scholarly journals DOES ACL TUNNEL PLACEMENT AFFECT QUALITY OF LIFE IN ADOLESCENTS?

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0004
Author(s):  
Brandon Tauberg ◽  
Ronen Sever ◽  
Regina Hanstein ◽  
Eric Fornari
Keyword(s):  
Acl Reconstruction ◽  
Femoral Tunnel ◽  
Tibial Tunnel ◽  
Self Report ◽  
Tunnel Placement ◽  
Secondary Surgery ◽  
Tourniquet Time ◽  
Pain Scores ◽  
Outcome Scores ◽  
Tunnel Angle

Purpose: The aim of this study was to evaluate the influence of surgical experience of an orthopaedic surgeon on femoral and tibial tunnel placement during anterior cruciate ligament (ACL) reconstruction, and the effect of tunnel angle on patient self-report outcomes. Methods: We retrospectively reviewed 115 consecutive ACL reconstruction surgeries by a single fellowship-trained orthopaedic surgeon over his first 5 years in practice. 70 patients with hamstring (HS) and 44 patients with bone-patellar tendon-bone (BTB) autografts were included, all epiphyseal approaches, graft hybrids or allografts were excluded. Posterior distal femoral angle (PDFA), femoral and tibial tunnel angulation were measured on AP and lateral radiographs by 2 independent raters with high inter-rater reliability (ICC >0.8 for all measures). Tunnel angulation was compared to recently reported ideal femoral angle of 33.5°±1.8 or ideal tibial angle of 62.5°±5 (Luthringer et al, 2016). Complications and self-report outcomes - pediIKDC, Tegner-Lysholm and KOOSChild - were recorded, as well as demographics, injury and surgery characteristics (e.g. concurrent meniscal repairs, chondroplasty, tourniquet time). Average follow-up was 1.14 years. Continuous variables were analyzed using unpaired t-test, Wilcoxon rank sum test and Spearman correlation. Categorical variables were analyzed using Fisher’s exact test. Results: ACL reconstruction was performed at an average age of 16.7 years (range, 11.8 to 20.4 years), 59% males. Figure 1 shows tunnel angles over case groups of N=15. For HS autografts, femoral tunnel angle and tibial tunnel angle improved toward the ideal angle after 15 cases (ANOVA, p=0.020 and p=0.031, respectively). For BTB autografts, femoral tunnel angle and tibial tunnel angle did not demonstrate a significant change over cases (Figure 1). The tibial tunnel angle in HS cases showed a negative weak correlation with the selected outcome scores at 6 months and 1 year after ACL reconstruction, whereas the tibial tunnel angle in BTB cases showed a weak positive correlation with KOOSChild pain scores 6 months after initial surgery (Table 1). For either graft type, femoral tunnel angle was not correlated with any outcome measure. Overall, self-report outcome scores were similar between patients with ideal and non-ideal tunnel angles (data not shown). Of the 70 patients with HS autografts, 5 (7%) required a secondary surgery: 2 revisions for graft tear, 1 revision for a non-functional graft, 1 for arthrofibrosis and 1 for a prominent tibial screw. PDFA, femoral and tibial tunnel angle were similar between patients needing secondary surgery and those who did not (Table 2). Patients needing revision surgery had significantly lower Tegner-Lysholm and KOOSChild Pain scores at 6 months after the initial ACL reconstruction. Of the 44 BTB patients, 3 (6.8%) had complications: 2 patients developed arthrofibrosis and subsequently underwent surgery, and 1 patient experienced neuropathy. In these patients, the PDFA was significantly higher, the femoral tunnel angle significantly lower and tibial tunnel angle similar compared to those without a complication (Table 2). Demographic factors, injury and surgical parameters (concurrent meniscal repairs, chondroplasty, tourniquet time, aso) were similar between HS patients with or without additional surgery and between BTB patients with and without complications. Conclusion/Significance: Femoral and tibial tunnel angle improved towards the reported ideal angle after 15 cases for HS autografts. PDFA, femoral and tibial tunnel angle were not associated with surgical complications in HS patients. For BTB autografts, no significant changes were seen in tunnel placement with surgical experience. Patients experiencing complications after BTB autografts had a low femoral tunnel angle and high PDFA. Overall, tibial tunnel angle, but not femoral tunnel angle, correlated with outcome scores of patients with BTB and HS autografts. [Figure: see text][Table: see text][Table: see text]

