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      3D computer tomography for measurement of femoral position in acl reconstruction

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          Abstract

          Objective:

          To validate intra- and inter-class correlation coefficients of a transparent 3D-TC protocol and investigate relationships between different axial rotations.

          Methods:

          Twenty unilateral knee TCs (iSite - Philips) were evaluated by means of a transparent 3D-TC OsiriX Imaging Software (v.3.9.4), 3D MPR protocol. Mathematical model of femoral tunnel projections acquired on vertical and horizontal rotations from -20 to +20 degrees. Height (h'/H) and length (t'/T) of tunnel projections have been analyzed by the Bernard and Hertel's method.

          Statistics:

          power of study=80%, ICC, ANOVA, p<0.05 (SPSS-19). Results: Transparent 3D-TC showed high reliability of both intra-observer (h'/H=0.941; t'/T=0.928, p<0.001) and inter-observer (h'/H=0.921; t'/T=0.890, p<0.001) ICC. ACL Length (t'/T) and Height (h'/H) projections were statistically different on vertical and horizontal rotations: p=0.01 and p<0.001, respectively.

          Conclusion:

          This new transparent 3D-TC protocol is an accurate and reproducible method that can be applied for ACL femoral tunnel or footprint measurement with high ICC reliability. Level of Evidence II, Descriptive Laboratory Study.

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          Most cited references26

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          Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography.

          The purpose of this study was to histologically identify the direct and indirect insertion of the femoral anterior cruciate ligament (ACL) insertion. Furthermore, we quantitatively measured the direct femoral insertion area by use of the 3-dimensional (3D) volume-rendered (VR) computed tomography (CT) model. By use of 8 intact cadaveric knees, the lateral femoral condyle including the ACL attachment was sectioned for histologic examination in 3 oblique-axial planes parallel to the roof of the intercondylar notch and in the sagittal planes. Before sectioning, these knees had been subjected to CT to obtain 3D VR images of the femur. Once the direct insertion of the ACL was identified on each histologic section, the corresponding image was superimposed on the corresponding CT image. The direct ACL insertion, in which dense collagen fibers were connected to the bone by the fibrocartilaginous layer, was microscopically identified at the region between the posteromedial articular cartilage margin of the lateral femoral condyle and the linear bony ridge 7 to 10 mm anterior to the articular cartilage margin. Meticulous comparison of histologic analysis and the 3D VR CT model showed that the ACL direct insertion coincided with a crescent-shaped hollow just behind the linear bony ridge. The direct insertion measured 17.4 +/- 0.9 mm (mean +/- SD) in length, 8.0 +/- 0.5 mm in width, and 128.3 +/- 10.5 mm(2) in area. The direct insertion of the ACL is located in the depression between the resident's ridge and the articular cartilage margin on the lateral femoral condyle. It measured 17.4 +/- 0.9 mm in length, 8.0 +/- 0.5 mm in width, and 128.3 +/- 10.5 mm(2) in area. Delineation of the ACL femoral direct insertion by 3D VR CT could be a useful tool for planning of accurate femoral tunnel positioning in anatomic ACL reconstruction.
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            Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography.

