The Knee Proprioception as Patient-Dependent Outcome Measures within Surgical and Non-Surgical Interventions

Mapping Intimacies ◽

10.5772/intechopen.94887 ◽

2020 ◽

Author(s):

Wangdo Kim

Keyword(s):

Acl Reconstruction ◽

Tibial Tunnel ◽

Mathematical Framework ◽

Tunnel Placement ◽

Surgical Interventions ◽

Musculoskeletal Tissues ◽

Active Sets ◽

Biological Environment ◽

Based Medicine ◽

Perceptual Systems

Proprioception considered as the obtaining of information about one’s own action does not necessarily depend on proprioceptors. At the knee joint, perceptual systems are active sets of organs designed to reach equilibrium through synergies. Many surgical procedures, such as ACL reconstruction in personalized medicine, are often based on native anatomy, which may not accurately reflect the proprioception between native musculoskeletal tissues and biomechanical artifacts. Taking an affordance-based approach to this type of “design” brings valuable new insights to bear in advancing the area of “evidence-based medicine (EBM).” EBM has become incorporated into many health care disciplines, including occupational therapy, physiotherapy, nursing, dentistry, and complementary medicine, among many others. The design process can be viewed in terms of action possibilities provided by the (biological) environment. In anterior crucial ligament (ACL) reconstruction, the design goal is to avoid ligament impingement while optimizing the placement of the tibial tunnel. Although in the current rationale for tibial tunnel placement, roof impingement is minimized to avoid a negative affordance, we show that tibial tunnel placement can rather aim to constrain the target bounds with respect to a positive affordance. We describe the steps for identifying the measurable invariants in the knee proprioception system and provide a mathematical framework for the outcome measure within the knee.

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Iatrogenic lateral meniscus anterior horn injury in different tibial tunnel placement techniques in ACL reconstruction surgery – A cadaveric study

Acta Orthopaedica et Traumatologica Turcica ◽

10.1016/j.aott.2016.08.009 ◽

2016 ◽

Vol 50 (5) ◽

pp. 514-518 ◽

Cited By ~ 6

Author(s):

Ahmet Karakasli ◽

Nihat Acar ◽

Onur Basci ◽

Ahmet Karaarslan ◽

Mehmet Erduran ◽

...

Keyword(s):

Acl Reconstruction ◽

Tibial Tunnel ◽

Lateral Meniscus ◽

Cadaveric Study ◽

Anterior Horn ◽

Tunnel Placement ◽

Reconstruction Surgery

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Radiological assessment of femoral and tibial tunnel placement in arthroscopic ACL reconstruction using hamstring tendon graft

International Journal of Orthopaedics Sciences ◽

10.22271/ortho.2020.v6.i2i.2099 ◽

2020 ◽

Vol 6 (2) ◽

pp. 563-568

Author(s):

Dr. Rajesh Naidu P ◽

Dr. M Krishna Chaitanya ◽

Dr. Ambareesh P ◽

Dr. Sheikh Mohammed Fahim ◽

Dr. Gowtham Reddy

Keyword(s):

Acl Reconstruction ◽

Tibial Tunnel ◽

Hamstring Tendon ◽

Tendon Graft ◽

Radiological Assessment ◽

Hamstring Tendon Graft ◽

Tunnel Placement

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Iatrogenic Lateral Meniscus Anterior Horn Injury in Different Tibial Tunnel Placement Techniques in ACL Reconstruction Surgery - A Cadaveric Study

Acta Orthopaedica et Traumatologica Turcica ◽

10.3944/aott.2016.15.0340 ◽

2016 ◽

Author(s):

Ahmet Karakasli

Keyword(s):

Acl Reconstruction ◽

Tibial Tunnel ◽

Lateral Meniscus ◽

Cadaveric Study ◽

Anterior Horn ◽

Tunnel Placement ◽

Reconstruction Surgery

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DOES ACL TUNNEL PLACEMENT AFFECT QUALITY OF LIFE IN ADOLESCENTS?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00042 ◽

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]

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Tibial Spine Location Influences Tibial Tunnel Placement in Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction

The Journal of Knee Surgery ◽

10.1055/s-0040-1713736 ◽

2020 ◽

Author(s):

Takanori Iriuchishima ◽

Bunsei Goto

Keyword(s):

