Femoral tunnel placement in anterior cruciate ligament reconstruction: rationale of the two incision technique |
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Authors: | Raffaele Garofalo Biagio Moretti Cyril Kombot Lorenzo Moretti Elyazid Mouhsine |
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Institution: | (1) Department of clinical methodology and surgical technique, orthopaedics section, University of Bari, Bari, Italy;(2) Department of traumatology and orthopaedic surgery, University Hospital, Lausanne, Swizerland |
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Abstract: | Endoscopic anterior cruciate ligament (ACL) reconstruction can be performed through one-incision or two-incision technique.
The current one-incision endoscopic ACL single bundle reconstruction techniques attempt to perform an isometric repair placing
the graft along the roof of the intercondylar notch, anterior and superior to the native ACL insertion. However the ACL isometry
is a theoretical condition, and has not stood up to detailed testing and investigation. Moreover this type of reconstruction
results in a vertically oriented non-anatomic graft, which is able to control anterior tibial translation but not the rotational
component of the instability. Femoral tunnel obliquity has a great effect on rotational stability. To improve the obliquity
of graft, an anatomical ACL reconstruction should be attempt. Anatomical insertion of ACL on the femur lies very low in the
notch, spreading between 11 and 9–8 o'clock position and the center lies lower than at 11 o'clock position. Femoral aiming
devices through the tibial tunnel aim at an isometric placement, and they do not aim at an anatomic position of the graft.
Also, a placement of tunnel in a position of 11 o'clock is unable to restore rotational stability. The two-incision technique,
with the possibility to position femoral tunnel independently by tibial tunnel, allows us to place femoral tunnel entrance
in a position of 10 'clock that can most accurately reproduce the anatomic behaviour of the ACL and can potentially improve
the response of the graft to rotatory loads. This positioning results in a more oblique graft placement, avoiding problem
related to PCL impingement during knee flexion. Further studies are required to understand if this kind of reconstruction
can ameliorate proprioception as well as clinical outcome at a long-term follow-up. |
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