The Location of Femoral and Tibial Tunnels in Anatomic Double … · 2017-10-20 · The Location of...

The Location of Femoral and Tibial Tunnels inAnatomic Double-Bundle Anterior Cruciate

Ligament Reconstruction Analyzed by Three-Dimensional Computed Tomography Models

By Brian Forsythe, MD, Sebastian Kopf, MD, Andrew K. Wong, BA, Cesar A.Q. Martins, MD, William Anderst, MS,Scott Tashman, PhD, and Freddie H. Fu, MD, DSc(Hon), DPs(Hon)

Investigation performed at the Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania

Background: Characterization of the insertion site anatomy inanterior cruciate ligament reconstruction has recently receivedincreasedattention in the literature, coincidingwithagrowing interest inanatomic reconstruction. Thepurposeof thisstudywasto visualize and quantify the position of anatomic anteromedial and posterolateral bone tunnels in anterior cruciate ligamentreconstruction with use of novel methods applied to three-dimensional computed tomographic reconstruction images.

Methods: Careful arthroscopic dissection and anatomic double-bundle anterior cruciate ligament tunnel drilling wereperformed with use of topographical landmarks in eight cadaver knees. Computed tomography scans were performed oneach knee, and three-dimensional models were created and aligned into an anatomic coordinate system. Tibial tunnelaperture centers were measured in the anterior-to-posterior and medial-to-lateral directions on the tibial plateau. Thefemoral tunnel aperture centers were measured in anatomic posterior-to-anterior and proximal-to-distal directions and withthe quadrant method (relative to the femoral notch).

Results: The centers of the tunnel apertures for the anteromedial and posterolateral tunnels were located at a mean (andstandard deviation) of 25% ± 2.8% and 46.4% ± 3.7%, respectively, of the anterior-to-posterior tibial plateau depth and ata mean of 50.5% ± 4.2% and 52.4% ± 2.5% of the medial-to-lateral tibial plateau width. On the medial wall of the lateralfemoral condyle in the anatomic posterior-to-anterior direction, the anteromedial and posterolateral tunnels were locatedat 23.1% ± 6.1% and 15.3% ± 4.8%, respectively. The proximal-to-distal locations were at 28.2% ± 5.4% and 58.1 ± 7.1%,respectively. With the quadrant method, anteromedial and posterolateral tunnels were measured at 21.7% ± 2.5% and35.1% ± 3.5%, respectively, from the proximal condylar surface (parallel to the Blumensaat line), and at 33.2% ± 5.6% and55.3% ± 5.3% from the notch roof (perpendicular to the Blumensaat line). Intraobserver and interobserver reliability washigh, with small standard errors of measurement.

Conclusions: This cadaver study provides reference data against which tunnel position in anterior cruciate ligamentreconstruction can be compared in future clinical trials.

Clinical Relevance: This study may help surgeons to evaluate tunnel position and facilitate anatomic tunnel placementin anterior cruciate ligament reconstruction.

Recent studies have contributed substantially to ourunderstanding of anterior cruciate ligament anatomyand have revealed that common techniques for anterior

cruciate ligament reconstruction may fail to replicate native liga-ment origins or insertions1-8. This has led to a growing interest inanatomic single-bundle and double-bundle anterior cruciate lig-

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants ofless than $10,000 from Smith and Nephew. Neither they nor a member of their immediate families received payments or other benefits or a commitmentor agreement to provide such benefits from a commercial entity.

A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site,www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

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COPYRIGHT � 2010 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2010;92:1418-26 d doi:10.2106/JBJS.I.00654

ament reconstruction, with the goal of better replicating theanatomy of the native anterior cruciate ligament9-11. There is someevidence that graft placement aligned with native insertionsites results in superior clinical outcomes12,13. A careful reviewof recently published articles, however, suggests that there isstill no consensus regarding appropriate tunnel placement inanatomic anterior cruciate ligament reconstruction14-17.

