Definitive landmarks for reproducible tibial tunnel placement in
anterior cruciate ligament reconstruction. Morgan C. D., Kalman, D.O., and Grawl D. M., Arthroscopy, 11, 3: 275-288, 1995. The purpose of this prospective study was to define constant anatomic intraarticular and extra-articular landmarks that can be used as definitive reference points to reproducibly create a tibial tunnel for anterior cruciate ligament (ACL) reconstruction that (1) results in an impingement-free graft in full extension without an intercondylar roofplasty; (2) positions the tibial tunnel's intraarticular orifice sagittally central in the original ACL insertion without guessing; (3) positions the tibial tunnel such that the sagittal tunnel-plateau angle is parallel with the intercondylar roof-plateau angle in full extension to minimize shear seen by the graft at the tibial tunnel inlet, and by doing so; (4) maximises tunnel length to avoid patellar tendon graft-tunnel mismatch allowing for endosteal interference fixation on both sides of the joint. Anatomic dissections in 50 knees showed the ACL sagittal central insertion point on the intercondylar floor averages 7 mm (range 7 to 8 mm) sagittally anterior to the anterior margin of the posterior cruciate ligament (PCL) with the knee flexed 90° such that the PCL may be used as a reliable reference landmark for locating the ACL sagittal central insertion. This constant relationship was found to be independent of knee size. Extraarticularly, beginning the tibial tunnel sagittally 1 cm above the superior (sartorial) border of the pes anserinus insertion and coronally 1.5 cm posteromedial from the medial margin of the tibial tubercle along the superior surface of the pes, directed toward the sagittal central ACL insertion, led to a sagittal tunnel-plateau angle that averaged 68° (range 64° to 72°) with a corresponding tunnel length that averaged 58 mm (range 50 to 65 mm) in 23 knees. This data correlated well with data obtained clinically in a series of 50 consecutive ACL reconstructions using intraarticular PCL and extra-articular pes anserine-medial tibial tubercle referenced tibial tunnels in which postoperative full extension lateral radiographs confirmed a sagittal tunnel-plateau angle parallel or near parallel with the intercondylar roof-plateau angle in all cases averaging 68° +/- 3.8°. Tibial tunnel length averaged 60 mm (range 52 to 66 mm) in no case was there patellar tendon autograft-tunnel length mismatch.
Original Text by Clifford R. Wheeless, III, MD.
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