Rev. bras. ortop. vol.50 número1

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w w w . r b o . o r g . b r

Original

article

Functional

result

relating

to

the

positioning

of

the

graft

in

cruciate

ligament

reconstruction

夽

Otávio

de

Melo

Silva

Júnior,

Bruno

do

Nascimento

Ohashi,

Murilo

Oliveira

de

Almeida

∗

_,

Murilo

Reis

Gonc¸alves

SobradinhoRegionalHospital,Brasília,DF,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received1November2013 Accepted7November2013 Availableonline14February2015

Keywords: Knee/surgery

Anteriorcruciateligament Treatmentresult

Traumaamongathletes

a

b

s

t

r

a

c

t

Objective:Toascertainthecoronalanglesforthefemoralandtibialtunnelsthatprovide thebestpostoperativeresultfromanteriorcruciateligament(ACL)reconstructionsurgery, throughassessingthevariablesoftheIKDCandLysholm–Tegnerquestionnairesandthe hoptest.

Methods:SixteenpatientswithasingleunilateralACLinjurywhounderwentthissurgery between24and36monthsearlierwereevaluated.Theyweredividedintofourgroupsin whichthetibialandfemoraltunnelanglesweregreaterthanorlessthan65◦_in_the_coronal

plane.

Results:Theresultsdemonstratedthatamoreverticalangleforthetibialtunnel(72◦₎_and_a

morehorizontalangleforthefemoraltunnel(60◦

),withvalgusalignmentof12◦

correlated withthebestvaluesforthevariablesstudied.Thismayindicatethatthelong-termresults fromthissurgeryareexcellent.

Conclusion: Amorehorizontalfemoralangleandamoreverticaltibialangleproducedbetter assessmentsintheteststhatwereappliedandinthefunctionalresultsevaluated.

Resultado

funcional

relacionado

ao

posicionamento

do

enxerto

na

reconstruc¸ão

do

ligamento

cruzado

r

e

s

u

m

o

Objetivo:Averiguarqualaangulac¸ãocoronaldostúneisfemoraletibialqueproporciona omelhorresultadono pós-operatóriode cirurgiade reconstruc¸ãodoLCA.Asvariáveis avaliadasforamosquestionáriosIKDCeLysholm-TegnereoHop-Test.

Métodos:Foramanalisados16pacientescompós-operatórioentre24e36meses,comlesão isoladaunilateraldoLCA.Foramdivididosemquatrogrupos,nosquaisosângulosdostúneis tibialefemoralforammenoresoumaioresdoque65◦_no_plano_coronal.

夽

WorkdoneattheOrthopedicsandTraumatologyService,SobradinhoRegionalHospital,Brasília,FederalDistrict,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](M.O.deAlmeida). http://dx.doi.org/10.1016/j.rboe.2015.01.008

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Resultados: Aangulac¸ãodotúneltibialmaisverticalizada(72◦

)edotúnelfemoralmais horizontalizada(60◦₎_com_o_alinhamento_em_valgo_de₁₂◦_{relacionou-se}_com_os_melhores

valoresparaasvariáveisestudadas,oquepodeindicarumresultadoótimoparaacirurgia emlongoprazo.

Conclusão:Aangulaçãofemoralmaishorizontalizadaeaangulaçãotibialmaisverticalizada têmmelhoresavaliaçõesnostestesaplicadosenosresultadosfuncionaisavaliados.

Introduction

Injuriesortearstotheanteriorcruciateligament(ACL)in ath-letesorphysicallyactiveindividualsare seenvery oftenin orthopedicpractice.Epidemiologicalstudieshaveshowedthat theincidenceisapproximately80,000injuriesperyear.1

ThefirstreportsonACLinjuriesappearedintheliterature inthe nineteenthcentury.2 _Records_of _surgical

reconstruc-tionfirstappearedatthebeginningofthetwentiethcentury.3

Overthelast30years,manysurgicaltechniqueshavebeen describedforreconstructingthisligament,usingseveral struc-turesasagraft source.Along pathwas followeduntilthe techniquedescribed byCampbell4 _in_1939,_which _used_the

patellarligament,wasreturnedto.Alsointhatyear,Macey5

describedthefirsttechniqueusingtheflexortendonsofthe semitendinosusandgracilis(ST-G).

