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- W2116760603 abstract "We congratulate Siebold et al.1Siebold R. Dehler C. Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 137-145Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar on their study in the February 2008 issue of Arthroscopy. Prospective studies are extremely valuable because they can provide evidence for causal relationships and support changes in clinical practice when evidence is valid. The authors reported postoperative 1+ pivot-shift results between their single-bundle (SB) and double-bundle patients as 30% and 3%, respectively. Comparatively, in similar studies by Asagumo et al.2Asagumo H. Kimura M. Kobayashi Y. Taki M. Takagishi K. Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: Surgical techniques, clinical outcomes, and complications.Arthroscopy. 2007; 23: 602-609Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar and Muneta et al.,3Muneta T. Koga H. Mochizuki T. et al.A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques.Arthroscopy. 2007; 23: 618-628Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar SB versus double-bundle groups had 19% versus 13% and 41% versus 15%, respectively, with similar grafts. With these significantly high incidences of SB rotatory instability, only Siebold et al.'s radiograph evidence suggests their poor results are due to the fact that some of the SB group had improper posterior tibial tunnel graft placement. We measured the tunnel in their radiograph in Figure 2B (single-bundle lateral view, reproduced here), and the center was placed at greater than 50% from the anterior tibia. Compared to the tibial tunnel placement protocols suggested by Good et al.4Good L. Odenstein M. Gillquist J. Precision in reconstruction of the anterior cruciate ligament A new positioning device compared with hand drilling.Acta Orthop Scand. 1987; 58: 658-661Crossref PubMed Scopus (54) Google Scholar (center at 33% of the anteroposterior diameter), Goble5Goble E.M. Fluoroarthroscopic allograft anterior cruciate reconstruction.Techniques Orthop. 1988; 2: 65-73Crossref Scopus (19) Google Scholar (33%), Khalfayan et al.6Khalfayan EE, Bruckner JD, Sharkey PF, Bynum EB, Alexander AH. The relationship of tunnel placement and clinical outcome following anterior cruciate ligament reconstruction. Presented at the American Academy of Orthopaedic Surgeons 61st Annual Meeting, New Orleans, Louisiana, February 24-March 1, 1994.Google Scholar (20% to 40%), Jackson and Gasser7Jackson D.W. Gasser S.I. Tibial tunnel placement in ACL reconstruction.Arthroscopy. 1994; 10: 124-131Abstract Full Text PDF PubMed Scopus (147) Google Scholar (40%), Howell and Barad8Howell S.M. Barad S.J. Knee extension and its relationship to the slope of the intercondylar roof.Am J Sports Med. 1995; 23: 288-294Crossref PubMed Scopus (128) Google Scholar (40%), or Staeubli et al.9Staeubli H, Rauschning W, Berg P, Porcellini B. Morphometric criteria for anatomic intraarticular ACL reconstruction. Presented at the American Academy of Orthopaedic Surgeons 62nd Annual Meeting, Orlando, Florida, February 16-21, 1995.Google Scholar (43%), the present authors' placement is the most posteriorly placed of all. Our method10McGuire D.A. Hendricks S.D. Sanders H.M. The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion.Arthroscopy. 1997; 13: 465-473Abstract Full Text PDF PubMed Scopus (18) Google Scholar of tibial tunnel placement resulted in mean centers at 41.5% and was within Howell et al.'s11Howell S.M. Clark J.A. Farley T.E. Serial magnetic resonance study assessing the effects of impingement on the MR image of the patellar tendon graft.Arthroscopy. 1992; 8: 350-358Abstract Full Text PDF PubMed Scopus (84) Google Scholar calculated range of native ACLs (37% to 47%). They advised a guide pin position identical to Jackson and Gasser's suggested method7Jackson D.W. Gasser S.I. Tibial tunnel placement in ACL reconstruction.Arthroscopy. 1994; 10: 124-131Abstract Full Text PDF PubMed Scopus (147) Google Scholar that the present authors referenced to identify their tibial tunnel placement. The very posterior placement measured in Fig 2B would indicate that a different method was used. Both of the tunnel placement references cited by the authors emphasized graft impingement risk in tunnels placed too anteriorly. Jackson and Gasser7Jackson D.W. Gasser S.I. Tibial tunnel placement in ACL reconstruction.Arthroscopy. 1994; 10: 124-131Abstract Full Text PDF PubMed Scopus (147) Google Scholar also stated that “placing the graft so that it touches the PCL reduces the need for a lateral wall notchplasty in most acute reconstructions.” This method may have been used by the authors as they indicated that “no notchplasty was performed.” A graft placement this far posterior coincides with our measurement of Fig 2B where the graft seems nearly vertical and the proximal tunnel aperture is too posterior on the tibial plateau. If this radiograph exemplifies this patient cohort, it may be the source of their poor SB results. The range of motion values in this article were reported incompletely. Clinical extension and flexion deficits are complications, occurred in both groups postoperatively, were only conveyed in the ranges in Table 4, and were absent from the Complications paragraph. Properly positioned grafts absent an adequate notchplasty will result in stability but risk extension contracture. Tibial tunnels placed too posteriorly are usually associated with pivot shift or pivot glide. In this case, posterior tibial tunnel placement may explain the unacceptable levels of rotational instability the authors experienced with their SB group. Without further clarification from the authors, the outcome reported in this study is of limited value. Author's ReplyArthroscopyVol. 24Issue 9PreviewWe thank Dr. McGuire and Mr. Hendricks for their comments regarding our article “Prospective Randomized Comparison of Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction.” We are pleased that our study has prompted a discussion about clinical assessment of rotational stability using the pivot-shift test and tibial tunnel positioning in single-bundle (SB) anterior cruciate ligament (ACL) reconstruction assessed on radiographs. Full-Text PDF" @default.
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- W2116760603 title "Improper Posterior Tibial Tunnel Graft Placement" @default.
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