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. 2014 Sep;26(3):168-76.
doi: 10.5792/ksrr.2014.26.3.168. Epub 2014 Aug 29.

Remnant-preserving Anterior Cruciate Ligament Reconstruction Using a Three-Dimensional Fluoroscopic Navigation System

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Free PMC article

Remnant-preserving Anterior Cruciate Ligament Reconstruction Using a Three-Dimensional Fluoroscopic Navigation System

Shuji Taketomi et al. Knee Surg Relat Res. .
Free PMC article

Abstract

Introduction: Recently, remnant-preserving anterior cruciate ligament (ACL) reconstruction has been increasingly performed to achieve revascularization, cell proliferation, and recovery of high-quality proprioception. However, poor arthroscopic visualization makes accurate socket placement during remnant-preserving ACL reconstruction difficult. This study describes a surgical technique used to create an anatomical femoral socket with a three-dimensional (3D) fluoroscopy based navigation system during technically demanding remnant-preserving ACL reconstruction.

Surgical technique: After a reference frame was attached to the femur, an intraoperative image of the distal femur was obtained, transferred to the navigation system and reconstructed into a 3D image. A navigation computer helped the surgeon visualize the entire lateral wall of the femoral notch and lateral intercondylar ridge, even when the remnant of the ruptured ACL impeded arthroscopic visualization of the bone surface. When a guide was placed, the virtual femoral tunnel overlapped the reconstructed 3D image in real time; therefore, only minimal soft tissue debridement was required.

Materials and methods: We treated 47 patients with remnant-preserving ACL reconstruction using this system. The center of the femoral socket aperture was calculated according to the quadrant technique using 3D computed tomography imaging.

Results: The femoral socket locations were considered to be an anatomical footprint in accordance with previous cadaveric studies.

Conclusions: The 3D fluoroscopy-based navigation can assist surgeons in creating anatomical femoral sockets during remnant-preserving ACL reconstruction.

Keywords: Anterior cruciate ligament; Computer-assisted surgery; Remnant; Three-dimensional computed tomography.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1
Fig. 1
Image data acquisition and reconstruction. (A) Intraoperative three-dimensional images are acquired with the C-arm. (B) The acquired image data are downloaded to the navigation computer.
Fig. 2
Fig. 2
Navigation views of the right knee. The surface of the lateral wall of the intercondylar notch in an orthogonal projection is visualized on the navigation computer screen. Concurrent axial, coronal, and sagittal two-dimensional images of any point can also be referenced.
Fig. 3
Fig. 3
Arthroscopic and navigation views of the femoral guide. (A) Arthroscopic view of the lateral wall of the femoral intercondylar notch can be obtained through the anteromedial (AM) portal with the knee in 90° flexion. The tip of the femoral guide is placed within the anatomical femoral footprint through a far AM portal. (B) Navigation view of the lateral wall and roof of the femoral intercondylar notch on the three-dimensional reconstructed image. The white arrow shows the tip of the femoral guide.
Fig. 4
Fig. 4
Navigation view of the right knee. (A) The three-dimensional image is rotated 90° on the navigation screen in order to evaluate the risk of a back wall blowout. (B) The image is rotated 180° to show the lateral aspect of the distal femur.
Fig. 5
Fig. 5
Intraoperative arthroscopic views of the right knee. (A) The triangles show residual remnant of the torn anterior cruciate ligament (ACL). (B) The ACL remnant is retracted medially by a probe. (C) The femoral guide (white arrow) is placed within the anatomical femoral footprint through a far anteromedial portal. (D) Two parallel guide wires are inserted within the femoral insertion of the ACL. The triangles show the residual remnant of the torn ACL and the black arrow shows the end of the guide pin.
Fig. 6
Fig. 6
Intraoperative arthroscopic views of the right knee. (A) Rectangular socket for bone-patellar tendon-bone graft (BTB) grafting. (B) The BTB graft is covered by the preserved remnant of the torn anterior cruciate ligament.
Fig. 7
Fig. 7
Intraoperative arthroscopic views of the right knee. Double hamstring grafts are covered by the remnant of the torn anterior cruciate ligament. (A) The triangles show the graft for the anteromedial bundle. (B) The black arrow indicates the graft for the posterolateral bundle.
Fig. 8
Fig. 8
Femoral socket(s) on three-dimensional computed tomography (3D CT) after surgery. Medial 3D CT view of the reconstructed distal femur at 1 week after surgery shows accurately placed femoral sockets for hamstring tendon graft (A) and an accurately placed rectangular femoral socket for a bone-patellar tendon-bone graft (BTB) (B). Morphometric assessment of femoral tunnel positioning was performed using the quadrant technique, as described by Bernard et al.. The horizontal position of the femoral tunnel center is defined as the percentage distance from the most posterior contour in reference to the total length of the lateral condyle, whereas its vertical position is defined as the percentage distance from Blumensaat's line in reference to the total lateral intercondylar notch height. For the rectangular tunnel for the BTB grafts, the center of the ellipse by which the rectangular tunnel aperture was approximated was defined as the center of the femoral tunnel for the BTB graft. The black square shows the location of the center of the anteromedial socket, the black triangle shows the location of the posterolateral socket, and the black dot shows the center of the socket location in anterior cruciate ligament reconstruction using a BTB graft.

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