Althoughthegreatadvancesinsurgicaltechniqueshave reducedthetimetakenforpatientsundergoingACL recon-structionto returnto theiractivities,6 _we_did_not _find_any

studiesintheliteraturecorrelatingtheanglesofthetunnels withthepostoperativeresults.

Thereisno consensusregardingthe various techniques forACLreconstructionthathavebeendescribed,inrelation tocomparisonsbetweenthepostoperativeresults.There is thereforeaneedforbetterexaminationofthepossiblevariable thatmightcorrelatewithabetterfinalresult.

Currently, tibial tunnels are constructed using prefabri-catedguidesthatareadjustableaccordingtotheanglethat isdesired.

Theobjectiveofthis studywas toascertainthe coronal angleofthe femoraland tibialtunnelsthat wouldprovide thebestpostoperativeresultfromACLreconstructionsurgery, usingthefollowingassessmentcriteria:patient’scomplaints, satisfaction with the result, Lysholm–Tegner questionnaire (Annex1),IKDCquestionnaire(Annex2),clinicalexamination andhoppingononefoot.

Material

The knees of 16 patients were evaluated (Table 1). These patientswere seenatthe kneesurgeryoutpatientclinicof theSobradinhoRegionalHospital,FederalDistrict,Brazil,and had undergoneACL reconstructionperformedbythe same surgeon,whowasaspecialistinkneesurgeon.

Thedemographiccharacteristics(gender,age bodymass index(BMI)anddominantleg)arelistedinTable1.

Table1–Characteristicsofthesample.

n(%)

Gender

Male 13(83.25)

Female 3(17.75)

Age(years)

Upto20 1(6.25)

21–30 9(56.25)

31–40 4(25)

Over40 2(12.5)

Mean=29.7

BMI(kg/m2₎

18.5–24.9(Normal) 10(62.5)

25–29.9(Overweight) 6(37.5)

Mean=24.96

Dominantleg

Right 11(68.75)

Left 3(18.75)

Ambidextrous 2(12.5)

The inclusion criteria were as follows: a postoperative period ofbetween24 and 48months; ACL injuryalone, as confirmedbymeansofmagneticresonance imagingbefore theoperation;physiotherapyappliedaftertheoperation;and having been released from rehabilitation (with or without returningtothesameactivitylevelasbeforetheinjury).

The exclusion criteria comprised presenceof any asso-ciated injuriesto the ligaments,menisci or joint cartilage, revision surgery, inflammatory signs, neuromuscular dis-orders, infection, arthrofibrosis, lower-limb fractures, or advancedosteoarthrosisinthefemoropatellarortibiofemoral jointswithevidentdisplacementofthejointaxis.

Table2detailsthefactorscorrelatedwiththetypeofsport practiced, the groundand the conditions under which the injuryandtherehabilitationtookplace.

All the patients underwent the same standard surgical technique, consisting of grafting a single band from the semitendinosusandgracilistendons(ST-G)anduseofa prox-imalcrosspinfixationimplantandanabsorbableinterference screw,withadistalcorticalpost(Fig.1).

