Anatomic Anterior Cruciate Ligament Reconstruction- A ... · otprint Use of post-operative 3-dimensional CT-scan fo. The year . 1995 was chosen as the starting date, since we are

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Anatomic anterior cruciate ligament reconstruction: a changing paradigm

van Eck, C.F.

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Citation for published version (APA):van Eck, C. F. (2011). Anatomic anterior cruciate ligament reconstruction: a changing paradigm.

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CHAPTER 7

Arthroscopy 2010;26-9 Suppl:S2-12

“ANATOMIC” ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION, A

SYSTEMATIC REVIEW OF SURGICAL TECHNIQUES AND REPORTING OF SURGICAL

DATA

Van Eck CF, Schreiber VM, Mejia HA, Samuelsson K, van Dijk CN, Karlsson J, Fu FH

Chapter 7: “Anatomic” ACL reconstruction: a systematic review

Abstract

urpose: The aim of this systematic review was to evaluate studies published on natomic double-bundle ACL reconstruction. ethods: A systematic electronic search was performed using the MEDLINE and

EMBASE databases. Studies th January 1995 to April 2009 were included. The selection that reported on a surgical technique for “anatomic double-bundle ACL reconstruction” on skeletally mature living human subjects, and written in English. Data collected and analyzed included view of surgical tResults: S al factors were ade ACL iHment, individualization of surgery a rative/post-operative imaging were poorly reported. Most variety was seen in knee flexion angle during femoral tunnel drilling and tensioning pattern of the grafts. C op technique are crucial for the v the outcomes. Therefore, we encourage authors to report their surgical technique in a specific and standardized fashion. Introduction

Recently, there has been a shift in interest from single-bundle to double-bundle reconstruction of the anterior cruciate ligament (ACL). The double-bundle graft is suggested to more closely restore or resemble the normal anatomy of the ACL by restoring the anteromedial (AM) and posterolateral (PL) bundles of the native ACL1. The two bundles display different characteristics; the AM bundle is tight in flexion, whereas the PL bundle is tight near full knee extension. This restoration of the native ACL anatomy has been an attempt to obtain better clinical outcomes.

The development of the double-bundle reconstruction concept has increasingly led to the use of the term “anatomic” reconstruction to describe a certain surgical technique. The use of this term suggests that the ACL anatomy is restored using the described surgical technique. It is also often used in combination with the term `double-bundle´. However, a `double-bundle´ ACL reconstruction is not the same as an ànatomic´ ACL reconstruction. Double-bundle reconstruction indicates that the ACL is restored using two separate bundles, and does not necessarily specify the location of the tunnels. Whereas an “anatomic” ACL

PaM

at were published fromcriteria w re studiese

a variety of surgical data. Tables were created to provide an overechniques for anatomic ACL reconstruction.

eventy-four studies were included in this review. Some surgicquately reported in the majority of the papers; visualizing the native

nsertion sites, placing the tunnels in the footprint, graft type and fixation method. owever, ACL insertion site measurement, femoral intercondylar notch measure-

nd intra-ope

onclusion: For most surgical data, there was a gross underreporting of specificerative technique data. We think that the details of an “anatomic” operative

alid interp etations of r

93

94

reconstruction suggests that the tunnels are placed in the center of the native femoral and tibial insertion sites, which is independent of whether a single or double-bundle is used. This difference in linguistic terms is therefore of major importance as “anatomic” and “double-bundle” are not interchangeable. Anatomic ACL reconstruction can be applied to both single- and double-bundle reconstruc-tions, as well as to augmentation surgery2. We define “anatomic ACL reconstruction” as: the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites (Figure 1). Complete restoration of the native ACL may not be possible, due to the complex nature of the ligament. However, the surgeon should strive towards close approximation.

Since the introduction of the term “anatomic”, many authors have reported their anatomic ACL reconstruction technique. However, little information is given in the methods section outlining their “anatomic” procedure. Our interest and goal was to assess the current studies describing anatomic double-bundle reconstruction and to evaluate the surgical data and the variety of these data among the different studies. This led us to present the following systematic review assessing the “anatomic” double-bundle ACL reconstruction techniques in the literature today. This systematic review aimed to investigate and assess studies published on anatomic double-bundle ACL reconstruction that provide a description of the surgical technique. A descriptive analysis of the reporting of a variety of surgical data was performed. We hypothesized that a substantial percentage of the reviewed surgical technique descriptions provided insufficient data needed for proper interpretation of their technique and reported outcomes.

Figure 1: Anatomic ACL reconstruction restores the native ACL anatomy. A. Arthroscopic lateral portal view of the native ACL of the right knee. B. Arthroscopic lateral portal view of an ACL graft of the right knee after anatomic double-bundle ACL reconstruction.