Evaluation of Tibial Tunnel Location with the Femoral Tunnel Created Behind the Resident's Ridge in Transtibial Anterior Cruciate Ligament Reconstruction

2021 ◽  
Author(s):  
Tsuneari Takahashi ◽  
Tomohiro Saito ◽  
Tatsuya Kubo ◽  
Ko Hirata ◽  
Hideaki Sawamura ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Femoral Tunnel ◽  
Cruciate Ligament ◽  
Tibial Tunnel ◽  
Bone Tunnel ◽  
Femoral Bone ◽  
Anterior Cruciate ◽  
Tunnel Positions ◽  
Tunnel Angle ◽  
Coronal View

AbstractFew studies have determined whether a femoral bone tunnel could be created behind the resident's ridge by using a transtibial (TT) technique-single bundle (SB)-anterior cruciate ligament (ACL) reconstruction. The aim of this study was to clarify (1) whether it is possible to create a femoral bone tunnel behind the resident's ridge by using the TT technique with SB ACL reconstruction, (2) to define the mean tibial and femoral tunnel angles during anatomic SB ACL reconstruction, and (3) to clarify the tibial tunnel inlet location when the femoral tunnel is created behind resident's ridge. Arthroscopic TT-SB ACL reconstruction was performed on 36 patients with ACL injuries. The point where 2.4-mm guide pin was inserted was confirmed, via anteromedial portal, to consider a location behind the resident's ridge. Then, an 8-mm diameter femoral tunnel with a 4.5-mm socket was created. Tunnel positions were evaluated by using three-dimensional computed tomography (3D-CT) 1 week postoperatively. Quadrant method and the resident's ridge on 3D-CT were evaluated to determine whether femoral tunnel position was anatomical. Radiological evaluations of tunnel positions yielded mean ( ±  standard deviation) X- and Y-axis values for the tunnel centers: femoral tunnel, 25.2% ± 5.1% and 41.6% ± 10.2%; tibial tunnel, 49.2% ± 3.5%, and 31.5% ± 7.7%. The bone tunnels were anatomically positioned in all cases. The femoral tunnel angle relative to femoral axis was 29.4 ± 5.5 degrees in the coronal view and 43.5 ± 8.0 degrees in the sagittal view. The tibial tunnel angle relative to tibial axis was 25.5 ± 5.3 degrees in the coronal view and 52.3 ± 4.6 degrees in the sagittal view. The created tibial bone tunnel inlet had an average distance of 13.4 ± 2.7 mm from the medial tibial joint line and 9.7 ± 1.7 mm medial from the axis of the tibia. Femoral bone tunnel could be created behind the resident's ridge with TT-SB ACL reconstruction. The tibial bone tunnel inlet averaged 13.4 mm from the medial tibial joint line and 9.7 mm medial from the tibia axis.

scholarly journals Can an Anatomical ACL Reconstruction be Performed with Two Standart Portals?

2014 ◽  
Vol 2 (11_suppl3) ◽  
pp. 2325967114S0012
Author(s):  
Cem Coşkun Avcı ◽  
Hüseyin Koca ◽  
Necdet Sağlam ◽  
Tuhan Kurtulmuş ◽  
Gürsel Saka
Keyword(s):  
Acl Reconstruction ◽  
Femoral Tunnel ◽  
Coronal Plane ◽  
Radiographic Measurement ◽  
Single Bundle ◽  
Anteromedial Portal ◽  
Tunnel Placement ◽  
Tunnel Length ◽  
Femoral Tunnel Drilling ◽  
Tunnel Angle

