r e v b r a s o r t o p . 2014;49(4):370–373
w w w . r b o . o r g . b r
Original
Article
Posterior
cruciate
ligament
reconstruction
by
means
of
tibial
tunnel:
anatomical
study
on
cadavers
for
tunnel
positioning
夽
,
夽夽
Antônio
Altenor
Bessa
de
Queiroz,
César
Janovsky
∗,
Carlos
Eduardo
da
Silveira
Franciozi,
Leonardo
Addêo
Ramos,
Geraldo
Sérgio
Mello
Granata
Junior,
Marcos
Vinicius
Malheiros
Luzo,
Moises
Cohen
UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazila
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received13April2012 Accepted10October2013 Availableonline5May2014
Keywords:
Posteriorcruciateligament Cadaver
Reconstruction
a
b
s
t
r
a
c
t
Objective:todeterminethereferencepointsfortheexitofthetibialguidewireinrelationto theposteriorcorticalboneofthetibia.
Methods:sixteenkneesfromfreshcadaverswereusedforthisstudy.Usingaviewingdevice andaguidemarkedoutinmillimeters,threeguidewireswerepassedthroughthetibiaat 0,10and15mmdistallyinrelationtotheposteriorcrestofthetibia.Dissectionswere per-formedandtheregionofthecenterofthetibialinsertionoftheposteriorcruciateligament (PCL)wasdeterminedineachknee.Thedistancesbetweenthecenterofthetibialinsertion ofthePCLandtheposteriortibialborder(CB)andbetweenthecenterofthetibialinsertion ofthePCLandwires1,2and3(CW1,CW2andCW3)weremeasured.
Results:inthedissectedknees,wefoundthecenterofthetibialinsertionofthePCLat 1.09±0.06cmfromtheposteriortibialborder.Thedistancesbetweenthewires1,2and3 andthecenterofthetibialinsertionofthePCLwererespectively1.01±0.08,0.09±0.05and 0.5±0.05cm.
Conclusion:theguidewireexitpoint10mmdistalinrelationtotheposteriorcrestofthetibia wasthebestpositionforattemptingtoreproducetheanatomicalcenterofthePCL.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Reconstruc¸ão
transtúnel
tibial
do
ligamento
cruzado
posterior:
estudo
anatômico
em
cadáveres
para
a
feitura
do
túnel
tibial
Palavras-chave:
Ligamentocruzadoposterior Cadáver
Reconstruc¸ão
r
e
s
u
m
o
Objetivo:determinarospontosdereferênciaparaasaídadofio-guiatibialemrelac¸ãoà corticalposteriordatíbia.
Métodos:foramusadosparaesteestudo16joelhosdecadáveresfrescos.Atravésdeuma escopiaecomumguiamilimetrado,foifeitaapassagemdetrêsfios-guiasa0,10e15mm
夽Pleasecitethisarticleas:deQueirozAAB,JanovskyC,daSilveiraFrancioziCE,RamosLA,GranataJuniorGSM,LuzoMVM,etal.
Reconstruc¸ãotranstúneltibialdoligamentocruzadoposterior:estudoanatômicoemcadáveresparaafeituradotúneltibial.RevBras Ortop.2014;49:370–373.
夽夽
WorkperformedintheDepartmentofOrthopedicsandTraumatology,EscolaPaulistadeMedicina,UniversidadeFederaldeSãoPaulo, SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:cesar.janovsky@gmail.com(C.Janovsky).
2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.
rev bras ortop.2014;49(4):370–373
371
distalmenteemrelac¸ãoàcristaposteriordatíbia.Foramfeitasdissecc¸õesefoideterminada aregiãodocentrodainserc¸ãotibialdoligamentocruzadoposterior(LCP)emcadajoelho. Forammedidasasdistânciasentreocentrodainserc¸ãotibialdoLCPeabordatibialposterior (CB)eentreocentrodainserc¸ãotibialdoLCPeosfios1–2e3(CF1-CF2-CF3).
Resultados: nosjoelhos dissecados,encontramos o centro da inserc¸ãotibial doLCP a 1,09cm±0,06dabordatibialposterior.Asdistânciasentreosfios1,2e3eocentroda inserc¸ãotibialdoLCPforamrespectivamente1,01±0,08;0,09±0,05e0,5±0,05.