To characterize the anterior cruciate ligament footprintwith its two bundles, a profound knowledge of the anteriorcruciate ligament anatomy and its surrounding structures isnecessary. Soft-tissue remnants from the anteromedial andposterolateral bundles, and anatomic structures such as theanterior horn of the lateral meniscus and the posterior cruciateligament, are essential landmarks for anterior cruciate ligamentbone-tunnel placement. Furthermore, topographical osseousanatomic landmarks that have recently been identified, such as

the lateral intercondylar ridge and lateral bifurcate ridge on thefemoral side2,18 and the tibial spine, the medial and lateral in-tercondylar tubercles, and the anterior intertubercle ridge onthe tibia4,19, are utilized to guide bone-tunnel placement. Im-portantly, these latter structures are readily visualized on three-dimensional computed tomography reconstruction scans,making them ideal reference points for the evaluation of tunnelposition4. By combining three-dimensional imaging with me-ticulous, arthroscopic dissection, it is anticipated that anatomicanteromedial and posterolateral tunnel positions relative to osseousmorphological landmarks can be identified arthroscopically.

The purpose of this study was to evaluate the position ofanatomically placed anteromedial and posterolateral tunnelson three-dimensional computed tomography models. We hopethat the results may be used as a clinical guide for surgeons toevaluate tunnel position. Such analysis may encourage stan-

Fig. 1

Following careful arthroscopic dissection and removal of soft-tissue remnants, key insertion site anatomy was

identified. On the femoral side, the lateral bifurcate and intercondylar ridges were identified. On the tibial side,

the tibial spine, the medial and lateral intercondylar tubercles, and the posterior cruciate ligament (PCL) were

identified. Corresponding three-dimensional computed tomography reconstructions delineate these topo-

graphical osseous landmarks. AM = anteromedial, PL = posterolateral, and ACL = anterior cruciate ligament.

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 92-A d NU M B E R 6 d J U N E 2010TH E LO C AT I O N O F F E M O R A L A N D TI B I A L TU N N E L S I N AN AT O M I C

DO U B L E -BU N D L E ACL R E C O N S T R U C T I O N

dardization of surgical technique and thus lead to more accu-rate placement of anatomic anterior cruciate ligament bonetunnels and more accurate reporting of the results. Toward thisend, we address two aims: (1) to establish a method to quantifytibial and femoral tunnel positions and (2) to define the locationof anatomically positioned anteromedial and posterolateraltunnels on the femur and tibia with use of three-dimensionalcomputed tomography models of cadaver knees.

Materials and Methods

Eight fresh-frozen cadaver knees were dissected and evaluatedarthroscopically. The average age (and standard deviation)

of the donors was 63 ± 4.4 years at the time of death; seven weremale, and one was female (Committee for Oversight of Re-search Involving the Dead [CORID] No. 223). Cadaver kneeswith previous surgery, gross evidence of arthritis, or osteophyteformation were excluded from the study.

Surgical ProcedureCadaver specimens were prepared with use of careful arthro-scopic debridement, visualization, and identification of theintact anterior cruciate ligament bundles and surroundinganatomical structures (Fig. 1). Additionally, differential ten-sioning patterns of the intact ligament observed during range

Fig. 2

Following careful arthroscopic anatomic dissection, bone tunnels were drilled at the centers of the femoral and

tibial anteromedial (AM) and posterolateral (PL) insertion sites. On the femoral side, the knee was flexed to 90�to demonstrate the area of nonanatomic tunnel positioning. On the tibial side, the relationship of the antero-

medial and posterolateral guide-wires to the anterior horn of the lateral meniscus, the lateral intercondylar

tubercle, and the posterior cruciate ligament (PCL) is shown. Note that in this specimen, the distance between

the posterior cruciate ligament and the center of the posterolateral insertion measures 14 mm. The antero-

medial tunnels appear anterior in the figure. However, a 6-mm drill-bit was used to drill the tunnel. Larger drill-

bits used commonly during anterior cruciate ligament (ACL) reconstruction would enlarge the tunnel aperture,

increasing its proximity to the posterolateral tunnel.

