title: Graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction: a new technique of intraarticular measurement and modified graft harvesting.
abstract: The purpose of this study was to determine the incidence of bitunnel interference fixation and accurate femoral insertion site targeting using a modified technique of endoscopic anterior cruciate ligament (ACL) reconstruction. Thirty-four consecutive central-third bone-patellar tendon-bone autograft modified endoscopic ACL reconstructions were prospectively studied. A new technique was used intraoperatively to directly measure (a) intraarticular (graft) distance (IAD) and (b) patellar tendon graft length, thereby allowing calculation of optimal tibial tunnel length for each case. Accuracy of guide pin placement through this tibial tunnel into the proposed femoral insertion site was assessed, as was the ability to achieve interference fixation in both tunnels (minimum of 20 mm bone interference fixation within the tibial tunnel). A new technique for patellar tendon-bone harvesting and proximal graft fixation to address graft mismatch is described. The average IAD from tibial origin to femoral ACL insertion measured 26.3 +/- 3.0 mm (range 21-33). The average patellar tendon length (LP) was 48.4 +/- 6.0 mm (range 40-63). The average calculated tibial tunnel length (TT) necessary to achieve bitunnel fixation (TT > or = LP + 20 - IAD) was 42.1 +/- 5.3 mm (range 36-57). Establishment of the calculated tibial tunnel length was achieved in 25 cases (74%) (no graft-tunnel mismatch). Graft-tunnel mismatch, in which the tibial tunnel could not be established to the length calculated necessary to accommodate a minimum of 20 mm of bone graft, occurred in nine cases (26%). Graft-tunnel mismatch occurred more frequently in patients whose patellar lengths were > or = 50 mm (p < 0.005), but was not found to correlate specifically to IAD. Recession of the graft up into the femoral tunnel allowed accommodation of the mismatched graft (bitunnel interference screw fixation) in these nine cases, averaging 22.0 +/- 2.98 mm (range 16-29 mm) of available distal bone block fixation. Tibial tunnel fixation of > or = 20 mm was achieved in 30 patients (88%), 18 mm in two, 17 mm in one, and 16 mm in one. Measurement error resulted in inadequate distal graft accommodation in four patients in whom error averaged 3 mm. Targeting of the femoral insertion site guide pin was achieved without requiring any knee manipulation for all cases. Patellar tendon graft protrusion through the tibial tunnel and potentially suboptimal graft fixation poses a frequent problem during endoscopic ACL reconstruction.(ABSTRACT TRUNCATED AT 400 WORDS)
authors.affiliation: Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC 20007.
authors.forename: B
authors.initials: B
authors.lastname: Shaffer
authors.forename: W
authors.initials: W
authors.lastname: Gow
authors.forename: J E
authors.initials: JE
authors.lastname: Tibone
mesh_terms: D016118:Anterior Cruciate Ligament / Q000601:surgery*; D001182:Arthroscopy / Q000379:methods*; D001696:Biomechanical Phenomena; D001863:Bone Screws; D006801:Humans; D007593:Joint Instability / Q000601:surgery*; D010027:Osteotomy / Q000379:methods; D010329:Patella / Q000601:surgery; D011183:Postoperative Complications; D011446:Prospective Studies; D013536:Suture Techniques; D013710:Tendons / Q000033:anatomy & histology / Q000637:transplantation*; D013977:Tibia / Q000033:anatomy & histology / Q000601:surgery