Method

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Table2–Factorsrelatingtotheinjury.

n(%)

Age(years)atthetimeoftheinjury

Upto20 4(25)

21–30 9(56.25)

31–40 2(12.5)

Over40 1(6.25)

Mean=26.2

Environmentatthetimeoftheinjury

Sportspractice(leisure) 13(81.25)

Others 3(18.75)

Sportpracticedatthetimeoftheinjury

Soccer 10(62.5)

Others 6(37.5)

Groundsurfacingatthetimeoftheinjury

Syntheticgrass 6(37.5)

Naturalgrass 4(25)

Parquetfloor 2(12.5)

Mat 2(12.5)

Others 2(12.5)

Intervalbetweeninjuryandsurgery(months)

<6 8(50)

6–12 2(12.5)

13–24 4(25)

>24 2(12.5)

Mean=13.85

Sideoperated

Right 7(43.75)

Left 9(56.25)

Relationshipbetweendominantandoperatedsides

Ipsilateral 6(37.5)

Contralateral 8(50)

Ambidextrous 2(12.5)

Thepresentstudy wassubmittedtothe researchethics committeeoftheFoundation forHealthSciences Teaching andResearch(FEPECS)andwasapprovedbythisbodyunder reportno.0018/2010andprotocolno.211/2010.

Non-sequentialnumberswereattributedtoeachkneethat underwentsurgery.

Theclinicalassessmentwasmadefirstlyinaconsultation office,wherethepatients’historiesrelatingtothe postopera-tiveperiodwere takenand the questions ofthesubjective InternationalKneeDocumentationCommitteequestionnaire (IKDC, 2000) and the Tegner–Lysholm Knee Scoring Scale wereappliedandscoreswereattributed.Thelatterscalehas beenvalidatedforthePortugueselanguage.7_Clinical

exam-inationswereperformedinordertofindoutwhether there wasanypresenceofjointeffusion,crepitation,painor lax-ity(Lachman,pivot-shiftandanteriordrawertests),andknee goniometrywasperformed.Allthesedatawererecordedona specificform(Annex3).

Thepatientsperformedahoptest,from whicha lower-limbsymmetryindexwasobtained.Thiscomprisedtheratio ofmeasurementsofthedistancejumpedbymeansofa one-leghoponthesidethatunderwentsurgeryincomparisonwith thenon-operatedside.

Lower-limb symmetry index=(distance with operated limb/distancewithcontralaterallimb)× 100

Fig.1–Radiographonkneethatunderwentthestandard technique.

Thepatients thenunderwent radiography (X-ray) ofthe operated knee in anteroposterior (AP) view, in an upright standing position withweight-bearingin paralleland with parallelrays.Thejointlinetangentialtothecondylesandthe axesofthetunnelsthathadbeenconstructedforthegrafts tobeinsertedweretracedoutontheseradiographs,andin thecoronalplane,andtheanglesindegreesweremeasured (Fig.2).

Meanvalueswere calculatedfrom theseanglesand the patientswerethengroupedintocategories,accordingtothe anglesofthefemoralandtibialtunnelsontheAPknee radio-graphs(Table3).

Thepostoperativeresultsintermsofthefollowing vari-ableswereevaluatedforeachgroup,inrelationtothetunnel data:

• Patients’subjectivesatisfactionwiththesurgicalresult;

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Fig.2–A=femoralcoronalangle/B=tibialcoronalangle.

• Limbsymmetryindex,withregardtotheone-foothoptest.

Results

Themeanangleofthetibialtunnelsinthecoronalplane(TTC) was64.81◦_and_that_of_the_femoral_tunnels_(FTC)_was_67.68◦_. Thevaluesmeasuredatbothsiteswerebetween61and70◦ formostofthepatients.Thedifferenceinalignmentbetween thetibialandfemoraltunnels(TTC–FTC)isshowninTable4. Thefactorsrelating tothepostoperative periodandthe evaluationsaccordingtothetestsappliedareshowninTable5.

Group

I

(femoral

tunnels

≤

65

◦

and

tibial

tunnels

in

the

coronal

plane

≤

65

◦

)

Therewerefiveindividualsinthisgroup(fourmenandone woman).Theirmeanagewas29.6years;theyoungestwas22 yearsofageandtheoldestwas46.

Thisgroupincludedthepatientswithtibialandfemoral anglesthatwere the mosthorizontalinthecoronal plane.