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of motion of the knee and the figure-of-four position were usedto distinguish between the two bundles20. The insertion sites ofthe anteromedial and posterolateral anterior cruciate ligamentbundles were identified and marked by electrocautery.

Femoral anteromedial and posterolateral bone tunnelswere placed at the estimated centers of the marked anatomicinsertion sites by means of an accessory anteromedial portaldrilling technique21. The tunnels were drilled at 110� and 130�of knee flexion, respectively. The tibial anteromedial and pos-terolateral tunnels were drilled with an anterior cruciate liga-ment tip guide (Smith and Nephew, Andover, Massachusetts)set to 55� and 45�, respectively, with the knee in 90� of flexionat their respective insertion sites under direct arthroscopic vi-sualization (Fig. 2). Computed tomography scans were per-formed on all knees after the creation of the bone tunnels, witha field of view measuring 140 mm, a slice spacing of 0.6 mm, apixel spacing of 0.27 · 0.27 mm, and a resolution of 512 · 512pixels per image.

Three-Dimensional Reconstruction of ComputedTomography ScansBone was segmented from the axial computed tomographyscan slices with use of Mimics (Materialise, Leuven, Belgium)and was processed into three-dimensional surface models with

use of Geomagic Studio (Geomagic, Research Triangle Park,North Carolina). Since the computed tomography scans in-cluded only partial bones (middle of the tibia to the middle ofthe femur), the surface models from each specimen were co-registered with properly scaled male or female base models,which had been prealigned to an anatomic coordinate systembased on the femoral head and tibial malleoli centers as rec-ommended by the International Society of Biomechanics22,23.

Measurements on Three-Dimensional ImagesThe centers of the tibial tunnel apertures were determined with useof an anatomically aligned coronal plane grid, as previously de-scribed24. The centers of the femoral tunnel apertures were mea-sured with two different techniques. First, a new measurementsystem was developed with use of an anatomical coordinate systembased on landmarks that can be determined either from three-dimensional computed tomography reconstruction images or bymeans of arthroscopy. Second, a system similar to the previouslyestablished quadrant method, which is based on a sagittal planegrid aligned to the Blumensaat line, was used (Fig. 3)25.

Tibial Tunnel PositionsWith use of a true proximal-to-distal view on the tibialplateau, the anterior-to-posterior and medial-to-lateral

Fig. 3

On the femoral side, the locations of the anteromedial and posterolateral tunnel aperture

centers were established within a 4 · 4 grid, which was oriented along the most anterior edge

of the notch roof. t = line parallel to the Blumensaat line, and h = line perpendicular to the

Blumensaat line.

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tunnel positions were determined (Fig. 4). Anterior-to-posterior positions were calculated as percentages of thedistance from the line (T1) running through the anteriorborder of the tibial plateau (where the plateau edge dropsdown to the shaft) to the line (T2) running through the

most posterior border of the tibial plateau. Medial-to-lateralpositions were calculated as percentages of the distance fromthe line (T3) running through the medial border of thetibial plateau to the line (T4) running through the lateralborder of the tibial plateau.

Fig. 4

Femoral anatomic coordinate axes posterior-to-anterior (P-A) measurements were made from the line (F1) running

through the posterior border of the medial wall of the lateral condyle to the line (F2) running through the most anterior

point of the notch. Proximal-to-distal (Pr-D) measurements were made from the line (F3) running through the proximal

border of the notch to the line (F4) running through the distal point of the notch roof. Posterior-to-anterior mea-

surements for anteromedial and posterolateral tunnels were calculated as B/C and A/C, respectively. Proximal-to-

distal measurements were calculated as a/c and b/c, respectively. Note that the knee is in 90� of flexion. Tibial

anterior-to-posterior (A-P) measurements were made from the line (T1) running through the anterior border of the tibial

plateau (where the plateau edge drops down to the shaft) to the line (T2) running through the most posterior border of

the tibial plateau. Medial-to-lateral (M-L) measurements were made from the line (T3) running through the medial

border to the tibial plateau to the line (T4) running through the lateral border of the tibial plateau. Anterior-to-posterior

