assessment of femoral tunnel placement in acl reconstruction
TRANSCRIPT
Tunnel Placement in ACL Reconstruction: Can Plain
Radiographs Accurately Assess Tunnel Position and Reaming Method
Jeremy M. Burnham, MDUK Orthopaedic Surgery and Sports Medicine
Senior Author: Mary Lloyd Ireland, MDUK Orthopaedic Surgery and Sports Medicine
Orthopaedic Surgery and Sports Medicine
Background:
• ACL injury 1 in 3000• More than 100,000 reconstructions each
year• Failure rate as high as 10-15%• This rate is holding fairly constant despite
improvements in the understanding of the ACL anatomy and its biomechanics
Orthopaedic Surgery and Sports Medicine
Background:
• Continued focus on more closely restoring normal anatomy during ACL reconstruction
• Tunnel placement is an important factor in the success of a reconstructed ACL
• Reaming methods: anteromedial (AM) vs. transtibial (TT)
• Many times X-rays are shown and failure of the graft is blamed on the non-anatomic position of the tunnels and/or the reaming method
Orthopaedic Surgery and Sports Medicine
Background:
• Ideally, estimating tunnel position would be simple to perform using common clinical imaging• Currently, most accurate method for assessing tunnel
position is 3D CT
• Plain radiographs have been suggested as a quicker and less expensive solution
• Limited research about our ability to determine reaming method by assessing plain films
Orthopaedic Surgery and Sports Medicine
Literature:
• Can we assess tunnel position reliably with radiographs?
Orthopaedic Surgery and Sports Medicine
Pinczewski, L. A., Salmon, L. J., Jackson, W. F. M., von Bormann, R. P. B., Haslam, P. G., & Tashiro, S. (2008). Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. Journal of Bone and Joint Surgery-British Volume, 90B(2), 172-179
Orthopaedic Surgery and Sports Medicine
Warme, B. A., et al. (2012). Reliability of Early Postoperative Radiographic Assessment of Tunnel Placement After Anterior Cruciate Ligament Reconstruction. Arthroscopy-the Journal of Arthroscopic and Related Surgery, 28(7)
Orthopaedic Surgery and Sports Medicine
Cole, J., Brand, J. C., Jr., Caborn, D. N., & Johnson, D. L. (2000). Radiographic analysis of femoral tunnel position in anterior cruciate ligament reconstruction. Am J Knee Surg, 13(4), 218-222.
Orthopaedic Surgery and Sports Medicine
Illingworth, KD, et. Al., Fu, “A Simple Evaluation of Anterior Cruciate Ligament Femoral Tunnel Position: The Inclination Angle and Femoral Tunnel Angle,” Am. J. Sports Med 39:12 (December, 2011), pp. 2611-2618.
Orthopaedic Surgery and Sports Medicine
Literature:
• Radiographic assessment of tunnels• Reaming methods
Orthopaedic Surgery and Sports Medicine
Harner, C. D., Honkamp, N. J., & Ranawat, A. S. (2008). Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy, 24(1), 113-115.
Orthopaedic Surgery and Sports Medicine
Ahn, J. H., et al (2013). 3-D reconstruction computed tomography evaluation of tunnel location during single-bundle anterior cruciate ligament reconstruction: a comparison of TT and 2-incision TTI techniques. Clin Orthop Surg, 5(1), 26-35.
Orthopaedic Surgery and Sports Medicine
Piasecki, D. P., Bach, B. R., Orias, A. A. E., & Verma, N. N. (2011). Anterior Cruciate Ligament Reconstruction Can Anatomic Femoral Placement Be Achieved With a Transtibial Technique? AJSM, 39(6), 1306-1315
Orthopaedic Surgery and Sports Medicine
Research Questions:
• Can the reaming method be predicted by postop x-rays
• Is one actual reaming method associated with more favorable assessments of tunnel placement on plain films