Objectives: Recent studies have demonstrated that ACL reconstruction via anatomic tunnel placement would provide superior stability. In order to achieve an anatomic femoral tunnel, accessory anteromedial portal (three-portal tecnique) and medial Hoffa excision is necessary. Femoral tunnel drilling through a far anteromedial portal facilitates anatomic tunnel placement but can also results in shorter femoral tunnel and articular cartilage damage of the medial femoral condyle. Our purpose in this study was to evaluate whether an anatomic single bundle ACL reconstruction can be performed with the use of the two standart portals (anteromedial and anterolateral). Methods: Fifty seven patient underwent single bundle ACL reconstruction in our clinic between 2012-2014, with the use of either standart portals or three-portal tecnique. We measured the tunnel length and and femoral tunnel angle in coronal plane to assess the reconstruction. Two portals group included thirty -three patients (twenty-nine males, four females with a mean age of 27±2,4) and three portals group included twenty–four patients (twenty-three males, one female with a mean age of 26±2,9). All patients were evaluated with computerized tomography (CT) scans to determine femoral tunnel length and obliquity. Tunnel length was defined as the distance between the intra-articular and extra-articular tunnel apertures in coronal sections. Femoral tunnel angle was measured in the coronal plane on AP radiographs of the knee. For statistical analysis, student t test was used for normal categorical data. A p value of <0.05 was considered significant. Results: Average tunnel length was 44.2 ±6.8 mm (range: 32.6-55.2) in two portals group and 32.8±7.9 mm (range: 24.8-43.2) in three portal group. The average tunnel length in three portal group was significantly smaller (p<0.05). According to radiographic measurement on the AP view, femoral tunnel angle averaged 48.20±7.10 (range:38.60-56.10) in two portals group and 47.20±6,30 (range: 39.40-55.20) in three portals group. This difference was not statistically significant (p=0.2). Conclusion: Femoral tunnels drilled with standart two-portal tecnique were longer than three-portal tecnique. However, femoral tunnel angles was not different in two groups. Tunnel characteristic in terms of anatomic position was obtained with standart two-portal tecnique. Consequently, femoral tunnels can be placed anatomically with standart portals.

scholarly journals ACL Roof Impingement Revisited: Does the Independent Femoral Drilling Technique Avoid Roof Impingement With Anteriorly Placed Tibial Tunnels?

2017 ◽  
Vol 5 (5) ◽  
pp. 232596711770415 ◽  
Author(s):  
John A. Tanksley ◽  
Brian C. Werner ◽  
Evan J. Conte ◽  
David P. Lustenberger ◽  
M. Tyrrell Burrus ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acl Reconstruction ◽  
Clinical Studies ◽  
Femoral Tunnel ◽  
Tibial Tunnel ◽  
Attachment Site ◽  
Tunnel Placement ◽  
Anterior Tibial ◽  
Drilling Technique ◽  
Graft Angle

Background: Anatomic femoral tunnel placement for single-bundle anterior cruciate ligament (ACL) reconstruction is now well accepted. The ideal location for the tibial tunnel has not been studied extensively, although some biomechanical and clinical studies suggest that placement of the tibial tunnel in the anterior part of the ACL tibial attachment site may be desirable. However, the concern for intercondylar roof impingement has tempered enthusiasm for anterior tibial tunnel placement. Purpose: To compare the potential for intercondylar roof impingement of ACL grafts with anteriorly positioned tibial tunnels after either transtibial (TT) or independent femoral (IF) tunnel drilling. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaver knees were randomized to either a TT or IF drilling technique. Tibial guide pins were drilled in the anterior third of the native ACL tibial attachment site after debridement. All efforts were made to drill the femoral tunnel anatomically in the center of the attachment site, and the surrogate ACL graft was visualized using 3-dimensional computed tomography. Reformatting was used to evaluate for roof impingement. Tunnel dimensions, knee flexion angles, and intra-articular sagittal graft angles were also measured. The Impingement Review Index (IRI) was used to evaluate for graft impingement. Results: Two grafts (2/6, 33.3%) in the TT group impinged upon the intercondylar roof and demonstrated angular deformity (IRI type 1). No grafts in the IF group impinged, although 2 of 6 (66.7%) IF grafts touched the roof without deformation (IRI type 2). The presence or absence of impingement was not statistically significant. The mean sagittal tibial tunnel guide pin position prior to drilling was 27.6% of the sagittal diameter of the tibia (range, 22%-33.9%). However, computed tomography performed postdrilling detected substantial posterior enlargement in 2 TT specimens. A significant difference in the sagittal graft angle was noted between the 2 groups. TT grafts were more vertical, leading to angular convergence with the roof, whereas IF grafts were more horizontal and universally diverged from the roof. Conclusion: The IF technique had no specimens with roof impingement despite an anterior tibial tunnel position, likely due to a more horizontal graft trajectory and anatomic placement of the ACL femoral tunnel. Roof impingement remains a concern after TT ACL reconstruction in the setting of anterior tibial tunnel placement, although statistical significance was not found. Future clinical studies are planned to develop better recommendations for ACL tibial tunnel placement. Clinical Relevance: Graft impingement due to excessively anterior tibial tunnel placement using a TT drilling technique has been previously demonstrated; however, this may not be a concern when using an IF tunnel drilling technique. There may also be biomechanical advantages to a more anterior tibial tunnel in IF tunnel ACL reconstruction.