Conclusão: asaídadofio-guiaa10mmdistalmenteemrelac¸ãoàcristaposteriordatíbia representaamelhorposic¸ãoparatentarreproduzirocentroanatômicodoLCP.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Ligamentinjuriesofthe posteriorregionofthe knee are a difficulttopicforkneesurgeonsandorthopedistsingeneral. Posteriorcruciateligament(PCL)injuriesareamongthemost challengingofthese,becausethereisnouniformlydefined approachtotheirtreatmentandbecauseofdifferent evolu-tionaryfeaturesthattheypresent.1,2
ThePCListhestrongestligamentofthekneeandcrosses themedialfemoralcondyletotheposteriorregionofthetibia. Itpresentstwofunctional bands:the anterolateraland the posteromedial.Inaddition,gradeIIIPCLinjuriesthatpresent instability,painandassociatedinjuriesareindicatedfor sur-gical treatment and therefore it isextremely important to understandtheiranatomy.3,4
Correctly positioning the tunnels during the ligament reconstructionsisthedeterminingfactorforsuccessinthis procedure.Somestudieshavedemonstratedthatthecenter ofinsertionofthePCLinthetibiaisintra-articularlyanterior totheposteriorborderofthetibia.5,6Othershaveshownthat
itisintheregionknownastheposteriorfacet,orevendistal tothisstructure.6,7
Theaimofthisstudywastodeterminethereferencepoints fortheexitofthetibialguidewire,sothatitwouldbecome possibletoestablishasecurebasisforthereconstruction tech-nique,takingthereferencepointoftheposteriorcorticalbone ofthetibia.
Materials
and
methods
Forthisstudy,16kneesfromfreshcadaverswereused(eight rightandeightleftknees).Themeanageofthedonorswas 60±7.3 years (range: 55–70years); theywere all male and theirmeanheightwas167±4.45cm.Thedissectionswere per-formedatthedeathinvestigationserviceofthecity ofSão Pauloandthestudywasapprovedbytheinstitution’sethics committee.Thecadaversusedwerenotmorethansevendays
postmortem,hadnotbeenclaimedbytheirrelatives;andwere sentforstudyandburial.Thekneesweredissectedbymeans ofaposterioraccessroute.Individualswhodidnotpresent anysignsofligamentinjuryorfracturingofthetibialplateau wereexcludedfromthestudy.
The cadaveric specimens were prepared and the dis-sections were guided toward simulatingthe usualsurgical procedureforPCLreconstruction.Thecadaverwaspositioned
inhorizontaldorsaldecubitusand thelowerlimbthatwas studiedwasflexed.UsingaviewerandwiththeaidofaPCL reconstruction guide marked out in millimeters, three 2.5-mmKirschnerguidewireswerepassedthroughat0,10and 15mmdistaltotheposteriorcrestofthetibia(Figs.1and2). Thesewireswerepassedthroughanterolaterallyto postero-medially.Dissectionwasperformedimmediatelyafterwards,
Fig.1–Passageofthe2.5-mmKirschnerguidewireusinga guidemarkedoutinmillimeters.
372
rev bras ortop.2014;49(4):370–373Fig.3–Imageoftheposteriorregionofthekneeafter dissection,whichshowstheexitpointoftheguidewires.
Fig.4–Measurementusingapachymeterbetweenthe centeroftibialinsertionofthePCLandtheguidewires.
withremovaloftheanatomicalspecimen,andthelocationof thecenteroftibialinsertionofthePCLwasdetermined(Fig.3). Thedistancesbetweenthecenteroftibialinsertionofthe PCLandtheposteriorborderofthetibia(CB)andbetweenthe centeroftibialinsertionofthePCLandthewires1,2and3 weremeasuredusingapachymeter(CF1-CF2-CF3)(Fig.4).
Results
Inthedissectedknees,wefoundthecenteroftibialinsertion ofthePCLatadistanceof1.09±0.06cmfromtheposterior borderofthetibia.Thedistancesbetweenthewires1,2and3 andthecenterortibialinsertionofthePCLwererespectively 1.01±0.08,0.09±0.05and0.5±0.05cm(Table1).
Discussion
ReconstructionofthePCLcontinuestobeoneofthemajor difficultiesinknee surgery, andthe surgicaltechnique has gonethroughmany modificationsover theyears.8The
tra-ditionalreconstructionmethodusingananteromedialtunnel resultsina“killerturn”curvatureofthegraftthatoftengives risetotearingorlaxity.9Toreducethisangularphenomenon,
someauthorshaveusedaninlayreconstructiontechniqueor
Table1–Measurementsusingthetechniqueshownin Fig.4.
(CB)DistancebetweenthecenteroftibialinsertionofthePCLand theposteriorborderofthetibia.