• Is one assumed reaming method associated with more favorable assessments of tunnel placement on plain films
Orthopaedic Surgery and Sports Medicine
Methods
• Operative reports of ACL reconstructions performed by the senior author from a four-year period (2006 – 2010) were reviewed
• 119 transtibial (TT), 101 anteromedial (AM) reaming• 40 of these were randomly chosen• Randomized into 2 groups of 20 each:
AM or TT reaming
Orthopaedic Surgery and Sports Medicine
Surgical Technique
• Usual degree of knee flexion 120°• Not measured with goniometer• No intraoperative radiographs
Orthopaedic Surgery and Sports Medicine
Postop X-rays
Orthopaedic Surgery and Sports Medicine
Methods
• 15 reviewers• 5 attendings, 6 fellows, 4 senior
residents• Research survey was sent as an
excel file• Radiographs were embedded in the file
• Reviewers were blinded
Orthopaedic Surgery and Sports Medicine
Worksheet Sample
Orthopaedic Surgery and Sports Medicine
Results - Assessment of Reaming Method
RaterReaming Method
judgedcorrectly
95% CI P Training Level
1 30/40 (75.0%) 61.6%, 88.4% 0.0016 Attending2 28/40 (70.0%) 55.8%, 84.2% 0.0114 Attending3 25/40 (62.5%) 47.5%, 77.5% 0.1138 Fellow4 29/40 (72.5%) 58.7%, 86.3% 0.0044 Resident5 21/40 (52.5%) 37.0%, 68.0% 0.7518 Fellow6 26/40 (65.0%) 50.2%, 79.8% 0.0578 Fellow7 20/40 (50.0%) 34.5%, 65.5% 1.0000 Resident8 34/40 (85.0%) 73.9%, 96.1% 0.0000 Attending9 24/40 (60.0%) 44.8%, 75.2% 0.2059 Fellow10 21/40 (52.5%) 37.0%, 68.0% 0.7518 Attending11 22/40 (55.0%) 39.6%, 70.4% 0.5271 Attending12 22/40 (55.0%) 39.6%, 70.4% 0.5271 Fellow13 25/40 (62.5%) 47.5%, 77.5% 0.1138 Resident14 33/40 (82.5%) 70.7%, 94.3% 0.0000 Fellow15 18/40 (45.0%) 29.6%, 60.4% 0.5271 Resident
Orthopaedic Surgery and Sports Medicine
Results – Assessment of Reaming Method
Training Level
Percentof TotalFrequency
Average Percentjudged Correct
Standard Deviation
Attending 5 67.50 13.69Fellow 6 62.92 10.66Resident 4 57.50 12.42
• Overall, the reaming method was correctly identified 64% of the time• 57% for AM and 71% for TT• Range 45-85%
Orthopaedic Surgery and Sports Medicine
Results – Assessment of Reaming Method
Orthopaedic Surgery and Sports Medicine
Results – Assessment of Reaming Method
Rater Correctly Judged AM
Correctly Judged TT Kappa 95% CI P-value Training
1 12/20 (60.0%) 18/20 (90.0%) 0.50000 0.2440, 0.7560 0.00092 Attending2 14/20 (70.0%) 14/20 (70.0%) 0.40000 0.1160, 0.6840 0.01141 Attending3 11/20 (55.0%) 14/20 (70.0%) 0.25000 -0.0467, 0.5467 0.10977 Fellow4 14/20 (70.0%) 15/20 (75.0%) 0.45000 0.1736, 0.7264 0.00438 Resident5 4/20 (20.0%) 17/20 (85.0%) 0.05000 -0.1852, 0.2852 0.67732 Fellow6 11/20 (55.0%) 15/20 (75.0%) 0.30000 0.0103, 0.5897 0.05281 Fellow7 17/19 (89.5%) 3/20 (15.0%) 0.04387 -0.1610, 0.2488 0.67617 Resident8 17/20 (85.0%) 17/20 (85.0%) 0.70000 0.4787, 0.9213 0.00001 Attending9 12/20 (60.0%) 12/20 (60.0%) 0.20000 -0.1036, 0.5036 0.20590 Fellow10 11/18 (61.1%) 10/17 (58.8%) 0.19935 -0.1254, 0.5241 0.23826 Attending11 9/19 (47.4%) 13/20 (65.0%) 0.12417 -0.1838, 0.4322 0.43251 Attending12 4/20 (20.0%) 18/20 (90.0%) 0.10000 -0.1202, 0.3202 0.37583 Fellow13 8/20 (40.0%) 17/20 (85.0%) 0.25000 -0.0180, 0.5180 0.07664 Resident14 14/20 (70.0%) 19/20 (95.0%) 0.65000 0.4220, 0.8780 0.00002 Fellow15 9/19 (47.4%) 9/20 (45.0%) -0.07622 -0.3888, 0.2363 0.63365 Resident
Orthopaedic Surgery and Sports Medicine
Results – Assessment of Reaming Method
Rater Correctly Judged AM
Correctly Judged TT Kappa 95% CI P-value Training
