Jeon Sang-Woo, Kim Sung-Hwan, Kim Kang-Il
Department of Orthopedic Surgery, Ewha Womans University Seoul Hospital, Seoul 07804, Republic of Korea.
Department of Orthopedic Surgery, Severance Hospital, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea.
Medicina (Kaunas). 2025 May 22;61(6):946. doi: 10.3390/medicina61060946.
Graft impingement against the intercondylar notch has been identified as a significant contributor to graft deterioration and suboptimal outcomes following anterior cruciate ligament (ACL) reconstruction. This study aimed to (1) identify the optimal combination of tunnel positions that minimizes impingement between the ACL graft and femoral intercondylar notch.
Three-dimensional models of nine normal knees were reconstructed using computed tomography scans obtained at four knee flexion angles (0°, 45°, 90°, and 120°). Virtual ACL grafts with diameters of 7 mm and 9 mm were modeled as cylinders. Nine graft configurations were investigated by varying femoral and tibial footprint locations (anteromedial, central, and posterolateral) in all possible combinations. For each configuration, impingement volume was quantified by measuring the overlap between the intercondylar notch and the virtual graft using Boolean operators in 3D simulation software. The effects of graft diameter, footprint location, and knee flexion angle on impingement volume were analyzed.
Maximum impingement volumes were observed at 0° knee extension, with significant reductions at 45° flexion ( < 0.01) and negligible impingement at 90° and 120° flexion. The 9 mm diameter grafts demonstrated significantly greater impingement volumes than 7 mm grafts ( < 0.01). Impingement volumes increased progressively as footprint locations shifted from posterolateral to anteromedial positions in both femoral and tibial components. However, statistically significant differences in impingement volume across footprint locations were observed only for tibial positioning ( < 0.001), not for femoral positioning ( > 0.05). The femoral anteromedial-tibial anteromedial configuration exhibited the highest impingement volume (577.8 ± 171.3 mm for 9 mm grafts), while the femoral posterolateral-tibial posterolateral configuration showed the lowest (73.5 ± 85.6 mm).
Tunnel position, graft diameter, and knee flexion angle significantly influence impingement risk in ACL reconstruction. Tibial tunnel position appears more critical than femoral position in minimizing graft impingement. Posterolateral positioning of tunnels, particularly on the tibial side, may reduce impingement volume.
This study provides quantitative evidence to guide surgeons in optimizing tunnel placement and graft selection for anatomical single-bundle ACL reconstruction, potentially reducing the risk of graft deterioration and failure due to mechanical impingement.
移植组织撞击髁间切迹已被确认为前交叉韧带（ACL）重建后移植组织退变及预后不佳的重要原因。本研究旨在：（1）确定能使ACL移植组织与股骨髁间切迹之间撞击最小化的隧道位置最佳组合。
使用在四个膝关节屈曲角度（0°、45°、90° 和 120°）获取的计算机断层扫描重建九个正常膝关节的三维模型。将直径为7毫米和9毫米的虚拟ACL移植组织建模为圆柱体。通过以所有可能组合改变股骨和胫骨足迹位置（前内侧、中央和后外侧）来研究九种植入物配置。对于每种配置，在三维模拟软件中使用布尔运算符通过测量髁间切迹与虚拟移植组织之间的重叠来量化撞击体积。分析了移植组织直径、足迹位置和膝关节屈曲角度对撞击体积的影响。
在膝关节伸展0°时观察到最大撞击体积，在屈曲45°时显著减小（<0.01），在屈曲90°和120°时撞击可忽略不计。9毫米直径的移植组织显示出比7毫米移植组织显著更大的撞击体积（<0.01）。随着股骨和胫骨组件中足迹位置从前外侧向后内侧移动，撞击体积逐渐增加。然而，仅在胫骨定位时观察到足迹位置间撞击体积的统计学显著差异（<0.001），而在股骨定位时未观察到（>0.05）。股骨前内侧 - 胫骨前内侧配置表现出最高的撞击体积（9毫米移植组织为577.8±171.3立方毫米），而股骨后外侧 - 胫骨后外侧配置显示出最低的撞击体积（73.5±85.6立方毫米）。
隧道位置、移植组织直径和膝关节屈曲角度显著影响ACL重建中的撞击风险。在使移植组织撞击最小化方面，胫骨隧道位置似乎比股骨位置更关键。隧道的后外侧定位，特别是在胫骨侧，可能会减小撞击体积。
本研究提供了定量证据，以指导外科医生优化解剖单束ACL重建的隧道放置和移植组织选择，潜在地降低因机械撞击导致移植组织退变和失败的风险。
