Correlation Between Anterior Cruciate Ligament Graft Obliquity and Tibial Rotation During Dynamic Pivoting Activities in Patients With Anatomic Anterior Cruciate Ligament Reconstruction: An In Vivo Examination

doi:10.1016/j.arthro.2011.08.285

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 28, Issue 2, February 2012, Pages 234-246

https://doi.org/10.1016/j.arthro.2011.08.285 Get rights and content

Purpose

To investigate the effect of coronal- and sagittal-plane anterior cruciate ligament (ACL) graft obliquity on tibial rotation (TR) range of motion (ROM) during dynamic pivoting activities after ACL reconstruction with bone–patellar tendon–bone (BPTB) autograft.

Methods

We evaluated 19 ACL-reconstructed patients (mean age, 29 years; age range, 18 to 38 years; mean time interval postoperatively, 19.9 months) and 19 matched control subjects (mean age, 30.6 years; age range, 24 to 37 years) using motion analysis during (1) descending a stairway and pivoting and (2) landing from a jump and pivoting. Magnetic resonance imaging was used to measure the coronal and sagittal ACL graft angle. The dependent variables were TR ROM during pivoting and the side-to-side difference (SSD) in TR ROM between the reconstructed knee and the contralateral intact knee.

Results

TR ROM of the ACL-reconstructed knee was significantly increased compared with both the contralateral intact knee and the healthy control knee (P < .05). A significant positive correlation was observed between TR ROM and coronal ACL graft angle (r = 0.727, P = .0006 for descending and pivoting; r = 0.795, P = .0001 for landing and pivoting) as well as between SSD of TR ROM and coronal ACL graft angle (r = 0.789, P < .0001 for descending and pivoting; r = 0.799, P < .0001 for landing and pivoting). No correlation was found with the sagittal ACL graft angle.

Conclusions

After ACL reconstruction with a BPTB graft, patients' knees showed higher TR values than their uninjured knees and the knees of uninjured control volunteers during dynamic pivoting activities. The findings of this study show that TR was better restored in ACL-reconstructed patients with a more oblique graft in the coronal plane. A similar relation was not observed for graft orientation in the sagittal plane. Although these data do not imply a cause-and-effect relation between the 2 variables, they may indicate that a more oblique placement of a single BPTB ACL graft in the coronal plane is correlated with better control of TR.

Level of Evidence

Level IV, case series.

Section snippets

Subjects

From February 2009 to November 2009, 70 patients underwent arthroscopically assisted ACL reconstruction at our institution. All operations were performed by the same surgeon (the senior author). To have a homogeneous study group and eliminate possible bias that would affect the results, especially the kinematics, strict selection criteria regarding the condition (examined by MRI and arthroscopically by the senior author) and demographics of the patients were used for the study population.

MRI Examination

The mean coronal ACL graft angle (± 1 SD) was 59.4° ± 3.7° (range, 54.3° to 68°), and the mean sagittal graft angle was 54.4° ± 3.4° (range, 50.5° to 62.5°). The intraobserver and interobserver agreement, as assessed by κ coefficient, was excellent in every case (0.92 [95% CI, 0.9 to 0.94] and 0.9 [95% CI, 0.89 to 0.91], respectively).

Clinical Examination

For the ACL-reconstructed patients, the mean Lysholm score was 96 (range, 86 to 100), the mean Tegner score was 7.4 (range, 7 to 9), and the mean subjective IKDC

Discussion

The main findings of this study are that even after clinically successful ACL reconstruction, patients show higher TR ROM in their ACL-reconstructed knees compared with their intact knees or compared with a healthy control group. In addition, a significant correlation was found between coronal-plane graft obliquity and TR ROM, suggesting that placing the graft in a more oblique orientation better controls TR. In contrast, no correlation was found between sagittal angle of ACL graft and TR.

