title: Clinical advantages of image-free navigation system using surface-based registration in anatomical anterior cruciate ligament reconstruction.
abstract: OBJECTIVE
  To evaluate the clinical advantages of a navigation system developed with an emphasis on attaining an appropriate femoral tunnel length and posterior wall margin with no posterior wall blowout, as well as having accurate tunnel positioning, in anatomical anterior cruciate ligament reconstruction (ACLR).
  
  
  METHODS
  Ten freshly frozen human knees were transected at mid-femur and mid-tibia. Each knee specimen underwent arthroscopic single-bundle anterior cruciate ligament reconstruction using the outside-in technique, with two knees by manual ACLR (control group) and another eight knees by only the navigational ACLR without arthroscopic assistance (experimental group). The position/orientation information of tunnel entry point, tunnel length, and posterior wall distance of pre-, intra-, and postoperative tunnel were recorded, and the reliability and errors among them were evaluated.
  
  
  RESULTS
  From comparison of the 3D models for preoperative planning and postoperative reconstruction, the mean differences for navigational femoral tunnelling and arthroscopic-assisted femoral tunnelling were recorded, respectively: (1) tunnel entry position, 1.4 mm (SD 0.3) versus 4.9 mm; (2) tunnel length, 0.7 mm (SD 0.2), similar to 0.6 mm in arthroscopic-assisted femoral tunnelling, and (3) posterior wall distance, 0.5 mm (SD 0.2), much smaller than 4.7 mm for arthroscopic-assisted femoral tunnelling. The intraclass correlation coefficients, calculated to determine the accuracy and reliability of navigational femoral tunnelling, showed excellent internal consistency that ranged from 0.965 to 0.989 for tunnel length and from 0.810 to 0.953 for posterior wall distance.
  
  
  CONCLUSIONS
  Navigation systems with enhancement of the registration accuracy by the developed system are feasible in anatomical ACLR, in reducing surgical failures such as short tunnel length or posterior wall breakage of distal femur. The present study revealed that computer navigation could aid in avoiding major mistakes in exact positioning and posterior wall blowout and help in attaining appropriate length for femoral tunnelling in anatomical ACLR.
authors.affiliation: Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Gil-dong, Seoul, 134-701, South Korea.
authors.forename: Byung Hoon
authors.initials: BH
authors.lastname: Lee
authors.affiliation: Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, South Korea.
authors.forename: Dong Ho
authors.initials: DH
authors.lastname: Kum
authors.affiliation: Department of Anatomy, College of Medicine, Korea University, Seoul, South Korea.
authors.forename: Im Joo
authors.initials: IJ
authors.lastname: Rhyu
authors.affiliation: Center for Bionics, Korea Institute of Science and Technology, Seoul, South Korea.
authors.forename: Youngjun
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Center for Bionics, Korea Institute of Science and Technology, Seoul, South Korea.
authors.forename: Hyunchul
authors.initials: H
authors.lastname: Cho
authors.affiliation: Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, South Korea. mdwang88@gmail.com.
authors.forename: Joon Ho
authors.initials: JH
authors.lastname: Wang
mesh_terms: D016118:Anterior Cruciate Ligament / Q000000981:diagnostic imaging / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries / Q000601:surgery; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D001182:Arthroscopy / Q000379:methods*; D002102:Cadaver; D005269:Femur / Q000601:surgery; D006801:Humans; D021621:Imaging, Three-Dimensional; D007719:Knee Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D015203:Reproducibility of Results; D025321:Surgery, Computer-Assisted / Q000379:methods*; D013977:Tibia / Q000601:surgery; D014057:Tomography, X-Ray Computed
keywords: ACL; Anatomical reconstruction; Computed tomography; Navigation; Outside-in technique