(CF1-CF2-CF3)Distancebetweenthecenteroftibialinsertionof thePCLandthewires1,2and3
CB 1.09±0.06(1.19–0.98)
CF1 1.01±0.08(1.24–0.89)
CF2 0.09±0.05(0–0.15)
CF3 0.53±0.05(0.45–0.62)
anterolateraltunnels.10–12Thereisnoconsensusregardingthe
centeroftibialinsertioninpublishedpapersontheanatomy ofthePCL.Somehavedescribeditslocationas1cmfromthe jointsurface,othersas1–1.5cmalongtheposteriorborderof thetibia13andyetothersas2–3mmfromthejointsurface.14In
thereconstructiontechnique,withtheaimofreproducingthe anatomyofthetibialinsertionofthePCLinthebestway pos-sible,someauthorshaveindicatedthatthetibialguideshould bepositioned7mmfromtheposteriortipofthefacetofthe PCL.15 Otherauthorshaveadvocatedusingapointbetween
thejointsurfaceandapoint4.6mmdistaltothisbecauseof thepresenceofseveralligamentbandsinthisarea.16Some
studieshaverecommendedusingatibialinsertionpointfor thePCLthatisimmediatelyabovetheupperborderofthe ten-donofthepoplitealmuscle.17Anotherparameterfortheexit
locationoftheguidewire,whichwefound,wasthe intersec-tionoftheposteriorcorticalboneandthesurfaceofthetibial plateau,inlateral-viewradiographicevaluationsoftheknee, whichhasbeenshowntobeasafepoint.10
Ourstudyaimedtoinvestigatetwofundamentalpointsin constructingthetunnelfortibialreconstruction:anterolateral positioning,soastodiminishthe“killerturn”;andpositioning ofthetibialguidesuchthattheguidewirewouldreachapoint 1cmdistaltotheposteriorborderofthetibia.Thiswasthe locationatwhichwefoundthecenteroftibialinsertionofthe PCL.
Conclusion
Aguidewireexitpoint10mmdistaltotheposteriorcrestof the tibiawasthebest positionforattemptingtoreproduce theanatomicalcenterofthePCL.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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s
1.VeltriDM,WarrenRF,SilverG.Complicationsinposterior cruciateligamentsurgery.OperTechSportsMed. 1993;1(2):154–8.
rev bras ortop.2014;49(4):370–373
373
3. SherlockMF,OttoD.Antegradetibialtunneltechniquefor posteriorcruciateligamentreconstruction.Arthroscopy. 2008;24(11):1301–5.
4. OstiM,TschannP,KünzelKH,BenedettoKP.Anatomic characteristicsandradiographicreferencesofthe anterolateralandposteromedialbundlesoftheposterior cruciateligament.AmJSportsMed.2012;40(7):1558–63.
5. RamosLA,deCarvalhoRT,CohenM,AbdallaRJ.Anatomic relationbetweentheposteriorcruciateligamentandthejoint capsule.Arthroscopy.2008;24(12):1367–72.
6. Moorman3rdCT,MurphyZaneMS,BansaiS,CinaSJ, WickiewiczTL,WarrenRF,etal.Tibialinsertionofthe posteriorcruciateligament:asagittalplaneanalysisusing gross,histologic,andradiographicmethods.Arthroscopy. 2008;24(3):269–75.
7. RamosLA,AsturD,NovarettiJV,RibeiroLM,CarvalhoRT, CohenM,etal.Ananatomicstudyoftheposteriorseptumof theknee.Arthroscopy.2012;28(1):100–4.
8. MatavaMJ,SethiNS,TottyWG.Proximityoftheposterior cruciateligamentinsertiontothepoplitealarteryasa functionofthekneeflexionangle:implicationsforposterior cruciateligamentreconstruction.Arthroscopy.
2000;16(8):796–804.
9. HuangTW,WangCJ,WengLH,ChanYS.Reducingthe“killer turn”inposteriorcruciateligamentreconstruction. Arthroscopy.2003;19(7):712–6.
10.SekiyaJK,WestRV,OngBC,IrrgangJJ,FuFH,HarnerCD. Clinicaloutcomesafterisolatedarthroscopicsingle-bundle posteriorcruciateligamentreconstruction.Arthroscopy. 2005;21(9):1042–50.
11.DunlopDG,WoodnuttDJ,NuttonRW.Anewmethodto determinegraftanglesafterkneeligamentreconstruction. Knee.2004;11(1):19–24.
12.AbdallaRJ,PacagnanAV,LoyolaHA,CohenM,CamanhoGL, ForgasA.Aproposalforanewtibialguidesystemfor posteriorcruciateligamentreconstruction.Arthroscopy. 2007;23(7):e1–4,793.
13.GironF,CuomoP,EdwardsA,BullAM,AmisAA,AgliettiP. Double-bundle“anatomic”anteriorcruciateligament reconstruction:acadavericstudyoftunnelpositioningwitha transtibialtechnique.Arthroscopy.2007;23(1):7–13.
14.IndersterA,BenedettoKP,KlestilT,KünzelKH,GaberO.Fiber orientationofposteriorcruciateligament:anexperimental morphologicalandfunctionalstudy.Part2.ClinAnat. 1995;8(5):315–22.
15.HarnerCD,XerogeanesJW,LivesayGA,CarlinGJ,SmithBA, KusayamaT,etal.Thehumanposteriorcruciateligament complex:aninterdisciplinarystudy.Ligamentmorphology andbiomechanicalevaluation.AmJSportsMed.
1995;23(6):736–45.
16.TakahashiM,MatsubaraT,DoiM,SuzukiD,NaganoA. Anatomicalstudyofthefemoralandtibialinsertionsofthe anterolateralandposteromedialbundlesofhumanposterior cruciateligament.KneeSurgSportsTraumatolArthrosc. 2006;14(11):1055–9.