scholarly journals Anterior Cruciate Ligament Reconstruction

2014 ◽  
Vol 2 (12_suppl4) ◽  
pp. 2325967114S0023
Author(s):  
Francisco Arcuri ◽  
Fernando Barclay ◽  
Ivan Nacul
Keyword(s):  
Acl Reconstruction ◽  
Tibial Plateau ◽  
Femoral Tunnel ◽  
Cruciate Ligament ◽  
Tibial Tunnel ◽  
Insertion Site ◽  
X Rays ◽  
Tunnel Position ◽  
Tibial Tunnel Position ◽  
Tunnel Angle

Introduction: The most recent advances in ACL reconstruction try to reproduce the anatomic femoral and tibial footprints as close as possible. Creating independent tunnels would allow an optimal of the entry point and the femoral tunnel obliquity, and together with an adequate reamer diameter they wouldreproduce with greater certainty the anatomy. Objective: To compare the radiographic parameters of the femoral and tibial tunnel positions in two groups of patients, one operated with a transtibial and other with transportal anatomic techniques. Materials and Methods: From December 2012 to December 2013, 59 patients with a primary ACL reconstruction divided in two groups, a trans tibial technique (TT), 19 patients, and an transportal one (TP) with 40 patients were prospectively evaluated with AP and lateral X-rays. The femoral tunnel angle, the insertion site with respect of the Blumensaat line, the trans osseous distance, the tibial tunnel position as a percentage of the tibial plateau in the AP and lateral views. And finally the tibial tunnel angle in the AP and Lateral views. Results: The femoral tunnel angle was in the TP group of 45,92º and in the TT one 24,53º, p 0,002. The insertion site percentage of the Blumensaat line was of 20,96 in TP and 20,74 in the TT, p 0,681.Trans osseous distance was in the TP of 3,43 cm and in the TT of 4,79 cm, p <0,000. The tibial tunnel position as a percentage in the AP tibial plateau was of 44,35 in TP and of 40,80 TT with a p of 0,076. The tibial tunnel position as a percentage of the lateral tibial plateau was of 28,70 in TP and 34,53 in TT with a p 0,367. Tibial tunnel angle in the AP was of 73,48º in TP and 62,81 in TT with a p of 0,002, and in the lateral plateau of 114,69º in TP and 112,79º in TT with a p of 0,427. Conclusion: It is possible to create tibial and femoral tunnel in optimal positions but not equal between both groups. Creating independent tunnels allow a more anterior and vertical tibial tunnel allowing a better coverage of the tibial footprint. A transportal femoral tunnel would allow a better inclination angle and a lesser trans-osseous distance, technical details that would allow a better coverage of the femoral footprint.

scholarly journals Three-Dimensional CT Evaluation of Tunnel Positioning in ACL Reconstruction Using the Single Anteromedial Bundle Biological Augmentation (SAMBBA) Technique

2017 ◽  
Vol 5 (5) ◽  
pp. 232596711770651 ◽  
Author(s):  
Florent Buscayret ◽  
Eduardo Frois Temponi ◽  
Adnan Saithna ◽  
Mathieu Thaunat ◽  
Bertrand Sonnery-Cottet
Keyword(s):  
Acl Reconstruction ◽  
Femoral Tunnel ◽  
Tibial Tunnel ◽  
Three Dimensional ◽  
Tunnel Placement ◽  
Anteromedial Bundle ◽  
Anatomic Acl Reconstruction ◽  
Ct Evaluation ◽  
Semitendinosus Graft ◽  
Biological Augmentation

