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, 14 (5), e0215778
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Positioning the Femoral Bone Socket and the Tibial Bone Tunnel Using a Rectangular Retro-Dilator in Anterior Cruciate Ligament Reconstruction

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Positioning the Femoral Bone Socket and the Tibial Bone Tunnel Using a Rectangular Retro-Dilator in Anterior Cruciate Ligament Reconstruction

Hiroteru Hayashi et al. PLoS One.

Abstract

Purpose: The purpose of this study was to evaluate the positions of femoral bone sockets and tibial bone tunnels made with the rectangular retro-dilator (RRD), which we manufactured for anterior cruciate ligament reconstruction (ACLR) with a bone-patella tendon-bone (BPTB) graft which is fixed into the rectangular bone socket and tunnel made at anatomical ACL insertion sites.

Methods: 42 patients who had undergone ACLR with BPTB using the RRD were evaluated to assess bone socket and tunnel positions by the quadrant method and Magnussen classification using three-dimensional (3-D) CT. Intra-operative complications were also investigated in all patients.

Results: 3-D CT of the operated knee joints using the RRD showed that the bone socket and tunnel were placed in anatomical positions. In the quadrant method, the mean position of the femoral bone socket aperture was located at 22.0 ± 4.2% along the Blumensaat's line, and 37.4 ± 7.2% across the posterior condylar rim. The mean positions of the tibial bone tunnel aperture were 37.7 ± 5.2% and 46.1 ± 2.2% antero-posteriorly and medio-laterally, respectively. In addition, according to the Magnussen classification, 39 cases were evaluated as type 1, and almost all were located behind the lateral intercondylar ridge (also known as the resident's ridge). 3 cases were classified as type 2, which overlapped with the resident's ridge. A partial fracture of BPTB bone fragment was observed in 2 patients, but no serious complications including neurovascular injury were observed.

Conclusion: The study indicates that the use of RRD achieves a safe anatomical reconstruction of the ACL.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Femoral socket and tibial tunnel preparation of right knee.
(A) After a round bone tunnel (6 mm in diameter and 25 mm deep) has been created in a retrograde fashion with the Short FlipCutter II, the dilator (arrow) is set on the 3.0-mm guide pin using the RetroConstruction Drill Guide within the knee joint. (B) The rounded edge of the rectangular retro-dilator (arrow) is inserted into the femoral bone tunnel; the dilator fits tightly into the tunnel. The dilator is then inserted into the femoral bone. (C) A rectangular bone tunnel is created in the femoral bone. (D) The cortical bone is drilled with a 10-mm drill, and then the bone is drilled with a 6.0-mm drill up to the joint space. A rectangular pull-type dilator (arrow) is attached to the retrograde guide, mounting the dilator to the 3.0-mm guide pin within the knee joint. (E) The rectangular retro-dilator (arrow) is inserted into the tibial bone. (F) A rectangular bone tunnel is created in the tibial bone. (G) Completed retro-dilator anatomic rectangular tunnel bone-patellar tendon-bone anterior cruciate ligament reconstruction image. The twist of the ligament can be reproduced.
Fig 2
Fig 2. Arthroscopic views of the right knee during surgery.
Arthroscopic views of the right knee through anteromedial (A-G) and anterolateral portals (H-L). (A) A 3.5-mm guide pin is inserted with a reference point at the center portion of the anterior cruciate ligament (ACL) femoral attachment behind the resident’s ridge. (B) A round bone tunnel with a diameter of 6.0 mm is created in a retrograde manner with the Short FlipCutter II. (C, D) The dilator is set on the 3-mm RetroDrill Guide Pin using the RetroConstruction Drill Guide within the knee joint. (E) The rounded edge of the rectangular retro-dilator is inserted into the femoral bone tunnel. (F, G) After the dilator’s direction is confirmed, the dilator is pulled into the femoral bone to about 18 mm depth and the rectangular bone socket is created. (H) A guide pin is inserted with the reference guide at the center portion of the ACL tibial attachment. (I) The dilator is set on the 3.0-mm RetroDrill Guide Pin using the RetroConstruction Drill Guide within the knee joint. (J) The rounded edge of the rectangular retro-dilator is inserted into the tibial bone tunnel. (K) After the dilator’s direction is confirmed, the dilator is pulled out of the tibia and the rectangular bone tunnel is created. (L) Arthroscopic view after retro-dilator anatomic rectangular tunnel bone-patellar tendon-bone (BTB) ACL reconstruction.
Fig 3
Fig 3. Post-operative radiographs and arthroscopic view of the left knee after surgery.
(a): Post-operative radiographs ((fixation to the femur by BTB TightRope (Arthrex, Naples, FL) and to the tibia by ABS button (Arthrex, Naples, FL)) (b): Arthroscopic view.
Fig 4
Fig 4. Evaluation of bone aperture positions using the quadrant method on 3-D CT scans.
Evaluation of bone aperture positions using the quadrant method on 3-D CT scans taken 3 weeks after the operation. The analysis showed that all bone apertures were placed in anatomically appropriate positions. (a): femur, (b): tibia.
Fig 5
Fig 5. 3 cases of Magnussen classification type2.
Two cases (a, b) were considered technical errors at the time of insertion of the guide pin, and one (c) was due to the incorrect orientation of the RRD. An outline of the ideal tunnel arrangement has been shown in Fig 5 (blue square).

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Grant support

The authors received no specific funding for this work.
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