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, 2018, 2643247
eCollection

Optimal Condition to Create Femoral Tunnel Considering Combined Influence of Knee Flexion and Transverse Drill Angle in Anatomical Single-Bundle ACL Reconstruction Using Medial Portal Technique: 3D Simulation Study

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Optimal Condition to Create Femoral Tunnel Considering Combined Influence of Knee Flexion and Transverse Drill Angle in Anatomical Single-Bundle ACL Reconstruction Using Medial Portal Technique: 3D Simulation Study

Sung-Hwan Kim et al. Biomed Res Int.

Abstract

There has been no previous study using three-dimensional (3D) measurement on femoral tunnel characteristics according to the combined influence of various flexion angles of knee and transverse drill angles in single-bundle ACL reconstruction with transportal technique. The purpose of this study was to determine optimal condition of knee flexion angle and transverse drill angle to create secure femoral tunnel in single-bundle ACL reconstruction with transportal technique considering tunnel length, tunnel wall breakage, and graft bending angle. This study was conducted using simulation of 3D computed tomography of thirty subjects. Three variables of femoral tunnel changed according to combined influence of four flexion angles of knee and three transverse drill angles were measured: tunnel length, wall breakage, and graft bending angle. There was no case of short femoral tunnel less than 25 mm at 120° and 130° of flexion. There was no case of breakage of femoral tunnel at 120° of flexion with maximum transverse drill angle (MTA) and MTA-10° and at 130° of flexion. Considering effect on graft bending angle, decrease of flexion angle and transverse drill angle could be appropriate in creating femoral tunnel. Increased flexion angle and transverse drill angle secured femoral tunnel having sufficiently long length without wall breakage. However, avoiding excessive flexion angle and maximum transverse drill angle could be recommended because they tended to cause more acute graft bending angle.

Figures

Figure 1
Figure 1
(a) 3D reconstructed model of femur was aligned in a true lateral position, where medial and lateral femoral condyles were superimposed. (b) The medial femoral condyle was virtually eliminated from the original 3D model at the most anterior aspect of the intercondylar notch, and A 4 × 4 grid was drawn on the medial wall of the lateral femoral condyle from a true medial view of the femur established at 90° of knee flexion. The femoral footprint center was determined according to the following coordinates: The distance parallel to the Blumensaat line was 28.4% along the line measured from the posterior border. The distance perpendicular to the Blumensaat line was 35.7% along the line measured from the Blumensaat line. (c) Transepicondylar axis was established as rotation axis of flexion to make change of the flexion angle.
Figure 2
Figure 2
Variables at the twelve conditions by combination of flexion angle and transverse drill angle were measured. (a) The knee flexion angles were changed at intervals of 10° from 100° to 130° on the transepicondylar axis. (b) The possible maximum transverse drill angle of rotation can be achieved without coming into contact with the cartilage of medial femoral condyle. The first drill angle was determined as the maximum transverse drill angle (MTA) and the other two drill angles were determined as MTA-10° and MTA-20° by moving drill laterally.
Figure 3
Figure 3
The graft bending angle at the femoral tunnel aperture was measured as the angle between the femoral tunnel penetrated by virtual cylinder and the extended line that passed through the tibial footprint center and the femoral footprint center with the knee in full extension. (a) The tibial footprint center was determined according to the following coordinates: the point located at 35.7% of the anterior-to-posterior depth of the tibia measured from the anterior border and at 51.5% of the medial-to-lateral width of the tibia measured from the medial border. (b) Anterior view. (c) Oblique view. Point A is the tibial footprint center, and point B is the femoral footprint center. Extended line that passed through these two centers is the line connecting points A, B, and C. Point D indicates the center of femoral tunnel at the external cortex. The graft bending angle is measured as the angle composed of points C, B, and D.

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