Comparison of femoral oval tunnel technique and round tunnel technique in single-bundle anterior cruciate ligament reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WEN Zhenxing ^1,2 , ZHANG Hua ¹ , YAN Wenlong ¹ , ZHAO Pei ¹ , HUANG Xiao ¹ , XU Zijie ^1,2 , ZHANG Jian ¹ ,  ZHOU Aiguo ¹

1. Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China;
2. Chongqing Medical University, Chongqing, 400016, P.R.China;

Corresponding author：

ZHOU Aiguo, Email: zhouaiguo@hospital.cqmu.edu.cn

Keywords：

Anterior cruciate ligament; single-bundle reconstruction; femoral tunnel; oval tunnel technique; round tunnel technique; arthroscopy

DOI：

10.7507/1002-1892.201908030

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Objective To evaluate the effectiveness of femoral oval tunnel technique versus round tunnel technique in single-bundle anterior cruciate ligament (ACL) reconstruction.Methods Between March 2016 and February 2018, 125 patients who underwent anatomical single-bundle ACL reconstruction with hamstring tendon and met the inclusive criteria were included in the retrospective study. Of the included patients, 43 patients underwent ACL reconstruction using oval tunnel technique (group A) and 82 patients with round tunnel technique (group B). There was no significant difference between the two groups in terms of age, gender, body mass index, the interval between injury and operation, the injured side, the cause of injury, and preoperative Lysholm score, International Knee Documentation Committee (IKDC) score, Tegner score, and the outcome of KT-1000 measurement (P>0.05). At 3, 6, 12, and 24 months after operation, the knee function scores (Lysholm score, IKDC score, Tegner score) were recorded; and KT-1000 was used to evaluate the knee stability. The position and shape of the tunnels were evaluated by the three-dimensional CT (3D-CT) at 1 day after operation; and MRI was performed at 6, 12, and 24 months to calculate the signal/noise quotient (SNQ) of ACL grafts. Secondary arthroscopy was conducted to estimate the graft status, synovial coverage, and tension.Results All patients were followed up 12-26 months (mean, 23 months). Two patients in group A and 5 patients in group B presented with redness and swelling of the surgical site, 1 patient in group B sustained a tibial tunnel fracture, and 1 patient in group A had postoperative stiffness. The Lysholm score, IKDC score, and Tegner score were significantly higher in group A than in group B at the different time points (P<0.05) except for the Tegner score at 3 months. The outcomes of KT-1000 measurement were significantly lower in group A than in group B (P<0.05). The entrances of the femoral tunnel and tibial tunnel in both groups were within the ACL anatomical footprint confirmed by 3D-CT. No re-rupture of ACL occurred confirmed by the MRI. There was no significant difference in SNQs of the middle and distal grafts between the two groups at 6 months (P>0.05), whereas the SNQ of the proximal grafts in group A was significantly lower than that in group B (P<0.05). The SNQs of the proximal, middle, and distal grafts in group A were significantly lower than those in group B at 12 and 24 months after operation (P<0.05). Twenty-one patients in group A and 38 patients in group B underwent secondary arthroscopy and the results showed no significant difference in graft status, synovial coverage, and tension between the two groups (P>0.05).Conclusion The effectiveness and graft maturity of the femoral oval tunnel technique were superior to the round tunnel technique. The single-bundle ACL reconstruction with femoral oval tunnel technique can obtain a better knee function.

Citation： WEN Zhenxing, ZHANG Hua, YAN Wenlong, ZHAO Pei, HUANG Xiao, XU Zijie, ZHANG Jian, ZHOU Aiguo. Comparison of femoral oval tunnel technique and round tunnel technique in single-bundle anterior cruciate ligament reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(3): 323-329. doi: 10.7507/1002-1892.201908030 Copy