1 12/20 (60.0%) 18/20 (90.0%) 0.50000 0.2440, 0.7560 0.00092 Attending2 14/20 (70.0%) 14/20 (70.0%) 0.40000 0.1160, 0.6840 0.01141 Attending3 11/20 (55.0%) 14/20 (70.0%) 0.25000 -0.0467, 0.5467 0.10977 Fellow4 14/20 (70.0%) 15/20 (75.0%) 0.45000 0.1736, 0.7264 0.00438 Resident5 4/20 (20.0%) 17/20 (85.0%) 0.05000 -0.1852, 0.2852 0.67732 Fellow6 11/20 (55.0%) 15/20 (75.0%) 0.30000 0.0103, 0.5897 0.05281 Fellow7 17/19 (89.5%) 3/20 (15.0%) 0.04387 -0.1610, 0.2488 0.67617 Resident8 17/20 (85.0%) 17/20 (85.0%) 0.70000 0.4787, 0.9213 0.00001 Attending9 12/20 (60.0%) 12/20 (60.0%) 0.20000 -0.1036, 0.5036 0.20590 Fellow10 11/18 (61.1%) 10/17 (58.8%) 0.19935 -0.1254, 0.5241 0.23826 Attending11 9/19 (47.4%) 13/20 (65.0%) 0.12417 -0.1838, 0.4322 0.43251 Attending12 4/20 (20.0%) 18/20 (90.0%) 0.10000 -0.1202, 0.3202 0.37583 Fellow13 8/20 (40.0%) 17/20 (85.0%) 0.25000 -0.0180, 0.5180 0.07664 Resident14 14/20 (70.0%) 19/20 (95.0%) 0.65000 0.4220, 0.8780 0.00002 Fellow15 9/19 (47.4%) 9/20 (45.0%) -0.07622 -0.3888, 0.2363 0.63365 Resident
Orthopaedic Surgery and Sports Medicine
Results – Assessment of Reaming Method
Slight Fair Moderate Substantial Perfect0
1
2
3
4
5
6
7Kappa
Orthopaedic Surgery and Sports Medicine
Results - Assessment of Reaming Method
RaterReaming Method
judgedcorrectly
95% CI P Training Level
1 30/40 (75.0%) 61.6%, 88.4% 0.0016 Attending2 28/40 (70.0%) 55.8%, 84.2% 0.0114 Attending3 25/40 (62.5%) 47.5%, 77.5% 0.1138 Fellow4 29/40 (72.5%) 58.7%, 86.3% 0.0044 Resident5 21/40 (52.5%) 37.0%, 68.0% 0.7518 Fellow6 26/40 (65.0%) 50.2%, 79.8% 0.0578 Fellow7 20/40 (50.0%) 34.5%, 65.5% 1.0000 Resident8 34/40 (85.0%) 73.9%, 96.1% 0.0000 Attending9 24/40 (60.0%) 44.8%, 75.2% 0.2059 Fellow10 21/40 (52.5%) 37.0%, 68.0% 0.7518 Attending11 22/40 (55.0%) 39.6%, 70.4% 0.5271 Attending12 22/40 (55.0%) 39.6%, 70.4% 0.5271 Fellow13 25/40 (62.5%) 47.5%, 77.5% 0.1138 Resident14 33/40 (82.5%) 70.7%, 94.3% 0.0000 Fellow15 18/40 (45.0%) 29.6%, 60.4% 0.5271 Resident
Orthopaedic Surgery and Sports Medicine
Results - Assessment of Reaming Method
RaterReaming Method
judgedcorrectly
95% CI P Training Level
1 30/40 (75.0%) 61.6%, 88.4% 0.0016 Attending2 28/40 (70.0%) 55.8%, 84.2% 0.0114 Attending3 25/40 (62.5%) 47.5%, 77.5% 0.1138 Fellow4 29/40 (72.5%) 58.7%, 86.3% 0.0044 Resident5 21/40 (52.5%) 37.0%, 68.0% 0.7518 Fellow6 26/40 (65.0%) 50.2%, 79.8% 0.0578 Fellow7 20/40 (50.0%) 34.5%, 65.5% 1.0000 Resident8 34/40 (85.0%) 73.9%, 96.1% 0.0000 Attending9 24/40 (60.0%) 44.8%, 75.2% 0.2059 Fellow10 21/40 (52.5%) 37.0%, 68.0% 0.7518 Attending11 22/40 (55.0%) 39.6%, 70.4% 0.5271 Attending12 22/40 (55.0%) 39.6%, 70.4% 0.5271 Fellow13 25/40 (62.5%) 47.5%, 77.5% 0.1138 Resident14 33/40 (82.5%) 70.7%, 94.3% 0.0000 Fellow15 18/40 (45.0%) 29.6%, 60.4% 0.5271 Resident
Orthopaedic Surgery and Sports Medicine
Results – Assessment of Reaming Method
Better Worse0
2
4
6
8
10
12
33%
66%
Compared to Chance
Orthopaedic Surgery and Sports Medicine
Conclusions
• Reaming method was properly identified 64% of the time
• Precision was suboptimal• Only 33% of the reviewers were able to
accurately identify the reaming method more often than would be expected by pure chance
Orthopaedic Surgery and Sports Medicine
Pending Analysis
• Is one actual reaming method associated with more favorable assessments of tunnel placement on plain films
• Is one assumed reaming method associated with more favorable assessments of tunnel placement on plain films
• Clockface analysis
Orthopaedic Surgery and Sports Medicine
Future Questions
• How does postoperative x-ray assessment correlate with tunnel position on 3D CT scan