscopy. 2007;23(12):1326-1333.
22.
JonssonHRiklund-AhlstromKLindJ. Positive pivot shift after ACL reconstruction predicts later osteoarthrosis: 63 patients followed 5-9 years after surgery. Acta Orthop Scand. 2004;75(5):594-599.
23.
KanamoriAZeminskiJRudyTWLiGFuFHWooSL. The effect of axial tibial torque on the function of the anterior cruciate ligament: a biomechanical study of a simulated pivot shift test. Arthroscopy. 2002;18(4):394-398.
24.
KatoYMaeyamaALertwanichP. Biomechanical comparison of different graft positions for single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):816-823.
25.
KocherMSSteadmanJRBriggsKKSterettWIHawkinsRJ. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32(3):629-634.
26.
KondoEMericanAMYasudaKAmisAA. Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2011;39(2):279-288.
27.
KopfSMusahlVBignozziSIrrgangJJZaffagniniSFuFH. In vivo kinematic evaluation of anatomic double-bundle anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(9):2172-2177.
28.
LohJCFukudaYTsudaESteadmanRJFuFHWooSL. 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(3):297-304.
29.
LorbachOKiebMDomnickC. Biomechanical evaluation of knee kinematics after anatomic single- and anatomic double-bundle ACL reconstructions with medial meniscal repair. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2734-2741.
30.
MusahlVPlakseychukAVanScyocA. Varying femoral tunnels between the anatomical footprint and isometric positions: effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med. 2005;33(5):712-718.
31.
OdenstenMGillquistJ. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am. 1985;67(2):257-262.
32.
PaxtonESKymesSMBrophyRH. Cost-effectiveness of anterior cruciate ligament reconstruction: a preliminary comparison of single-bundle and double-bundle techniques. Am J Sports Med. 2010;38(12):2417-2425.
33.
PetersenWTillmannB. Structure and vascularization of the cruciate ligaments of the human knee joint. Anat Embryol (Berl). 1999;200(3):325-334.
34.
PetersenWTretowHWeimannA. Biomechanical evaluation of two techniques for double-bundle anterior cruciate ligament reconstruction: one tibial tunnel versus two tibial tunnels. Am J Sports Med. 2007;35(2):228-234.
35.
PetersenWZantopT. Anatomy of the anterior cruciate ligament with regard to its two bundles. Clin Orthop Relat Res. 2007;454:35-47.
36.
PetersenWZantopT. Medial portal aimers: for anatomic femoral tunnel placement in ACL reconstructions using the medial portal technique. EndoWorld. 2014;96152040(ART 43-2 06/2014/EW-E):1-7.
37.
PiaseckiDPBachBRJrEspinoza OriasAAVermaNN. Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique?Am J Sports Med. 2011;39(6):1306-1315.
38.
RibohJCHasselbladVGodinJAMatherRC3rd. Transtibial versus independent drilling techniques for anterior cruciate ligament reconstruction: a systematic review, meta-analysis, and meta-regression. Am J Sports Med. 2013;41(11):2693-2702.
39.
RudyTWLivesayGAWooSLFuFH. A combined robotic/universal force sensor approach to determine in situ forces of knee ligaments. J Biomech. 1996;29(10):1357-1360.
40.
ScoppJMJasperLEBelkoffSMMoormanCT3rd. The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy. 2004;20(3):294-299.
41.
SilvaASampaioRPintoE. ACL reconstruction: comparison between transtibial and anteromedial portal techniques. Knee Surg Sports Traumatol Arthrosc. 2012;20(5):896-903.
42.
SuomalainenPJarvelaTPaakkalaAKannusPJarvinenM. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 5-year results. Am J Sports Med. 2012;40(7):1511-1518.
43.
TompkinsMMilewskiMDBrockmeierSFGaskinCMHartJMMillerMD. Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling. Am J Sports Med. 2012;40(6):1313-1321.
44.
van EckCFKopfSIrrgangJJ. Single-bundle versus double-bundle reconstruction for anterior cruciate ligament rupture: a meta-analysis. Does anatomy matter?Arthroscopy. 2012;28(3):405-424.
45.
WooSLFisherMB. Evaluation of knee stability with use of a robotic system. J Bone Joint Surg Am. 2009;91(suppl 1):78-84.
46.
WooSLKanamoriAZeminskiJYagiMPapageorgiouCFuFH. The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon: a cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am. 2002;84(6):907-914.
47.
YoumYSChoSDLeeSHYounCH. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Am J Sports Med. 2014;42(12):2941-2947.
48.
ZaffagniniSBruniDMartelliSImakiireNMarcacciMRussoA. Double-bundle ACL reconstruction: influence of femoral tunnel orientation in knee laxity analysed with a navigation system. An in-vitro biomechanical study. BMC Musculoskelet Disord. 2008;9:25.
49.
ZaffagniniSMarcheggiani MuccioliGMSignorelliC. Anatomic and nonanatomic double-bundle anterior cruciate ligament reconstruction: an in vivo kinematic analysis. Am J Sports Med. 2014;42(3):708-715.
50.
ZantopTDiermannNSchumacherTSchanzSFuFHPetersenW. Anatomical and nonanatomical double-bundle anterior cruciate ligament reconstruction: importance of femoral tunnel location on knee kinematics. Am J Sports Med. 2008;36(4):678-685.
51.
ZantopTHerbortMRaschkeMJFuFHPetersenW. The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation. Am J Sports Med. 2007;35(2):223-227.
52.
ZantopTPetersenWSekiyaJKMusahlVFuFH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):982-992.
53.
ZantopTWellmannMFuFHPetersenW. Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med. 2008;36(1):65-72.