1.	McLean SG, Mallett KF, Arruda EM. Deconstructing the anterior cruciate ligament: what we know and do not know about function, material properties, and injury mechanics. J Biomech Eng, 2015, 137(2): 020906.
2.	李飞龙, 罗小辑, 梁熙, 等. 前交叉韧带解剖研究进展及其对韧带重建技术的影响. 中国修复重建外科杂志, 2018, 32(3): 377-381.
3.	涂俊, 徐斌. 前交叉韧带损伤早期治疗与延期治疗的并发症分析及临床疗效对比. 中国运动医学杂志, 2018, 37(7): 558-564.
4.	Acevedo RJ, Rivera-Vega A, Miranda G, et al. Anterior cruciate ligament injury: identification of risk factors and prevention strategies. Curr Sports Med Rep, 2014, 13(3): 186-191.
5.	Markatos K, Kaseta MK, Lallos SN, et al. The anatomy of the ACL and its importance in ACL reconstruction. Eur J Orthop Surg Traumatol, 2013, 23(7): 747-752.
6.	Śmigielski R, Zdanowicz U, Drwięga M, et al. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J, 2016, 98-B(8): 1020-1026.
7.	李箭. 膝关节前交叉韧带损伤修复与重建. 中国修复重建外科杂志, 2019, 33(9): 1057-1059.
8.	Buoncristiani AM, Tjoumakaris FP, Starman JS, et al. Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy, 2006, 22(9): 1000-1006.
9.	Kato Y, Hoshino Y, Ingham SJ, et al. Anatomic double-bundle anterior cruciate ligament reconstruction. J Orthop Sci, 2010, 15(2): 269-276.
10.	Mayr HO, Benecke P, Hoell A, et al. Single-bundle versus double-bundle anterior cruciate ligament reconstruction: A comparative 2-year follow-up. Arthroscopy, 2016, 32(1): 34-42.
11.	程治平, 毛子木, 余家阔. 青少年前交叉韧带双束重建的研究进展. 中国修复重建外科杂志, 2019, 33(9): 1060-1063.
12.	Śmigielski R, Zdanowicz U, Drwięga M, et al. Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3143-3150.
13.	Kraeutler MJ, Wolsky RM, Vidal AF, et al. Anatomy and biomechanics of the native and reconstructed anterior cruciate ligament: surgical implications. J Bone Joint Surg (Am), 2017, 99(5): 438-445.
14.	Noh JH, Yang BG, Roh YH, et al. Anterior cruciate ligament reconstruction using 4-strand hamstring autograft: conventional single-bundle technique versus oval-footprint technique. Arthroscopy, 2011, 27(11): 1502-1510.
15.	Petersen W, Forkel P, Achtnich A, et al. Technique of anatomical footprint reconstruction of the ACL with oval tunnels and medial portal aimers. Arch Orthop Trauma Surg, 2013, 133(6): 827-833.
16.	Petersen W, Zantop T. Anatomy of the anterior cruciate ligament with regard to its two bundles. Clin Orthop Relat Res, 2007, 454: 35-47.
17.	Daniel DM, Malcom LL, Losse G, et al. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg (Am), 1985, 67(5): 720-726.
18.	Sajovic M, Strahovnik A, Dernovsek MZ, et al. Quality of life and clinical outcome comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: an 11-year follow-up of a randomized controlled trial. Am J Sports Med, 2011, 39(10): 2161-2169.
19.	Tanaka Y, Yonetani Y, Shiozaki Y, et al. MRI analysis of single-, double-, and triple-bundle anterior cruciate ligament grafts. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1541-1548.
20.	Ma Y, Murawski CD, Rahnemai-Azar AA, et al. Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 661-668.
21.	Kondo E, Yasuda K. Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability. Arthroscopy, 2007, 23(11): 1198-1209.
22.	Lee JH, Bae DK, Song SJ, et al. Comparison of clinical results and second-look arthroscopy findings after arthroscopic anterior cruciate ligament reconstruction using 3 different types of grafts. Arthroscopy, 2010, 26(1): 41-49.
23.	Fu FH, van Eck CF, Tashman S, et al. Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 640-648.
24.	Siebold R, Schuhmacher P, Fernandez F, et al. Flat midsubstance of the anterior cruciate ligament with tibial “C”-shaped insertion site. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3136-3142.
25.	Sasaki N, Ishibashi Y, Tsuda E, et al. The femoral insertion of the anterior cruciate ligament: discrepancy between macroscopic and histological observations. Arthroscopy, 2012, 28(8): 1135-1146.
26.	Mochizuki T, Fujishiro H, Nimura A, et al. Anatomic and histologic analysis of the mid-substance and fan-like extension fibres of the anterior cruciate ligament during knee motion, with special reference to the femoral attachment. Knee Surg Sports Traumatol Arthrosc, 2014, 22(2): 336-344.
27.	Oshima T, Nakase J, Numata H, et al. The cross-sectional shape of the fourfold semitendinosus tendon is oval, not round. J Exp Orthop, 2016, 3(1): 28.
28.	Nakase J, Toratani T, Kosaka M, et al. Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator. Knee, 2016, 23(1): 91-96.
29.	张家豪, 刘振龙, 胡晓青, 等. 椭圆形骨道与圆形骨道重建膝关节前交叉韧带术后移植物成熟度对比研究. 中国运动医学杂志, 2018, 37(2): 104-109.
30.	Lopes OV Jr, de Freitas Spinelli L, Leite LHC, et al. Femoral tunnel enlargement after anterior cruciate ligament reconstruction using RigidFix compared with extracortical fixation. Knee Surg Sports Traumatol Arthrosc, 2017, 25(5): 1591-1597.