Conclusions

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Cited by (29)

Does the position of interference screw in tibial tunnel effect anatomic orientation in single bundle anterior cruciate ligament reconstruction?
2020, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
Citation Excerpt :
The p value was 0.051. Zampelli et al. stressed upon the importance of coronal obliquity concluding that a more oblique graft in coronal orientation controlled tibial rotation better than a vertical graft.12 They, however did not find any relationship with a sagittal graft obliquity.
The purpose of the study was to evaluate the change in orientation of the reconstructed ACL with the change in position of the interference screw in the tibial tunnel.
It was a retrospective review of Magnetic Resonance Imaging (MRI) in which 51 normal and 61 MRI of patients who had undergone ACL reconstruction at our institute were evaluated. Postoperative ACL reconstruction group MRI studies were obtained and evaluated by two sports medicine fellows independently to assess the position of interference screw, distance of the graft from the anterior cortex of tibia and inclination of the graft. The data was collected and compared with MRI data of normal ACL patients.
There were total 61 patients with ACL reconstruction. 32 patients had anterior screw placement and 29 patients had posterior screw placement in the tibial tunnel. The distance of the graft from the anterior cortex was 39.18% in ACL intact group, 50.35% in anterior screw group and 41.64% in posterior screw group. The inclination angle was 44.49⁰ in intact group, 49.69° and 42.20° in anterior and posterior screw group respectively. The difference between intact group and anterior screw group was statistically significant.
Posterior position of interference screw in tibial tunnel increases graft obliquity than anterior position and decreases its distance from the anterior tibial cortex. This increased graft obliquity and distance from the anterior tibial cortex is similar to the native ACL.
Tibial insertion of the anterior cruciate ligament and anterior horn of the lateral meniscus share the lateral slope of the medial intercondylar ridge: A computed tomography study in a young, healthy population
2019, Knee
Citation Excerpt :
These differences among the sexes may somewhat be correlated with the incidence of ACL injuries. Ideal and accurate creation of the tibial tunnel is critical, while anterior positioning of the tibial tunnel brings better postoperative anterior knee stability [18–20]. The preoperative planning tailored to the individual bony landmarks might be useful not only for ideal anatomical ACL reconstruction but also for avoiding damage to the AHLM tibial insertion.
The central intercondylar ridge (CIR) is an anatomical bony landmark that bisects the slope of the medial intercondylar ridge (MIR) between the tibial insertion of the anterior cruciate ligament (ACL) and anterior horn of lateral meniscus (AHLM) and was recently revealed by computed tomography (CT) evaluation corresponding to histologic slices of cadaveric knees. The purpose of this study was to clarify the shape and size of ACL and AHLM tibial insertion in young, healthy knees using the new bony landmark (CIR) and previously reported landmarks.
The contralateral healthy knees in 34 ACL-reconstructed patients (18 male patients, 16 female patients, mean age: 24.0 years) were scanned by CT. In the reconstructed coronal/sagittal images, bony landmarks of ACL (anterior: anterior ridge, posterior: blood vessel in tubercle fossa, medial: MIR, lateral: CIR) and AHLM (medial: CIR, lateral: bottom of the slope) were plotted for evaluation. The length of sagittal slices and the width in five coronal slices of the insertion were measured.
The ACL insertion consistently showed a boot-like-shape adjacent to the square shape of AHLM on three-dimensional imaging. The mean ACL sagittal length was 14.5 ± 1.9 mm, while the mean ACL widths (in mm) from anterior to posterior were 12.7 ± 2.7, 8.1 ± 1.9, 7.9 ± 2.0, 7.5 ± 1.5, and 7.2 ± 1.6, which was highly correlated with the tibial plateau size.
The boot-like-shape of the ACL tibial footprint insertion shared the slope of MIR with the rectangular shape of AHLM in young, healthy knees. This study may provide useful information for safe tibial tunnel creation at the time of ACL reconstruction.
A Biomechanical Comparison of Single-, Double-, and Triple-Bundle Anterior Cruciate Ligament Reconstructions Using a Hamstring Tendon Graft
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
The first objective of our cadaveric study was to perform a biomechanical comparison of single-bundle (SB), double-bundle (DB), and triple-bundle (TB) anterior cruciate ligament (ACL) reconstructions using a hamstring tendon graft to determine the laxity match pre-tension (LMP) value, which is the tension within the graft required to re-create the same anterior laxity as the ACL-intact knee. The second objective was to determine the anterior laxity and force distribution during the application of both an anterior force and a simulated pivot-shift test.
Eleven fresh-frozen cadaveric knees were tested using a robotic/universal force-moment sensor system in the intact state, TB-reconstructed knee, DB-reconstructed knee, and SB-reconstructed knee. The LMP in each reconstruction was recorded. Each reconstructed knee was tested with an external load of 100-N anterior drawer and combined rotatory loads of 10-Nm valgus moment and 5-Nm internal rotation. The anterior tibial translation and tensile forces of each graft bundle were measured.
The LMP values for the TB reconstruction were 1.7 N for the anteromedial-medial graft, 1.7 N for the anteromedial-lateral graft, and 3.4 N for the posterolateral graft (PLG). The LMP value was 5.6 N for the anteromedial graft and PLG in the DB reconstruction. The LMP value was 26.3 N for the whole graft in the SB reconstruction. No statistically significant difference in stability was found between TB and DB reconstructions during the anterior load and the combined rotatory load test. For force distribution, the PLG tension in the TB reconstruction was statistically lower than that in the DB reconstruction.