Acl Reconstruction ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

Single Bundle ◽

Tunnel Placement ◽

Anterior Border ◽

Medial Border ◽

Tibial Spine ◽

Anterior Cruciate ◽

Tibia Plateau

AbstractThe purpose of this study was to assess the influence of tibial spine location on tibial tunnel placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT). A total of 39 patients undergoing anatomical single-bundle ACL reconstruction were included in this study (30 females and 9 males; average age: 29 ± 15.2 years). In anatomical single-bundle ACL reconstruction, the tibial and femoral tunnels were created close to the anteromedial bundle insertion site using a transportal technique. Using postoperative 3D-CT, accurate axial views of the tibia plateau were evaluated. By assuming the medial and anterior borders of the tibia plateau as 0% and the lateral and posterior borders as 100%, the location of the medial and lateral tibial spine, and the center of the tibial tunnel were calculated. Statistical analysis was performed to assess the correlation between tibial spine location and tibial tunnel placement. The medial tibial spine was located at 54.7 ± 4.5% from the anterior border and 41.3 ± 3% from the medial border. The lateral tibial spine was located at 58.7 ± 5.1% from the anterior border and 55.3 ± 2.8% from the medial border. The ACL tibial tunnel was located at 34.8 ± 7.7% from the anterior border and 48.2 ± 3.4% from the medial border. Mediolateral tunnel placement was significantly correlated with medial and lateral tibial spine location. However, for anteroposterior tunnel placement, no significant correlation was found. A significant correlation was observed between mediolateral ACL tibial tunnel placement and medial and lateral tibial spine location. For clinical relevance, tibial ACL tunnel placement might be unintentionally influenced by tibial spine location. Confirmation of the ACL footprint is required to create accurate anatomical tunnels during surgery. This is a Level III; case–control study.

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

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117704152 ◽

2017 ◽

Vol 5 (5) ◽

pp. 232596711770415 ◽

Cited By ~ 2

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.

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Tibial tunnel placement in anatomic ACL reconstruction

Journal of Biomechanics ◽

10.1016/s0021-9290(06)83107-6 ◽

2006 ◽

Vol 39 ◽

pp. S56-S67

Author(s):

W. Petersen ◽

T. Zantop

Keyword(s):

Acl Reconstruction ◽

Tibial Tunnel ◽

Tunnel Placement ◽

Anatomic Acl Reconstruction

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Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/0363546519873633 ◽

2019 ◽

Vol 47 (13) ◽

pp. 3187-3194 ◽

Cited By ~ 1

Author(s):

Christopher Pedneault ◽

Carl Laverdière ◽

Adam Hart ◽

Mathieu Boily ◽

Mark Burman ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

3D Mri ◽

Tunnel Placement ◽

Anatomic Acl Reconstruction ◽

Imaging Protocol ◽

Tibial Footprint ◽

Anterior Cruciate

Background: Anatomic anterior cruciate ligament (ACL) reconstruction improves knee kinematics and joint stability in symptomatic patients who have ACL deficiency. Despite a concerted effort to place the graft within the ACL’s native attachment sites, the accuracy of tunnel placement using contemporary techniques is not well established. Purpose: To use 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate the accuracy of tibial tunnel placement after anatomic ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Forty patients with symptomatic, ACL-deficient knees were prospectively enrolled in the study and underwent 3D MRI of both their injured and uninjured knees before and after surgery through use of a validated imaging protocol. The root ligament of the anterior horn of the lateral meniscus was used as a radiographic reference, and the center of the reconstructed graft was compared with that of the contralateral normal knee. The tunnel angles and intra-articular graft angles were also measured, as was the percentage overlap between the native tibial footprint and tibial tunnel. Results: The reconstructed tibial footprint was placed at a mean ± SD of 2.14 ± 2.45 mm ( P < .001) medial and 5.11 ± 3.57 mm ( P < .001) posterior to the native ACL footprint. The mean distance between the center of the native and reconstructed ACL at the tibial attachment site was 6.24 mm. Of the 40 patients, 18 patients had a tibial tunnel that overlapped more than 50% of the native footprint, and 10 patients had maximal (100%) overlap. Further, 22 of the 40 patients had less than 50% overlap with the native footprint, and in 12 patients the footprint was missing completely. Conclusion: Despite the use of contemporary surgical techniques to perform anatomic ACL reconstruction, a significant positioning error in tibial tunnel placement remains.

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