Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. May 18, 2017; 8(5): 379-384
Published online May 18, 2017. doi: 10.5312/wjo.v8.i5.379
Technical note: Anterior cruciate ligament reconstruction in the presence of an intramedullary femoral nail using anteromedial drilling
Matthew Lacey, Joseph Lamplot, Kempland C Walley, Joseph P DeAngelis, Arun J Ramappa
Matthew Lacey, Joseph Lamplot, Kempland C Walley, Joseph P DeAngelis, Arun J Ramappa, Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
Author contributions: Lacey M, Lamplot J, Walley KC, DeAngelis JP and Ramappa AJ contributed equally to this technical note.
Institutional review board statement: This study was reviewed and approved for publication by our Institutional Reviewer Board at Beth Israel Deaconess Medical Center, Boston, MA.
Informed consent statement: This retrospective study design did not require informed consent, as deemed appropriate by our institution’s ethics committee/IRB. Had this been deemed necessary, all study participants or their legal guardian would have been provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Arun J Ramappa, MD, Chief, Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215, United States. aramappa@bidmc.harvard.edu
Telephone: +1-617-6673940 Fax: +1-617-6672155
Received: October 26, 2016
Peer-review started: October 28, 2016
First decision: December 13, 2016
Revised: February 3, 2017
Accepted: March 12, 2017
Article in press: March 13, 2017
Published online: May 18, 2017
Processing time: 198 Days and 11.9 Hours
Abstract
AIM

To describe an approach to anterior cruciate ligament (ACL) reconstruction using autologous hamstring by drilling via the anteromedial portal in the presence of an intramedullary (IM) femoral nail.

METHODS

Once preoperative imagining has characterized the proposed location of the femoral tunnel preparations are made to remove all of the hardware (locking bolts and IM nail). A diagnostic arthroscopy is performed in the usual fashion addressing all intra-articular pathology. The ACL remnant and lateral wall soft tissues are removed from the intercondylar, to provide adequate visualization of the ACL footprint. Femoral tunnel placement is performed using a transportal ACL guide with desired offset and the knee flexed to 2.09 rad. The Beath pin is placed through the guide starting at the ACL’s anatomic footprint using arthroscopic visualization and/or fluoroscopic guidance. If resistance is met while placing the Beath pin, the arthroscopy should be discontinued and the obstructing hardware should be removed under fluoroscopic guidance. When the Beath pin is successfully placed through the lateral femur, it is overdrilled with a 4.5 mm Endobutton drill. If the Endobutton drill is obstructed, the obstructing hardware should be removed under fluoroscopic guidance. In this case, the obstruction is more likely during Endobutton drilling due to its larger diameter and increased rigidity compared to the Beath pin. The femoral tunnel is then drilled using a best approximation of the graft’s outer diameter. We recommend at least 7 mm diameter to minimize the risk of graft failure. Autologous hamstring grafts are generally between 6.8 and 8.6 mm in diameter. After reaming, the knee is flexed to 1.57 rad, the arthroscope placed through the anteromedial portal to confirm the femoral tunnel position, referencing the posterior wall and lateral cortex. For a quadrupled hamstring graft, the gracilis and semitendinosus tendons are then harvested in the standard fashion. The tendons are whip stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient’s autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference.

RESULTS

The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft.

CONCLUSION

This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.

Keywords: Anteromedial drilling; Intramedullary femoral nail; Anterior cruciate ligament reconstruction; Retained hardware

Core tip: The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In anterior cruciate ligament (ACL) reconstruction, intramedullary (IM) nails may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft. We strongly recommend delaying the ACL graft harvest until creation of the femoral tunnel has been successful in these settings. Although unlikely when using anteromedial portal drilling, if the IM rod needs to be removed for anatomic graft placement but cannot be removed, the ACL reconstruction may have to be delayed until this issue is addressed.