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Document Title: Segawa-AJARS-Apr05.shtml
Article Title: Contact pressure in anterior cruciate ligament bone tunnels: Comparison of endoscopic and two-incision technique
Authors: Hiroyuki Segawa M.D., Yoshio Koga M.D., Go Omori M.D.c, Makoto Sakamoto Ph.D. and Toshiaki Hara Ph.D.
Publication: Arthroscopy: The Journal of Arthroscopic & Related Surgery
Date: April 2005
Volume 21, Issue 4, Pages 439-444
Keywords: ACL, anterior cruciate ligament, reconstruction, arthroscopic, endoscopic, two-incision technique, bone-tunnel contact pressure, bone tunnel enlargement.
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Comments: This study delves into the topic of bone-tunnel enlargement (also referred to as widening), a problem often observed with soft-tissue (e.g. hamstring DLSTG) grafts, and thus is of particular relevance to ACL reconstruction via hamstring autografting and also allografting. The authors noted that in their clinical investigation of 87 hamstring-autograft ACL-recon cases (with EndoButton anchorage; note that some concern of the "bungee-cord effect" remains with this method), bone tunnel enlargement occurred in 25% of femoral tunnels and 30% of tibial tunnels. In any case, the gold standard of ACL reconstruction remains the patellar-tendon autograft, since this is the only graft which brings the security of bone-to-bone healing (conferred by the graft having bone plugs at both ends).
Abstract
Purpose: To investigate differences in contact pressure in the bone tunnel between the inside-out and outside-in techniques used for anterior cruciate ligament reconstruction.
Type of Study: In vitro cadaveric analysis.
Methods: Four fresh-frozen cadaver knees were tested. A femoral tunnel was generated through the tibial tunnel (inside-out technique). Another femoral tunnel was created using a rear-entry guide at the same intra-articular exit (outside-in technique). Aluminum cylinders containing 4-way (anterior, posterior, medial, and lateral) conductive rubber pressure sensors at the entrance of the joint were inserted into the tibial and femoral tunnels. Dynamic changes in the contact pressure of grafts in the femoral and tibial tunnels during 0° to 130° of knee flexion were measured.
Results: Contact pressure of the graft migrated from the anterior to the posterior portion of the femoral tunnel upon alignment of the femoral and tibial tunnels. At 0°, 30°, and 60° of knee flexion, significantly greater contact pressure was observed at the anterior portion of the femoral tunnel made by the inside-out technique compared with that in the tunnel made by the outside-in technique. At 0°, 30°, and 60° of knee flexion, significantly greater contact pressure was observed at the lateral portion of the femoral tunnel made by the outside-in technique. Constant contact pressure was observed in the medial portion of the tunnel made by the inside-out technique. Pressure changes in the tibial tunnel were slight; moreover, changes were not influenced by the femoral tunnel direction under any conditions.
Conclusions: This study shows that contact pressure in the femoral tunnel is influenced by the direction of the femoral tunnel.
Clinical Relevance: The femoral tunnel direction in anterior cruciate ligament reconstruction is an important factor for femoral tunnel enlargement. A horizontal direction of the femoral tunnel might be needed for mature bone graft incorporation.
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