(A-P) measurements for anteromedial and posterolateral tunnels were calculated as A/C and B/C, respectively. Medial-

to-lateral measurements were calculated as a/c and b/c, respectively.

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Femoral Tunnel PositionsAnatomic Coordinate Axes MethodThe rationale for this anatomical method was to design a three-dimensional assessment of femoral tunnel position relative tostructures that can be visualized arthroscopically through themedial portal (see Fig. 1)21. Thus, the measurements derivedfrom three-dimensional computed tomography models couldbe applied during arthroscopy as a guide to anatomical tunnelplacement. To improve visualization of the medial wall of thelateral femoral condyle, the medial condyle was removed fromthe three-dimensional computed tomography model at themost anterior aspect of the distal notch3. A true medial view ofthe femur (perpendicular to the medial-lateral femoral axis)was established at 90� of knee flexion, allowing standardizedvisualization of the medial wall of the lateral condyle (see Fig.4). The tunnel positions were determined in the posterior-to-anterior and proximal-to-distal directions, parallel to the re-spective anatomical axes similar to published techniques26.More specifically, posterior-to-anterior positions were calculatedas percentages of the distance from the line (F1) runningthrough the posterior border of the medial wall of the lateralcondyle to the line (F2) running through the most anterior pointof the notch. Proximal-to-distal positions were calculated aspercentages of the distance from the line (F3) running throughthe proximal border of the notch to the line (F4) runningthrough the distal point of the notch roof.

Quadrant MethodA true medial view of the femur was established at 90� of kneeflexion, as described above. Similar to the quadrant method foruse on standard lateral radiographs, a 4 · 4 grid was applied tothe three-dimensional computed tomography images (see Fig.3). The grid was drawn, and measurements were performed aspreviously described25. On radiographs, the grid is aligned with theBlumensaat line, which is a projection of the femoral notch roofon the radiograph. However, since no such line exists on a three-dimensional computed tomography model, the most anterioredge of the femoral notch roof was chosen as the reference for thegrid alignment. The segments of the grid along the Blumensaatline (t) were labeled from a to d. The segments of the grid per-pendicular to the Blumensaat line (h) were labeled from 1 to 4.

All measurements were performed with use of ImageJsoftware (National Institutes of Health, Bethesda, Maryland),and all statistical analyses were performed with use of SPSSsoftware (SPSS, Chicago, Illinois). Data for the location of theanteromedial and posterolateral femoral and tibial tunnels arepresented as the mean and the standard deviation, with therange in parentheses. The interobserver and intraobserver re-liability (intraclass correlation coefficient) was calculated forthe anatomic coordinate axes method results with use of mea-sures of absolute agreement. The two individuals (S.K. andA.K.W.) who performed the interobserver and intraobserverreliability tests were the same individuals who developed andagreed on the measurement technique together. A time period ofthree weeks elapsed between test and retest measurements. Allobserver-dependent steps in the analysis, including coregistra-

tion of the three-dimensional computed tomography models tothe base models, establishment of the center of the tunnel ap-ertures, and measurement and calculation of the position of alltibial and femoral bone tunnels, were repeated. For intraobserverand interobserver reliability, the intraclass correlation coefficient,95% confidence interval for the intraclass correlation coefficient,and standard error of measurement were reported.

Source of FundingThe study was funded in part by the Smith and Nephew Re-search fund.

