Tank Shekhar, Dutt Saurabh, Sehrawat Rakesh, Kumar Vinod, Sabat Dhananjaya
SGT Medical College and Research Institute, Gurgaon, Haryana, India.
Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India.
J Clin Orthop Trauma. 2020 Nov 17;15:22-26. doi: 10.1016/j.jcot.2020.11.004. eCollection 2021 Apr.
An anatomical double bundle ACL reconstruction replicates the anatomy of native ACL as the tunnels are made to simulate the anatomy of ACL with AM and PL bundle foot prints. The goal of anatomic ACL reconstruction is to tailor the procedure to each patient's anatomic, biomechanical and functional demands to provide the best possible outcome. The shift from single bundle to double bundle technique and also from transtibial to transportal method has been to provide near anatomic tunnel positions.
To determine the position of femoral and tibial tunnels prepared by double bundle ACL reconstruction using three dimensional Computed tomography.
A prospective case series involving forty patients with ACL tear who underwent transportal double bundle ACL reconstruction.
Computed tomography scans were performed on forty knees that had undergone double bundle anterior cruciate ligament reconstruction. Three-dimensional computed tomography reconstruction models of the knee joint were prepared and aligned into an anatomical coordinate axis system for femur and tibia respectively. Tibial tunnel centres were measured in the anterior-to-posterior and medial-to-lateral directions on the top view of tibial plateau and femoral tunnel centres were measured in posterior to anterior and proximal-to-distal directions with anatomic coordinate axis method. These measurements were compared with published reference data.
Analysing the Femoral tunnel, the mean posterior-to-anterior distances for anteromedial and posterolateral tunnel centre position were 46.8% ± 7.4% and 34.5% ± 5.0% of the posterior-to-anterior height of the medial wall and the mean proximal-to-distal distances for the anteromedial and posterolateral tunnel centre position were 24.1% ± 7.1% and 61.6% ± 4.8%. On the tibial side, the mean anterior-to-posterior distances for the anteromedial and posterolateral tunnel centre position were 28.8% ± 4.3% and 46.2% ± 3.6% of the anterior-to posterior depth of the tibia measured from the anterior border and the mean medial-to-lateral distances for the anteromedial and posterolateral tunnel centre position were 46.5% ± 2.9% and 50.6% ± 2.8% of the medial-to-lateral width of the tibia measured from the medial border. There is high Inter-observer and Intra-observer reliability (Intra-class correlation coefficient).
Femoral AM tunnel was positioned significantly anterior and nearly proximal whereas the femoral PL tunnel was positioned significantly anterior and nearly distal with respect to the anatomic site. Location of tibial AM tunnel was nearly posterior and nearly medial whereas the location of tibial PL tunnel was very similar to the anatomic site Evaluation of location of tunnels through the anatomic co-ordinate axes method on 3D CT models is a reliable and reproducible method. This method would help the surgeons to aim for anatomic placement of the tunnels. It also shows that there is scope for improvement of femoral tunnel in double bundle ACL reconstruction through transportal technique.
解剖双束前交叉韧带重建术可复制天然前交叉韧带的解剖结构，因为所创建的隧道模拟了前交叉韧带前内侧束和后外侧束的足迹的解剖结构。解剖前交叉韧带重建的目标是根据每位患者的解剖、生物力学和功能需求调整手术方式，以实现最佳治疗效果。从单束技术转变为双束技术，以及从经胫骨入路转变为经髁间窝入路，都是为了实现接近解剖位置的隧道定位。
使用三维计算机断层扫描确定双束前交叉韧带重建术中股骨隧道和胫骨隧道的位置。
一项前瞻性病例系列研究，纳入40例前交叉韧带撕裂并接受经髁间窝双束前交叉韧带重建术的患者。
对40例接受双束前交叉韧带重建术的膝关节进行计算机断层扫描。制备膝关节的三维计算机断层扫描重建模型，并分别将其与股骨和胫骨的解剖坐标轴系统对齐。在胫骨平台顶视图上，以前后方向和内外方向测量胫骨隧道中心；以解剖坐标轴法，在前后方向和远近方向测量股骨隧道中心。将这些测量结果与已发表的参考数据进行比较。
分析股骨隧道，前内侧和后外侧隧道中心位置的平均前后距离分别为内侧壁前后高度的46.8%±7.4%和34.5%±5.0%，前内侧和后外侧隧道中心位置的平均远近距离分别为24.1%±7.1%和61.6%±4.8%。在胫骨侧，前内侧和后外侧隧道中心位置的平均前后距离分别为从胫骨前缘测量的胫骨前后深度的28.8%±4.3%和46.2%±3.6%，前内侧和后外侧隧道中心位置的平均内外距离分别为从胫骨内侧缘测量的胫骨内外宽度的46.5%±2.9%和50.6%±2.8%。观察者间和观察者内的可靠性较高（组内相关系数）。
相对于解剖位置，股骨前内侧隧道显著靠前且近乎靠上，而股骨后外侧隧道显著靠前且近乎靠下。胫骨前内侧隧道位置近乎靠后且近乎靠内，而胫骨后外侧隧道的位置与解剖位置非常相似。通过三维CT模型上的解剖坐标轴法评估隧道位置是一种可靠且可重复的方法。该方法有助于外科医生实现隧道的解剖学定位。这也表明，经髁间窝技术在双束前交叉韧带重建中，股骨隧道的定位仍有改进空间。
