Guler Olcay, Mahırogulları Mahir, Mutlu Serhat, Cercı Mehmet H, Seker Ali, Cakmak Selami
Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey.
Orthopedics and Traumatology Department, Kanuni Sultan Suleyman Training Hospital, Istanbul, Turkey.
Arch Orthop Trauma Surg. 2016 Nov;136(11):1571-1580. doi: 10.1007/s00402-016-2532-7. Epub 2016 Aug 2.
When treating anterior cruciate ligament (ACL) injuries, the position of the ACL graft plays a key role in regaining postoperative knee function and physiologic kinematics. In this study, we aimed to compare graft angle, graft position in tibial tunnel, and tibial and femoral tunnel positions in patients operated with anteromedial (AM) and transtibial (TT) methods to those of contralateral healthy knees.
Forty-eight patients who underwent arthroscopic ACL reconstruction with ipsilateral hamstring tendon autograft were included. Of these, 23 and 25 were treated by AM and TT techniques, respectively. MRI was performed at 18.4 and 19.7 months postoperatively in AM and TT groups. Graft angles, graft positions in the tibial tunnel and alignment of tibial and femoral tunnels were noted and compared in these two groups. The sagittal graft insertion tibia midpoint distance (SGON) has been used for evaluation of graft position in tunnel.
Sagittal ACL graft angles in operated and healthy knees of AM patients were 57.78° and 46.80° (p < 0.01). With respect to TT patients, ACL graft angle was 58.87° and 70.04° on sagittal and frontal planes in operated knees versus 47.38° and 61.82° in healthy knees (p < 0.001). ACL graft angle was significantly different between the groups on both sagittal and frontal planes (p < 0.001). Sagittal graft insertion tibia midpoint distance ratio was 0.51 and 0.48 % in the operated and healthy knees of AM group (p < 0.001) and 0.51 and 0.48 % in TT group (p < 0.001). Sagittal tibial tunnel midpoint distance ratio did not differ from sagittal graft insertion tibia midpoint distance of healthy knees in either group. Femoral tunnel clock position was better in AM [right knee 10:19 o'clock-face position (310° ± 4°); left knee 1:40 (50° ± 3°)] compared with TT group [right knee 10:48 (324° ± 5°); left knee 1:04 (32° ± 4°)]. With respect to the sagittal plane, the anterior-posterior position of femoral tunnel was better in AM patients. Lysholm scores and range of motion of operated knees in the AM and TT groups showed no significant difference (p > 0.05).
Precise reconstruction on sagittal plane cannot be obtained with either AM or TT technique. However, AM technique is superior to TT technique in terms of anatomical graft positioning. Posterior-placed grafts in tibial tunnel prevent ACL reconstruction, although tibial tunnel is drilled on sagittal plane.
在治疗前交叉韧带（ACL）损伤时，ACL移植物的位置对于术后膝关节功能和生理运动学的恢复起着关键作用。在本研究中，我们旨在比较采用前内侧（AM）和经胫骨（TT）方法手术的患者与对侧健康膝关节的移植物角度、胫骨隧道内的移植物位置以及胫骨和股骨隧道的位置。
纳入48例行关节镜下自体腘绳肌腱ACL重建术的患者。其中，分别有23例和25例采用AM和TT技术治疗。AM组和TT组分别在术后18.4个月和19.7个月进行MRI检查。记录并比较两组的移植物角度、胫骨隧道内的移植物位置以及胫骨和股骨隧道的对线情况。矢状面移植物插入胫骨中点距离（SGON）已用于评估移植物在隧道内的位置。
AM患者手术侧和健康侧膝关节的矢状面ACL移植物角度分别为57.78°和46.80°（p<0.01）。对于TT患者，手术侧膝关节矢状面和额状面的ACL移植物角度分别为58.87°和70.04°，而健康侧膝关节分别为47.38°和61.82°（p<0.001）。两组在矢状面和额状面上的ACL移植物角度均有显著差异（p<0.001）。AM组手术侧和健康侧膝关节的矢状面移植物插入胫骨中点距离比分别为0.51%和0.48%（p<0.001），TT组分别为0.51%和0.48%（p<0.001）。两组的矢状面胫骨隧道中点距离比与健康膝关节的矢状面移植物插入胫骨中点距离无差异。AM组股骨隧道时钟位置优于TT组[右膝为10:19（310°±4°）；左膝为1:40（50°±3°）]，而TT组右膝为10:48（324°±5°），左膝为1:04（32°±4°）。在矢状面上，AM患者股骨隧道的前后位置更佳。AM组和TT组手术侧膝关节的Lysholm评分和活动范围无显著差异（p>0.05）。
AM和TT技术均无法在矢状面上实现精确重建。然而，在解剖学移植物定位方面，AM技术优于TT技术。尽管胫骨隧道是在矢状面上钻孔，但胫骨隧道内移植物后置会妨碍ACL重建。