Background: Remnant preservation may confer important advantages in the anterior cruciate ligament (ACL)–reconstructed knee. However, the presence of a large remnant may obscure visualization and impair the ability to correctly place tunnels during surgery. Purpose: To determine whether tunnel placement during anatomic ACL reconstruction using the single anteromedial bundle biological augmentation (SAMBBA) technique is consistent and precise when a large native remnant is preserved. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were 99 patients undergoing an ACL reconstruction during which at least 50% of the native ACL was preserved. The femoral tunnel was created using an outside-in specific guide. The tibial tunnel was positioned in the anteromedial region of the ACL footprint, and the remnant was carefully preserved while drilling and passing the semitendinosus graft through it. Postoperatively, 3-dimensional computed tomography (3D CT) was used to evaluate tunnel placement. The mean tunnel locations were calculated and the standard deviation was used to evaluate precision of positioning. Inter- and intrareader agreement were determined to assess reliability of evaluation of tunnel position. Results: The center of the femoral tunnel was positioned at a mean 19.4% (SD, 2%) of the depth of the notch and a mean 23.1% (SD, 3.5%) of the lateral wall height. The center of the tibial tunnel was positioned at a mean 36.3% (SD, 3.8%) of the anteroposterior length of the tibial plateau and at a mean 47.0% (SD, 2.7%) of the mediolateral width. The small standard deviations demonstrate that this technique allows precise tunnel placement. The tunnel positions achieved were consistent with previous anatomic studies of femoral and tibial anteromedial bundle insertion. Intra- and interobserver reliability were high. Conclusion: Three-dimensional CT evaluation demonstrated that despite the presence of a large remnant, placement of femoral and tibial tunnels for anatomic ACL reconstruction using the SAMBBA technique is consistent and precise.

Effect of tibial tunnel diameter on femoral tunnel placement in transtibial single bundle ACL reconstruction

2014 ◽  
Vol 24 (1) ◽  
pp. 51-57 ◽  
Author(s):  
Sanjeev Bhatia ◽  
Kyle Korth ◽  
Geoffrey S. Van Thiel ◽  
Rachel M. Frank ◽  
Deepti Gupta ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Femoral Tunnel ◽  
Tibial Tunnel ◽  
Single Bundle ◽  
Tunnel Placement ◽  
Tunnel Diameter ◽  
Femoral Tunnel Placement

scholarly journals Radiologic and Clinical Evaluation of Anatomic and Transtibial ACL Reconstruction in a Population Excluding Professional Athletes

2014 ◽  
Vol 2 (11_suppl3) ◽  
pp. 2325967114S0012
Author(s):  
Zeki Taşdemir ◽  
Safiye Tokgöz Özal ◽  
Nurzat Elmalı ◽  
Fevzi Sağlam
Keyword(s):  
Acl Reconstruction ◽  
Sagittal Plane ◽  
Femoral Tunnel ◽  
Tibial Tunnel ◽  
Single Bundle ◽  
Lateral Condyle ◽  
Anteromedial Portal ◽  
Angular Difference ◽  
Significant Difference ◽  
Tunnel Angle