Table3–Distributionofpatientsintogroupsaccording toanteroposteriorradiography(coronalplane).

TTC≤65◦ TTC>65◦

FTC≤65◦ _GROUP_I _GROUP_II

FTC>65◦ _GROUP_III _GROUP_IV

Table4–Tunnelangles.

n(%)

Coronalangleofthetibialtunnel(TTC)

≤60◦ ₄₍₂₅₎

61–70◦ ₉_(56.25)

>70◦ ₃_(18.75)

Mean=64.81◦

Coronalangleofthefemoraltunnel(FTC)

≤60◦ ₂_(12.5)

61–70◦ ₁₁_(68.75)

>70◦ ₃_(18.75)

Mean=67.68◦

TTC-FTC(◦₎

<−10◦_(varus) ₁_(6.25)

−10to−1◦_(varus) ₁₁_(68.75)

1a10◦_(valgus) ₃_(18.75)

>10◦_(valgus) ₁_(6.25)

Mean=−2.87◦_(varus)

Both thefemoraltunnelsand thetibialtunnelshadangles ofbetween55◦_and₆₄◦_,_with_a_mean_of_61.2◦_for_the_femoral tunnelsand61◦_for_the_tibial_tunnels._The_difference_between theanglesofthetibialandfemoralaxesrangedfromvarusof 9◦_to_valgus_of₉◦_.

All ofthesepatientshadsuffered injurieswhile practic-ingsports,eachonadifferenttypeofgroundsurfacing.One ofthemsaidthathehadnotreturnedtosportsactivityand declared that he was dissatisfied with the resultfrom the surgery.

ThemeanIKDCscorewas86.4(range:72–96)andthemean Lysholmscorewas94.4(range:85–100).

Table5–Factorsrelatingtopostoperativeperiod.

n(%)

Lengthoftimesinceoperation(months)

24–36 10(62.5)

36–48 6(37.5)

Mean=34.5

IKDC

95–100(Excellent) 5(31.25)

84–94(Good) 9(56.25)

65–83(Fair) 2(12.5)

Mean=89.94

Lysholm–Tegner

<91 4(25)

91–99 5(31.25)

100 7(43.75)

Mean=95.5

Hoptest(limbsymmetryindex)

<0.9 2(12.5)

0.91–0.99 6(37.5)

1.00 7(43.75)

>1.00 1(6.25)

Mean=0.968

Satisfactionwiththeresultfromthesurgery

Yes 14(87.5)

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Duringthephysicalexamination,twopatientspresented positiveLachmantests.

Inthehoptest,thevaluesrangedfrom0.87to1andthe meanlimbsymmetryindexwas0.95.

Group

II

(femoral

tunnels

≤

65

◦

and

tibial

tunnels

in

the

coronal

plane

>

65

◦

₎

Theinclusioncriteriaforthisgroupwerefulfilledbyonlyone individual:a25-year-oldmale.

Thispatientpresentedatibialanglethatwasmorevertical andafemoralanglethatwasmorehorizontal,i.e.inprinciple similartowhatisseeninthetechniqueforconstructingan arthroscopictransportalfemoraltunnel.

Thediaphysis-tunnelangleinthefemurwas60◦_and_in_the tibia,72◦_._The_difference_between_the_angles_of_the_tibial_and femoralaxeswasavalgusangleof12◦_.

ThispatientpresentedmaximumscoresintheIKDCand Lysholm–Tegner questionnaires(100and 97 points, respec-tively) and had negative Lachman, anterior drawer and pivot-shifttestsinthephysicalexamination.Hislimb sym-metryindexwas1inthehoptest.Thispatientdidnotpresent any spontaneouscomplaintswhenasked duringthe study period.Hedeclaredthathewassatisfiedwiththeresultfrom thesurgeryandhereturnedtophysicalactivityeightweeks aftertheoperation.