ResultsTibial Tunnel Positions

The mean anterior-to-posterior distances for the antero-medial and posterolateral tunnel center locations were

25% ± 2.8% (range, 21.1% to 29.5%) and 46.4% ± 3.7%(range, 40.1% to 51.5%), respectively, of the anterior-to-posterior depth of the tibia measured from the anteriorborder. The mean medial-to-lateral distances for the antero-medial and posterolateral tunnel center locations were 50.5% ±4.2% (range, 44.1% to 54.7%) and 52.4% ± 2.5% (range,49.5% to 56.1%), respectively, of the medial-to-lateral width ofthe tibia measured from the medial border.

Femoral Tunnel PositionsAnatomical Coordinate Axes MeasurementsThe mean posterior-to-anterior distances for anteromedial andposterolateral tunnel center locations were 23.1% ± 6.1%(range, 16.3% to 36.4%) and 15.3% ± 4.8% (range, 8.9% to24.3%), respectively, of the posterior-to-anterior height of themedial wall of the lateral condyle measured from the posteriorborder (F1 in Fig. 4). The mean proximal-to-distal distancesfor the anteromedial and posterolateral tunnel center locationswere 28.2% ± 5.4% (range, 20.1% to 36.2%) and 58.1% ± 7.1%(range, 50.2% to 73.1%), respectively, of the proximal-to-distaldepth of the medial wall of the lateral condyle measured fromthe proximal border (F3 in Fig. 4). The reliability estimates forthe anatomic coordinate axes method results are presented inTable I.

Quadrant Method MeasurementsThe mean distances of the anteromedial and posterolateraltunnel center locations parallel to the Blumensaat line were21.7% ± 2.5% (range, 18.9% to 25.7%) and 35.1% ± 3.5%(range, 31.2% to 40.0%), respectively, along line t measuredfrom the posterior border of the medial wall of the lateralcondyle (see Fig. 3). The mean distances perpendicular to theBlumensaat line for anteromedial and posterolateral tunnelcenter locations were 33.2% ± 5.6% (range, 24.4% to 42.1%)and 55.3% ± 5.3% (range, 47.7% to 65.1%), respectively, alongline h measured from the Blumensaat line. The center of theanteromedial bundle was located in box 1a for one cadaver andbox 2a for the seven other cadavers. The center of the postero-lateral bundle was located in box 2b for one cadaver and box 3bfor the seven other cadavers.

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Discussion

In this study, the centers of the anteromedial and postero-lateral bone tunnels in anatomic double-bundle anterior

cruciate ligament reconstruction were identified and quantifiedon three-dimensional computed tomography reconstructionimages on the basis of anatomic landmarks. Established ra-diographic measurement methods were adapted, and newmeasurement techniques were developed for three-dimensionalmodel-based analysis of the bone tunnel positions. Throughmeticulous arthroscopic dissection, revealing the individualanterior cruciate ligament bundle anatomy and the sur-rounding native soft-tissue and osseous landmarks, bonetunnels were placed as closely as possible to the centers of theanteromedial and posterolateral bundle insertions. The posi-tion of these tunnels relative to known osseous landmarkswas determined from three-dimensional bone models re-constructed from high-resolution computed tomographyscans. The technique showed high reliability with regard toboth intraobserver and interobserver variation. By defininganatomic locations for the anteromedial and posterolateralbundle insertion sites relative to easily identified anatomiclandmarks, the results of this study may facilitate anatomicpositioning of bone tunnels intraoperatively.

Tunnel locations have traditionally been determined fromplain radiographs, which provide a two-dimensional projectionof the three-dimensional bone geometry8,27. Accurate measure-

ments from two-dimensional radiographs are dependent onalignment of the bone with the imaging plane, which may bedifficult to achieve reliably and can introduce errors in estimatedtunnel position. Furthermore, potentially important osseouslandmarks, such as the lateral intercondylar ridge or the lateralbifurcate ridge2,18, are not visible on conventional radiographs.

