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Posterior Tibial Tunnel Placement to Avoid Anterior Cruciate Ligament Graft Impingement by the Intercondylar Roof

An In Vitro and In Vivo Study

Uniformed Services University and United States Air Force Academy, Colorado

Albert D. Olszewski, MAJ, MC, USAF

Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas

Recent recommendations to "customize" tibial tunnel placement based on the slope of the intercondylar roof and the amount knee hyperextension were derived from a series of cases with graft impingement by the intercondylar roof. We believe that this impingement is caused by anterior placement of the graft and not by variations of notch anatomy among individual patients. In Phase 1 of this study, we drilled tibial tunnels in the posteromedial aspect of the anterior cruciate ligament "footprint" after the ligament was excised in cadaveric knees. We then passed an impingement rod into the back of the knee joint. Lateral radiographs with the knee in hyperextension were taken of each specimen, and the distance between the superior border of the rod and intercondylar roof was measured. In Phase 2, we prospectively obtained lateral hyperextension ra diographs of 75 consecutive knees with anterior cruci ate ligament reconstructions and evaluated them for graft impingement based on recently published guide lines. In Phase 1, we found no cases of impingement and an average roof clearance of 8.3 mm. In Phase 2, we noted no cases of severe impingement, 3 cases of moderate impingement (4%), and 72 cases (96%) with no impingement. We conclude that posteromedial tibial tunnel placement alone is adequate to avoid graft im pingement in almost all patients. Individualized tibial tunnel placement with specialized tibial guidance sys tems is not necessary.

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