Group

III

(femoral

tunnels

>

65

◦

_and

_tibial

tunnels

in

the

coronal

plane

≤

65

◦

)

Therewerefiveindividualsinthisgroup(fourmenandone woman. The mean age of this group was 30.4 years: the youngestwas23yearsofageandtheoldestwas40.

Thisgroupincludedpatientswithtibialanglesthatwere morehorizontalandfemoralanglesthatweremorevertical inthecoronalplane.

Theanglesformedbytheaxesofthediaphysesandtunnels were,forthefemur,between68◦_and₇₀◦_(mean:_69.2◦₎_and,_for thetibia,between60◦ _and₆₄◦ _(mean:_61.8◦_)._The_difference

betweentheanglesofthefemoralandtibialaxesvariedfrom −10◦_to₋₄◦_,_i.e._always_in_varus.

Allofthepatientsinthisgrouphadsufferedinjurieswhile practicingsports:threeonsyntheticgrassandtwoonmats.

ThescoresfromtheIKDCquestionnairerangedfrom85to 97,withameanvalueof91.2,andthescoresfromtheLysholm questionnairewerefrom88to100,withameanof93.4.

During the physicalexamination,onepatientpresented positiveLachmanandpivot-shifttests.Oneindividualstated thathehadnotreturnedtosportsactivity,butheconsidered himselfsatisfiedwiththeresultsfromthesurgery.

Inthehoptest,themeanvalueofthelimbsymmetryindex was0.94,withaminimumof0.85andamaximumof1.

Allofthesepatientsstatedthattheyweresatisfiedwiththe postoperativeresults,althoughthereweresomespontaneous complaintssuchaspainwhilesquatting,snapsandinsecurity inperformingjumpsusingtheoperatedleg.

Group

IV

(femoral

tunnels

>

65

◦

_and

_tibial

tunnels

in

the

coronal

plane

>

65

◦

₎

Therewerefiveindividualsinthisgroup(fourmenandone woman).Theirmeanagewas30years:theyoungestwas20 yearsofageandtheoldestwas45.

Theanglesformedbetweentheaxesofthediaphysesand tunnelsamongthepatientsinthisgroupwerethemost verti-calinthecoronalplane.Inthefemur,thevaluesrangedfrom 70◦_to₈₂◦ _(mean:_74.2◦_),_while_in_the_tibia_they_ranged_from 66◦_to₇₃◦_(mean:_70.2◦_)._The_difference_between_the_angles_of thefemoralandtibialtunnelsvariedfrom−12◦_to₊₃◦_,_with_a meanof−4◦_(varus).

Allofthepatientsinthisgrouphadsufferedinjurieswhile practicingsports:threeonnaturalgrass,oneonaparquetfloor andoneonsyntheticgrass.

ThescoresfromtheIKDCquestionnairerangedfrom89to 96,withameanof92.2,andthescoresfromtheLysholm ques-tionnairerangedfrom95to100,withameanof97.8(Fig.3).

Duringthephysicalexamination,twopatientspresented positiveLachmanandpivot-shift signs.Oneindividualsaid

Group I Group II Group III Group IV Mean

86.4 97 91.2 92.2 90.375

95.5 97.8 93.4 100 94.4 105 100 95 90 85 80 75 IKDC Lysholm Scores Questionnaires

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Group I Group II Group III Group IV Mean 1.01 1 0.99 0.98 0.97 0.96 0.95 0.94 0.93 0.92 0.91

Limb symmetry index (hop test)

LSI

Fig.4–Limbsymmetryindexfromthehoptest.

thathehadnotreturnedtosportsactivity,butheconsidered himselfsatisfiedwiththeresultfromthesurgery.

Inthehoptest,themeanvalueofthelimbsymmetryindex was0.99withaminimumof0.92andmaximumof1.07(Fig.4). There were spontaneous complaints with regard to increasedflexibilityandparesthesiaonthelateralfaceofthe legoperated.

Themeansobtainedfromevaluatingthestudyvariables arepresentedinTable6.