Three-dimensional computed tomography reconstruc-tion enables visualization of the bone model in its entirety. Byselectively removing sections of the bone from the model androtating the model view, regions of the bone that are tradi-tionally difficult to see (e.g., the medial wall of the lateralfemoral condyle) can be clearly visualized. Subtle bone surfacefeatures that were previously seen only during arthroscopyor gross dissection are easily discernible. Since each bone modelis aligned with an anatomically defined coordinate system,measurements are independent of limb orientation duringimaging. The methods employed to evaluate tunnel positionsfrom three-dimensional computed tomography models wereselected to be conceptually similar to radiographic and cadavermeasurement techniques described in the literature25,26. Thequadrant method is one of the most commonly used tech-niques for measuring femoral tunnel position on standardlateral radiographs. However, this method references theBlumensaat line, which is not a fixed osseous landmark butrather a projection of the roof of the femoral intercondylarnotch onto the radiograph. Because this so-called line does not

TABLE I Interobserver and Intraobserver Reliability for the Anatomic Coordinate Axes Method

Intraclass CorrelationCoefficient

95% ConfidenceInterval

Standard Errorof Measurement

Interobserver

Femur

Posterior-to-anterior measurement of anteromedial tunnel 0.988 0.924–0.998 0.68

Posterior-to-anterior measurement of posterolateral tunnel 0.975 0.884–0.995 0.72

Proximal-to-distal measurement of anteromedial tunnel 0.963 0.841–0.992 0.98

Proximal-to-distal measurement of posterolateral tunnel 0.963 0.84–0.992 1.36

Tibia

Anterior-to-posterior measurement of anteromedial tunnel 0.982 0.921–0.996 0.39

Anterior-to-posterior measurement of posterolateral tunnel 0.980 0.908–0.996 0.50

Medial-to-lateral measurement of anteromedial tunnel 0.995 0.978–0.999 0.30

Medial-to lateral measurement of posterolateral tunnel 0.988 0.945–0.997 0.27

Intraobserver

Femur

Posterior-to-anterior measurement of anteromedial tunnel 0.967 0.835–0.993 1.19

Posterior-to-anterior measurement of posterolateral tunnel 0.965 0.851–0.993 0.79

Proximal-to-distal measurement of anteromedial tunnel 0.965 0.836–0.993 0.92

Proximal-to-distal measurement of posterolateral tunnel 0.985 0.927–0.997 0.86

Tibia

Anterior-to-posterior measurement of anteromedial tunnel 0.968 0.864–0.993 0.54

Anterior-to-posterior measurement of posterolateral tunnel 0.974 0.876–0.995 0.53

Medial-to-lateral measurement of anteromedial tunnel 0.988 0.947–0.998 0.47

Medial-to lateral measurement of posterolateral tunnel 0.977 0.9–0.995 0.37

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actually represent a specific physical structure, it is difficult todefine on three-dimensional computed tomography models.For this study, the problem was addressed by defining theBlumensaat line as the most anterior (superior) aspect of thenotch (see Fig. 3).

The anatomic coordinate axes method for femoral tunnelmeasurements in this study was again based on a method re-ported in the literature by Watanabe et al.26, who describedtunnel position relative to the border between the medial walland the articular surface of the lateral condyle. Since thislandmark is visible during arthroscopy, this position descrip-tion may be easier to apply in an operative setting. Unlike theapproach of Watanabe et al., the method used in the currentstudy references the entire medial wall of the lateral femoralcondyle, including areas both within and outside the anatomicanterior cruciate ligament insertion area. Additionally, in thecurrent study, the rotation of the bone models within three-dimensional space was standardized to ensure standardizedmeasurements.

We compared tunnel positions with data from previouslypublished cadaver and radiographic studies (Table II)1,8,24. On thetibia, our three-dimensional computed tomography analysisyielded similarly positioned anteromedial and posterolateraltunnel positions in the medial-to-lateral direction but moreanteriorly positioned anteromedial and posterolateral tunnels inthe anterior-to-posterior direction compared with the previ-ously published cadaver study24. Of note, the aforementionedstudy measured the position of the native insertion site of theanterior cruciate ligament, while measures in the current studywere based on anatomically positioned tunnels.