Anatomic TB ACL reconstruction with the lowest initial tension on the graft stabilized the knee equally to DB or SB reconstruction, which required greater initial tension.
Although SB, DB, and TB ACL reconstructions through the anatomic tunnel position could equally restore stability, the initial tension on the graft required to restore stability was less in the latter 2 multi-tunnel reconstructions.
Early Structural Results After Anatomic Triple Bundle Anterior Cruciate Ligament Reconstruction Validated by Tunnel Location, Graft Orientation, and Static Anteroposterior Tibia-Femur Relationship
2018, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Several studies have investigated the orientation of ACL grafts by evaluating the graft itself in the sagittal and coronal images in conventional orthogonal MRI. Zampeli et al.18 demonstrated a correlation between dynamic kinematic abnormality and the coronal graft angle, but not with the sagittal graft angle. If we consider that the graft is mainly responsible for controlling the anterior translation of the tibia, their negative results in the sagittal plane might have been compromised by insidious anterior subluxation of the tibia resulting from incompetent grafts.
To elucidate how closely the structural characteristics of the anterior cruciate ligament (ACL) grafts after anatomic triple bundle (ATB) reconstruction resembled those of the normal ACL.
From 2012 to 2016, patients who underwent primary ATB ACL reconstruction using hamstring tendon autografts and the same number of healthy control subjects were included. Using magnetic resonance imaging (MRI) taken at 6 months postoperatively, ACL graft orientation was evaluated by the angles against the tibial plateau measured in the sagittal and oblique coronal planes at the anteromedial and posterolateral portions (ACL-tibial plateau angle [ATA]). For factors affecting the graft orientation, the static tibiofemoral relationship was evaluated by anteroposterior tibial translocation (APTT) in the identical MRI using a previously established method, and tunnel locations were evaluated using the quadrant method. To test equivalence, the widely used two one-sided test procedure was performed, with the equivalence margins of 5° and 3 mm for ATA and APTT, respectively.
Thirty-five patients were enrolled for each group. ATAs were not significantly different, and the 95% confidence interval (CI) of these differences was within 5° (sagittal: P = .211 [95% CI, −2.9 to 0.6]; oblique coronal ATA for the anteromedial and posterolateral portions: P = .269 [95% CI, −1.9 to 0.5] and P = .456 [95% CI,−2.1 to 0.9], respectively). The difference in APTT was neither statistically nor clinically significant (P = .114; 95% CI, −2.0 to 0.2).
These data suggest that ACL grafts using the ATB technique achieved a graft orientation equivalent to that of the normal ACL, with an equivalent postoperative anteroposterior tibiofemoral relationship in the static MRI. Thus, the ATB ACL reconstruction technique with the presented tunnel locations produced grafts that were similar to the native ACL in orientation.
Level III, case-control study.
American Society of Biomechanics Clinical Biomechanics Award 2017: Non-anatomic graft geometry is linked with asymmetric tibiofemoral kinematics and cartilage contact following anterior cruciate ligament reconstruction
2018, Clinical Biomechanics
Abnormal knee mechanics may contribute to early cartilage degeneration following anterior cruciate ligament reconstruction. Anterior cruciate ligament graft geometry has previously been linked to abnormal tibiofemoral kinematics, suggesting this parameter may be important in restoring normative cartilage loading. However, the relationship between graft geometry and cartilage contact is unknown.
Static MR images were collected and segmented for eighteen subjects to obtain bone, cartilage, and anterior cruciate ligament geometries for their reconstructed and contralateral knees. The footprint locations and orientation of the anterior cruciate ligament were calculated. Volumetric, dynamic MR imaging was also performed to measure tibiofemoral kinematics, cartilage contact location, and contact sliding velocity while subjects performed loaded knee flexion-extension. Multiple linear regression was used to determine the relationship between non-anatomic graft geometry and asymmetric knee mechanics.
Non-anatomic graft geometry was related to asymmetric knee mechanics, with the sagittal plane graft angle being the best predictor of asymmetry. A more vertical sagittal graft angle was associated with greater anterior tibial translation (β = 0.11 $\frac{mm}{deg}$ , P = 0.049, R² = 0.22), internal tibial rotation (β = 0.27 $\frac{deg}{deg}$ , P = 0.042, R² = 0.23), and adduction angle (β = 0.15 $\frac{deg}{deg}$ , P = 0.013, R² = 0.44) at peak knee flexion. A non-anatomic sagittal graft orientation was also linked to asymmetries in tibial contact location and sliding velocity on the medial (β = −4.2 $\frac{\frac{mm}{s}}{deg}$ , P = 0.002, R² = 0.58) and lateral tibial plateaus (β = 5.7 $\frac{\frac{mm}{s}}{deg}$ , P = 0.006, R² = 0.54).
This study provides evidence that non-anatomic graft geometry is linked to asymmetric knee mechanics, suggesting that restoring native anterior cruciate ligament geometry may be important to mitigate the risk of early cartilage degeneration in these patients.
Motion Analysis in Anterior Cruciate Ligament Deficient and Reconstructed Knees
2018, The Anterior Cruciate Ligament: Reconstruction and Basic Science: Second Edition
The objective measurement of knee motion during functional activities with 3D motion analysis has provided great insights into the restoration of knee biomechanics after ACL reconstructions and any remaining deficits. Several studies have documented that ACL reconstruction reduces but does not restore excessive internal knee rotation. This finding may provide a biomechanical rationale for the increased rate of knee osteoarthritis among athletes who had an ACL tear. More recent, anatomic ACL reconstruction techniques may ameliorate this problem and lead to better long-term outcomes.