Objectives: Two different approaches for drilling the femoral tunnel are commonly used in single-bundle anterior cruciate ligament (ACL) reconstruction: creating the femoral tunnel through the tibial tunnel or drilling the tunnel through a low anteromedial portal. The purpose of this retrospective study was to compare the radiological and clinical outcomes of hamstring ACL reconstruction using the transtibial (TT) versus the anteromedial portal (AM) technique for drilling the femoral tunnel by two different surgeons in non-professional athletes. Methods: Using the elevator system with hamstring tendons, single-bundle ACL reconstruction was applied to 24 patients with the TT technique and to 15 patients with the AM technique. Radiological outcome was evaluated by the postoperative X-rays and MRI images at the 6-9 month and clinical outcomes by the modified Cincinnati Knee Score. The angle made by the tunnel with the anatomic axis of the femur (FTA) and the angle made by the tunnel with the anatomic axis of the tibia (TTA) were examined on direct radiographs and the angular difference between the tunnels was evaluated. On MRI, evaluation was made of the anterior length in the sagittal plane of the exit point of the tibial tunnel in the joint (TAS) in ratio to the whole plateau (TSR) and the posterior length in the sagittal plane of the entrance point of the femoral tunnel in the femoral lateral condyle (FPS) in ratio to the anterior posterior diameter of the whole condyle (FCR) and the height of the lateral condyle location in the sagittal plane (FH). Results: The FH height ratio of the TT group was statistically significant when compared to the AM group (p<0.01). No statistically significant difference was found between the groups in respect of FPS (p>0.05). The mean femoral tunnel angle of the AM group was statistically significant compared to that of the TT group (p<0.01). The mean tibial tunnel angle of the TT group was statistically significant compared to that of the AM group (p<0.01). The angular difference of the AM group was statistically significant compared to that of the TT group (p<0.01). In both the AM and TT groups, the increase seen in the postoperative clinical scores compared to the preoperative scores was determined to be statistically significant (p<0.01). No statistically significant relationship was determined in either the AM group or the TT group between the postoperative clinical scores and the femoral tunnel angle, the tibial tunnel angle and the angular difference (p>0.05). Conclusion: When using a transtibial drilling technique, the location of the femoral tunnel is restricted by the angulation of the tibial tunnel in the coronal plane and may lead to a high placement of the femoral tunnel in a non-anatomical position. The use of the anteromedial portal (AMP) for the femoral drilling provides the surgeon with more freedom to anatomically place the tunnel in the natural femoral ACL footprint, thus improving rotational stability. In this early stage study of individuals not participating in professional sports, although a significant difference was seen in favour of the anatomic group, in the radiological measurements between the anatomic and transtibial groups, no significant difference was determined in respect of clinical results. This can be considered to be due to a low requirement for rotational stability in individuals who do not participate sports.

scholarly journals Three-Dimensional Reconstruction Computed Tomography Evaluation of the Tunnel Location and Angle during Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

2017 ◽  
Vol 5 (2_suppl2) ◽  
pp. 2325967117S0009
Author(s):  
Sang Hak Lee ◽  
Kyung Hk Yoon ◽  
Chan Il Bae
Keyword(s):  
Acl Reconstruction ◽  
Femoral Tunnel ◽  
Cruciate Ligament ◽  
Tibial Tunnel ◽  
Posterior Wall ◽  
Width Ratio ◽  
Single Bundle ◽  
Tunnel Length ◽  
Tunnel Position ◽  
The Mean

Purpose: Tibial tunnel-independent drilling has attracted increased interest in recent years for anatomic anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the geometry and position of the femoral tunnel between the anteromedial portal (AMP) and outside-in (OI) techniques after anatomic single-bundle ACL reconstruction. Methods: We prospectively evaluated 82 patients undergoing single-bundle ACL reconstruction with hamstring tendon autografts using either the AMP (n=40) or OI (n=42) technique. The locations of the tibial and femoral tunnel apertures were assessed by immediate postoperative 3-dimensional computed tomography (3D CT) imaging with OsiriX imaging software. The femoral graft bending angle, femoral tunnel aperture shape (height/width ratio), femoral tunnel length, and posterior wall breakage were also measured. Results: The two techniques did not differ significantly in the femoral tunnel position perpendicular to the Blumensaat line. However, the mean femoral tunnel position parallel to the Blumensaat line was more caudally positioned in the AMP group than in the OI group (P=0.025) The two groups did not differ significantly in tibial tunnel position. The mean femoral tunnel length did not differ between the AMP (36.1±0.33 mm) and OI groups (35.6±0.37 mm; P=0.548) The mean femoral graft angle in the OI group (99.6°±7.1°) was significantly more acute than that of the AMP group (108.9°±10.2°) (p < 0.0001). The mean height/width ratio of the AMP group (1.21±0.20) was significantly more ellipsoidal than that of the OI group (1.07±0.09) (p < 0.0001). Posterior wall breakage was detected in 3 cases (7.5%), all in the AMP group. Conclusions: After single-bundle anatomic ACL reconstruction, 3D CT showed a significantly shallower femoral tunnel in the AMP group than in the OI group. The AMP group had a more ellipsoidal femoral tunnel with a risk of posterior wall breakage than the OI group. The OI group showed a more acute bending angle of the femoral tunnel than the AMP group. [Figure: see text][Figure: see text]

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