1. McLean SG, Mallett KF, Arruda EM. Deconstructing the anterior cruciate ligament: what we know and do not know about function, material properties, and injury mechanics. J Biomech Eng, 2015, 137(2): 020906.
2. 李飞龙, 罗小辑, 梁熙, 等. 前交叉韧带解剖研究进展及其对韧带重建技术的影响. 中国修复重建外科杂志, 2018, 32(3): 377-381.
3. 涂俊, 徐斌. 前交叉韧带损伤早期治疗与延期治疗的并发症分析及临床疗效对比. 中国运动医学杂志, 2018, 37(7): 558-564.
4. Acevedo RJ, Rivera-Vega A, Miranda G, et al. Anterior cruciate ligament injury: identification of risk factors and prevention strategies. Curr Sports Med Rep, 2014, 13(3): 186-191.
5. Markatos K, Kaseta MK, Lallos SN, et al. The anatomy of the ACL and its importance in ACL reconstruction. Eur J Orthop Surg Traumatol, 2013, 23(7): 747-752.
6. Śmigielski R, Zdanowicz U, Drwięga M, et al. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J, 2016, 98-B(8): 1020-1026.
7. 李箭. 膝关节前交叉韧带损伤修复与重建. 中国修复重建外科杂志, 2019, 33(9): 1057-1059.
8. Buoncristiani AM, Tjoumakaris FP, Starman JS, et al. Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy, 2006, 22(9): 1000-1006.
9. Kato Y, Hoshino Y, Ingham SJ, et al. Anatomic double-bundle anterior cruciate ligament reconstruction. J Orthop Sci, 2010, 15(2): 269-276.
10. Mayr HO, Benecke P, Hoell A, et al. Single-bundle versus double-bundle anterior cruciate ligament reconstruction: A comparative 2-year follow-up. Arthroscopy, 2016, 32(1): 34-42.
11. 程治平, 毛子木, 余家阔. 青少年前交叉韧带双束重建的研究进展. 中国修复重建外科杂志, 2019, 33(9): 1060-1063.
12. Śmigielski R, Zdanowicz U, Drwięga M, et al. Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3143-3150.
13. Kraeutler MJ, Wolsky RM, Vidal AF, et al. Anatomy and biomechanics of the native and reconstructed anterior cruciate ligament: surgical implications. J Bone Joint Surg (Am), 2017, 99(5): 438-445.
14. Noh JH, Yang BG, Roh YH, et al. Anterior cruciate ligament reconstruction using 4-strand hamstring autograft: conventional single-bundle technique versus oval-footprint technique. Arthroscopy, 2011, 27(11): 1502-1510.
15. Petersen W, Forkel P, Achtnich A, et al. Technique of anatomical footprint reconstruction of the ACL with oval tunnels and medial portal aimers. Arch Orthop Trauma Surg, 2013, 133(6): 827-833.
16. Petersen W, Zantop T. Anatomy of the anterior cruciate ligament with regard to its two bundles. Clin Orthop Relat Res, 2007, 454: 35-47.
17. Daniel DM, Malcom LL, Losse G, et al. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg (Am), 1985, 67(5): 720-726.
18. Sajovic M, Strahovnik A, Dernovsek MZ, et al. Quality of life and clinical outcome comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: an 11-year follow-up of a randomized controlled trial. Am J Sports Med, 2011, 39(10): 2161-2169.
19. Tanaka Y, Yonetani Y, Shiozaki Y, et al. MRI analysis of single-, double-, and triple-bundle anterior cruciate ligament grafts. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1541-1548.
20. Ma Y, Murawski CD, Rahnemai-Azar AA, et al. Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 661-668.
21. Kondo E, Yasuda K. Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability. Arthroscopy, 2007, 23(11): 1198-1209.
22. Lee JH, Bae DK, Song SJ, et al. Comparison of clinical results and second-look arthroscopy findings after arthroscopic anterior cruciate ligament reconstruction using 3 different types of grafts. Arthroscopy, 2010, 26(1): 41-49.
23. Fu FH, van Eck CF, Tashman S, et al. Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 640-648.
24. Siebold R, Schuhmacher P, Fernandez F, et al. Flat midsubstance of the anterior cruciate ligament with tibial “C”-shaped insertion site. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3136-3142.
25. Sasaki N, Ishibashi Y, Tsuda E, et al. The femoral insertion of the anterior cruciate ligament: discrepancy between macroscopic and histological observations. Arthroscopy, 2012, 28(8): 1135-1146.
26. Mochizuki T, Fujishiro H, Nimura A, et al. Anatomic and histologic analysis of the mid-substance and fan-like extension fibres of the anterior cruciate ligament during knee motion, with special reference to the femoral attachment. Knee Surg Sports Traumatol Arthrosc, 2014, 22(2): 336-344.
27. Oshima T, Nakase J, Numata H, et al. The cross-sectional shape of the fourfold semitendinosus tendon is oval, not round. J Exp Orthop, 2016, 3(1): 28.
28. Nakase J, Toratani T, Kosaka M, et al. Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator. Knee, 2016, 23(1): 91-96.
29. 张家豪, 刘振龙, 胡晓青, 等. 椭圆形骨道与圆形骨道重建膝关节前交叉韧带术后移植物成熟度对比研究. 中国运动医学杂志, 2018, 37(2): 104-109.
30. Lopes OV Jr, de Freitas Spinelli L, Leite LHC, et al. Femoral tunnel enlargement after anterior cruciate ligament reconstruction using RigidFix compared with extracortical fixation. Knee Surg Sports Traumatol Arthrosc, 2017, 25(5): 1591-1597.

Chinese Journal of Reparative and Reconstructive Surgery

Comparison of femoral oval tunnel technique and round tunnel technique in single-bundle anterior cruciate ligament reconstruction

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