View all citing articles on Scopus

: Supported by the Hellenic Association of Orthopaedic Surgery and Traumatology (HAOST-EEXOT).

: The authors report no conflict of interest.

Note: To access the videos accompanying this report, visit the February issue of Arthroscopy at www.arthroscopyjournal.org.

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Original Article With Video IllustrationsCorrelation Between Anterior Cruciate Ligament Graft Obliquity and Tibial Rotation During Dynamic Pivoting Activities in Patients With Anatomic Anterior Cruciate Ligament Reconstruction: An In Vivo Examination

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Subjects

MRI Examination

Clinical Examination

Discussion

Conclusions

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Magn Reson Imaging

Arthroscopy

Hum Mov Sci

J Biomech

Arthroscopy

Arthroscopy

Arthroscopy

Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament-deficient and reconstructed knee during walking

Am J Sports Med

Follow-up evaluation 2 years after ACL reconstruction with bone-patellar tendon-bone graft shows that excessive tibial rotation persists

Clin J Sport Med

Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction

Am J Sports Med

Kinematics and laxity of the knee joint after anterior cruciate ligament reconstruction: Pre- and postoperative radiostereometric studies

Am J Sports Med

Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction

Am J Sports Med

Tibial rotation in anterior cruciate ligament (ACL)-deficient and ACL-reconstructed knees: A theoretical proposition for the development of osteoarthritis

Sports Med

Strategies to improve anterior cruciate ligament healing and graft placement

Am J Sports Med

Effect of femoral tunnel placement for reconstruction of the anterior cruciate ligament on tibial rotation

J Bone Joint Surg Am

Graft orientation influences the knee flexion moment during walking in patients with anterior cruciate ligament reconstruction

Am J Sports Med

Knee rotational laxity in a randomized comparison of single- versus double-bundle anterior cruciate ligament reconstruction

Am J Sports Med

Original Article With Video Illustrations
Correlation Between Anterior Cruciate Ligament Graft Obliquity and Tibial Rotation During Dynamic Pivoting Activities in Patients With Anatomic Anterior Cruciate Ligament Reconstruction: An In Vivo Examination