Discussion

Thepresent studywasconductedwiththeaimof correlat-ing the angles ofthe bone tunnels withthe postoperative resultsfrom ACLreconstruction. Someremarksneedtobe maderegardingthecriteriathatledtochoosingthistopicand inrelationtothemethodologyused.

Studies onpatients withACLreconstructions that com-paredtwotypesofgraft,i.e.ST-Gandthepatellartendon(PT), usingthesamefixationtechnique,haveshownthatthereis nosignificantdifference inanteriorizationofthetibia. The choicebetweengraftsthereforecontinuestobeatthe sur-geon’sdiscretion.8_This_study_did_not_aim_to_compare_graft

sources.Thus,onlypatientswho underwentthe technique withST-Ggraftswereselectedinthepresentstudy.

Withregardtograftfixation,comparisonbetweendifferent fixationmethodswasnotourobjective.Thepersonal prefer-enceofthesurgeoninvolvedinthisstudy,whohashadgreat experienceinsuchprocedures,istouseaproximalcrosspin

withanabsorbableinterferencescrewandadistalpostwith ametalscrewandwasher.

Theinclusionandexclusioncriteriahadtheobjectiveof limitingtheindividualsstudiedtothosewhosolelypresented aunilateralACLinjury,therebyeliminatingthebiasrelating toassociatedinjuries.However,amongthe300patientswho underwentthissurgeryoverthethree-yearstudyperiod,only 26fulfilledallthecriteriaand,ofthese,only16returnedtothe clinicforassessmentsforthepresentstudy.

Themeasurementsofthetunnelangleswereallmadeby thesameresearcher,bymeansofsimpleradiographs.Thisis aninexpensiveandwidelyavailabletechnique,butitgivesrise tothepossibilityofvariationoftheanglemeasured accord-ingtotheincidenceoftherays.Newstudiesusingmagnetic resonanceimagingmightreduceoreveneliminatethisbias.

The patients were divided into groups according to the meanvaluesfortheanglesofthetunnelsconstructed.Thus, onlyonepatientcouldbeincludedinGroupII_._It_was_precisely

this individualwho presentedthe bestvaluesforthe post-operativeresults,amongthevariablesstudied.Inthefuture, morepatientscouldbeincludedinnewstudies,inorderto obtainalargersampleandascertainwhetherthesefindings wouldbemaintained,andalsowhethersignificancewouldbe reachedwithamoresubstantialnumberofindividuals stud-ied.

Biomechanicalstudiesoncadavershaveshownthat con-structingthefemoraltunnelatanangleof60◦_in_the_coronal planeminimizes theimpactofthegraft againstthe poste-riorcruciateligament(PCL)andreducesthetensiononthe graftunderflexion.Thesestudieshavealsoshownthatthe lossofflexionandanteriorlaxityaregreaterwhenthetibial tunnelisdrilledatanangle≥75◦ inthecoronalplane,and thatifthefemoraltunnelisconstructedmoreverticallyvia antranstibial route(between70◦ _and ₈₀◦_), _there_will_be_an impactagainstthePCL.These tunnelsincreasethetension onthegraftunderflexion,whichexplainsthelimitationon flexionthatisobservedclinically.ThisimpactagainstthePCL stretches the graft,whichmay explainthegreater anterior laxity.9

Ithasbeensuggestedfrominvitrostudiesthat,inorder toreducethetensionunderflexion,thetibialtunnelshould bepositionedat60◦ _in_the_coronal_plane,_because_the_angle ofthefemoraltunnelandthetensiononthegraftwouldbe controlledbythisangleandthiswouldimprovetheflexion anddiminishtheanteriorlaxity.10

Thus,theenthusiasmforconductingnewstudieswiththe aimoffindingtheidealangleforthetibialandfemoraltunnels isjustified.

Table6–Meanvaluesforthevariablesanalyzed,pergroup.