On the femur, our three-dimensional computed to-mography analysis of the quadrant method yielded results,with regard to the distance parallel to the Blumensaat line (t),within the range of those in previously published cadaverstudies1,8. With regard to distances perpendicular to the Blu-mensaat line (h), our three-dimensional computed tomogra-phy analysis found the posterolateral tunnel locations to benearly the same as those determined by Zantop et al.8, whereasthe anteromedial tunnel locations in our study were slightlymore distally and posteriorly placed.

The methods used to describe the location of the fem-oral and tibial tunnels based on three-dimensional computedtomography scans demonstrated high levels of intraobserverand interobserver reliability. Because only two observerswere utilized to assess interobserver reliability, the reliabilityresults can be generalized only to other individuals who havea similar level of experience with the software program andmeasurement methods that were utilized in this study.The time between repeat measurements was on the orderof three weeks. As such, recall of the measurements mayhave artificially inflated the reliability estimates; however,given the nature of the measurements, we believe that this wasunlikely. A sample size of only eight specimens should notappreciably affect the point estimates for the reliability coef-ficients, but it could affect the width of the confidence in-tervals for the reliability estimates. Therefore, because of therelatively small sample size, the lower bounds of the confi-dence intervals for the intraclass correlation coefficients mayreflect a more conservative (i.e., worst case) estimate of thereliability of these measurement methods. Considering theselimitations, we believe that the methods presented to measurethe location of the femoral and tibial tunnels followinganterior cruciate ligament reconstruction based on three-dimensional computed tomography scans are sufficientlyreliable.

In this study, we visualized and quantified the positionof anatomic double-bundle anteromedial and posterolateraltunnels, utilizing a novel three-dimensional computed to-mography reconstruction measurement technique. Preciseknowledge of tunnel locations is critical for our approach toanterior cruciate ligament surgery, which is based on the ap-plication of anatomical reconstruction concepts. Referencinganatomic landmarks, including anterior cruciate ligamentremnants, osseous and surrounding soft-tissue landmarks, andinsertion site anatomy, are crucial to achieving an anatomicanterior cruciate ligament reconstruction. These data providea reference against which tunnel position can be judgedin future clinical studies. By utilizing this method of three-dimensional computed tomography analysis to evaluate tunnelposition in clinical scenarios, surgeons may be able to improve

TABLE II Summary of Studies on Tibial and Femoral Positions of the Anteromedial and Posterolateral Bundles and Bone Tunnels

Tibial Measurements*Femoral Measurements with Quadrant Method*

Anterior toPosterior (%)

Medial toLateral (%)

Parallel toBlumensaatLine (t) (%)

Perpendicularto Blumensaat

Line (h) (%)

Study AM PL AM PL Study AM PL AM PL

Tsukada et al.24 (2008) 37.6 50.1 46.5 51.2 Colombet et al.1 (2006) 26.4 47.6 25.3 32.3

Current study 25 46.4 50.5 52.4 Zantop et al.8 (2008) 18.5 29.3 22.3 53.6

Current study 21.7 35.1 33.2 55.3

*AM = anteromedial, and PL = posterolateral.

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anatomic tunnel positioning during anterior cruciate ligamentreconstruction. n

Brian Forsythe, MDSebastian Kopf, MD

Andrew K. Wong, BACesar A.Q. Martins, MDWilliam Anderst, MSScott Tashman, PhDFreddie H. Fu, MD, DSc(Hon), DPs(Hon)Department of Orthopaedic Surgery, University of Pittsburgh,3471 Fifth Avenue, Pittsburgh, PA 15213.E-mail address for F.H. Fu: [email protected]

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