            Transtibial drilling techniques are widely used for arthroscopic reconstruction of the anterior cruciate ligament, most likely because they simplify femoral tunnel placement and reduce surgical time. Recently, however, there has been concern that this technique results in nonanatomically positioned bone tunnels, which may cause abnormal knee function. The purpose of this study was to use three-dimensional computed tomography models to visualize and quantify the positions of femoral and tibial tunnels in patients who underwent traditional transtibial single-bundle reconstruction of the anterior cruciate ligament and to compare these positions with reference data on anatomical tunnel positions. Computed tomography scans were performed on thirty-two knees that had undergone transtibial single-bundle reconstruction of the anterior cruciate ligament. Three-dimensional computed tomography models were aligned into an anatomical coordinate system. Tibial tunnel aperture centers were measured in the anterior-to-posterior and medial-to-lateral directions on the tibial plateau. Femoral tunnel aperture centers were measured in anatomic posterior-to-anterior and proximal-to-distal directions and with the quadrant method. These measurements were compared with reference data on anatomical tunnel positions. Tibial tunnels were located at a mean (and standard deviation) of 48.0% +/- 5.5% of the anterior-to-posterior plateau depth and a mean of 47.8% +/- 2.4% of the medial-to-lateral plateau width. Femoral tunnels were measured at a mean of 54.3% +/- 8.3% in the anatomic posterior-to-anterior direction and at a mean of 41.1% +/- 10.3% in the proximal-to-distal direction. With the quadrant method, femoral tunnels were measured at a mean of 37.2% +/- 5.5% from the proximal condylar surface (parallel to the Blumensaat line) and at a mean of 11.3% +/- 6.6% from the notch roof (perpendicular to the Blumensaat line). Tibial tunnels were positioned medial to the anatomic posterolateral position (p < 0.001). Femoral tunnels were positioned anterior to both anteromedial and posterolateral anatomic tunnel locations (p < 0.001 for both). Transtibial anterior cruciate ligament reconstruction failed to accurately place femoral and tibial tunnels within the native anterior cruciate ligament insertion site. If anatomical graft placement is desired, transtibial techniques should be performed only after careful identification of the native insertions. If anatomical positioning of the femoral tunnel cannot be achieved, then an alternative approach may be indicated.
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              Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography.

              Controversy exists regarding the locations of the anterior cruciate ligament insertions on the femur and tibia and visualization of these insertions during surgical reconstruction. Anatomical insertions of the anterior cruciate ligament have relationships to bony landmarks of the tibia and femur. Descriptive laboratory study. Eight cadaveric knees were scanned by computed tomography, reconstructed 3-dimensionally, and examined from simulated arthroscopic, sagittal, and axial perspectives. Volume-rendering software was used to document the relationship of the anterior cruciate ligament to the bony anatomy. A bony ridge (Resident's Ridge) at the anterior border of the anterior cruciate ligament was readily noted on the medial wall of the lateral femoral condyle. Superiorly, anterior cruciate ligament fibers inserted up to the roof of the notch and to 3 to 3.5 mm of the articular surface posteriorly and inferiorly. The anterior cruciate ligament inserted into a fovea anterior to the tibial eminence. Posteriorly, anterior cruciate ligament fibers inserted up to a ridge between the medial and lateral intercondylar tubercles. Medially, anterior cruciate ligament fibers inserted onto the ridge at the lateral border of the medial tibial condyle. There was no distinct anterior or lateral bony border with anterior cruciate ligament fibers blending into the anterior horn of the lateral meniscus. The anterior border of the femoral anterior cruciate ligament origin is Resident's Ridge. The ridge between the medial and lateral intercondylar tubercles at the base of the tibial eminence is the posterior margin of the anterior cruciate ligament on the tibia. Bony landmarks can be used to aid in anatomical anterior cruciate ligament reconstruction.
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                Author and article information

                Journal
                Acta Ortop Bras
                Acta Ortop Bras
                Acta Ortopedica Brasileira
                Sociedade Brasileira de Ortopedia e Traumatologia
                1413-7852
                1809-4406
                Jan-Feb 2015
                : 23
                : 1
                : 11-15
                Affiliations
                [I ]University of São Paulo, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Brazil, Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo, Medical School. Brazil
                [II ]IFEI University Center, Department of Mechanical Engineering, São Paulo, SP, Brazil, FEI University Center, Department of Mechanical Engineering, São Paulo, SP, Brazil
                Author notes
                Correspondence: Institute of Orthopedics and Traumatology. Hospital das Clínicas. University of São Paulo, Medical School. Dr. Ovídio Pires de Campos. São Paulo, SP, Brazil. 05403-010. tiago.lazzaretti@ 123456usp.br

                All the authors declare that there is no potential conflict of interest referring to this article.

                Article
                10.1590/1413-78522015230100993
                4544512
                26327787
                5fe11f42-d687-4df1-b952-d62a678a6059

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 04 August 2014
                : 02 October 2014
                Page count
                Figures: 7, References: 20, Pages: 5
                Categories
                Original Article

                anterior cruciate ligament,anatomy,image processing computer-assisted,imaging, three-dimensional

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