Group FTC(◦₎ _TTC₍◦₎

Coronal(◦₎ _IKDC _Lysholm _LSI

I _61.2 ₆₁ −0.2 86.4 94.4 0.956

II ₆₀ ₇₂ ₁₂ ₉₇ ₁₀₀ _1.00

III _69.2 _61.8 −7.4 89.8 93.4 0.946

IV _74.2 _70.2 −4 92.2 97.8 0.996

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In the present study, it was observed that the groups analyzed presented differences in the outcome variables accordingtothetunnelangles.GroupI,inwhichthetunnels weremosthorizontal(meanvalueforthetibialtunnel=61◦ andforthefemoraltunnel,61.2◦_),_had _the_lowest_score_for theIKDCquestionnaire(mean:86.4)and thesecondlowest scorefortheLysholmquestionnaire(mean=94.4)andforthe limbsymmetry(mean:0.956).GroupII,inwhichthetibial tun-nelwasmorevertical(72◦₎_while_the_femoral_tunnel_remained morehorizontal(60◦_),_showed_the_best_results_and_the_values werethemaximumpossiblefortheIKDC,Lysholmandlimb symmetryindexvariables.GroupIII_,_in_which_the_femoral

tun-nelwasmorevertical(mean:69.2◦₎_while_the_tibial_tunnel_was morehorizontal(61.8◦_),_had _the_second _worst_IKDC_(mean: 91.2)andtheworstvaluesfortheLysholmvariables(93.4)and forthelimbsymmetryindex(0.946).GroupIV_,_in_which_the

tibialtunnel(70.2◦₎_and_femoral_tunnel_(64.2◦₎_were_the_most vertical,showedthesecondbestresultsforthethreevariables: Lysholm(97.8),IKDC(92.2)andlimbsymmetryindex(0.996).

Conclusion

Fromthedataobtainedinthepresentstudy,itcanbe con-cludedthattheresultsfromgroupsIIandIVweresuperior tothosefromgroupsI_andIII_._The_two_groups_with_the_best

indicesweretheoneswiththetibialtunnelmorevertical.The highestscoresfromthe IKDC,Lysholm andlimbsymmetry indexwereobtainedfromapatientinwhomtheangles con-structedwere60◦_for_the_femoral_tunnel_and₇₂◦_for_the_tibial tunnel,whichgaverisetoavarusalignmentforthetunnels. Theworstresultsforthevariablesstudiedwerefoundinthe groupinwhichthetibialtunnelwasmosthorizontalandthe alignmentofthetunnelswasmostdisplacedtowardvalgus. Nonetheless,furtherstudiesareneededinordertoconfirm thesefindings.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Annex

1. Lysholm

questionnaire.

Limping(5points) Pain(25points)

Never=5 None=25

Slightorperiodic=3 Occasionalorslightduring heavyexercise=20

Annex1(Continued)

Severeorconstant=0 Limpingduringheavy exercise=15

Considerableduringorafter walkingformorethan 2km=10

Support(5points) Considerableduringorafter walkingforlessthan2km=5

Never=5 Constant=0

Stickorcrutch=2

Impossible=0 Swelling(10points)

None=10

Locking(15points) Withheavyexercise=6 Nolockingorfeelingof

locking=10

Withordinaryexercise=2

Thereisafeeling,but withoutlocking=10

Constant=0

Occasionallocking=6

Frequent=2 Goingupstairs(10point)

Jointlockedduring examination=0

Noproblem=10

Slightlyimpaired=6

Instability(25points) Onestepatatime=2 Neverunstable=25 Impossible=0 Rarely,duringathletic

activitiesandother heavyexercises=20

Squatting(5points)

Frequentlyduring athleticactivitiesand otherheavyexercises (orincapableof participation)=15

Noproblem=5

Slightlyimpaired=4 Occasionallyduring

dailyactivities=10

Notbeyond90degrees=2

Frequentlyduringdaily activities=5

Impossible=0

Ateachstep=0

Totalscore:

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