Methods

This systematic review was conducted following the guidelines provided by the Cochrane Handbook3. Criteria for Considering Studies for this Review Types of studies

Studies that report on a surgical technique for anatomic double-bundle ACL reconstruction, either with or without outcomes, were included. Level of evidence was not a factor for inclusion or exclusion. Studies that reported on an

ypes of interventions tervention was anatomic double-bundle ACL reconstruction. Since

ere were no readily available criteria for anatomic ACL reconstruction, we chose to inclu

Types o

anatomic single-bundle reconstruction technique were excluded in this review, for the purpose of creating a more homogeneous literature sample. Types of participants

Studies describing surgical techniques for application to skeletally mature living human subjects with an ACL-rupture were eligible for inclusion. Studies focusing on children, congenitally deformed people, and patients with severe degenerative diseases, rheumatologic, neurologic and cardiovascular disorders and animals were all excluded. If studies had a mixed population of participants of the included and before mentioned excluded participants, they were only included when the data could be analyzed separately. T

The inth

de all papers in which the authors stated that the reconstructive surgical procedure they performed was anatomic. All studies focusing primarily on graft types and fixation methods were included. Studies comparing reconstructive techniques, such as double-bundle reconstruction to single-bundle reconstruction were included. However, in these comparative studies, only the technique for anatomic double-bundle ACL reconstruction was included for analysis. Studies focusing exclusively on revision surgery were also included.

f outcome measures A descriptive review of the reporting of a variety of surgical data was

performed by means of a worksheet. Demographic data that were obtained from the included papers were; authors, year and journal of publication. The data that were obtained from the included papers were: level of evidence, use of the accessory medial portal, visualization of the tibial and femoral insertion sites, visualization of the lateral intercondylar ridge and lateral bifurcate ridge, measuring of the tibial and femoral insertion site, measuring the size of the femoral

95

intercondylar notch, performing notchplasty, use of the o’clock face, flexion angle during femoral tunnel drilling, placing the tunnels in the center of the tibial and femoral ACL insertion sites, proof of tunnel placement (i.e. arthroscopic pictures, a diagram, figures or imaging etc.), placement of the tibial and femoral tunnels at a fixed distance from another anatomic structure (i.e. PCL, posterior wall of the notch, etc.), individualization of the surgery (determining graft type and size on the patient characteristics), use of fluoroscopy, use of navigation, tibial and femoral fixation, different tension pattern for the two bundles and post operative imaging (radiographs, Magnetic Resonance Imaging (MRI), Computer Tomography (CT) and/or 3D CT). A worksheet for data extraction was created and used to obtain informa

uded studies

tion from each study, including demographics and surgical data (Table 1). The data were recorded as either ‘Yes, reported’ or ‘No, not reported’. In addition, if an item was scored as ‘Yes, reported’, more specific data were collected where possible. Search Strategy

A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published from January 1995 to April 2009 were included. The search was carried out in April 2009. Table 1. Demographic and surgical data recorded from inclAuthor 1 - 7 Placement of the femoral tunnel in ACL

footprint

Year of publication Proof of tunnel placement provided† Journal of publication Placement of the tibial tunnel at fixed

distance from another anatomic structure

Level of evidence Placement of the tibial tunnel at fixed distance from another anatomic structure

Use of an accessory medial portal Individualization of surgical technique based on patient characteristics

Visualization of the tibial insertion site Graft type that was used Visualization of the femoral insertion site Use of fluoroscopy Visualization of the lateral intercondylar

d bifurcate ridge Use of navigation

anMeasuring the tibial insertion site Tibial fixation method Measuring the femoral insertion site Femoral fixation method Measuring the dimensions of the femoral Use of a different tension pattern for

tercondylar notch the

anteromedial and posterolateral bundle

ingraft

Performing wall or notchplasty Use of post-operative radiography

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Use of o’clock face for femoral tunnel osition

Use of post-operative MRI pFlexion angle during femoral drilling Use of post-operative CT-scan Placement of the tibial tunnel in ACL

otprint Use of post-operative 3-dimensional CT-scan

fo

The year 1995 was chosen as the starting date, since we are not aware of the term

en in English were of the selected studies were investigated

tudies that were not found through our electronic search.

lusion in the review, two authors ng the previously described criteria. The

ed in a blinded fashion, i.e. blacking out authors, title and so on. D

Inc., Chicago, IL) was used to data that were recorded, a frequency table was made.

The Le

“anatomic” being used before the year 1998 and a 3 year margin was added. The following key search terms were used in all fields including MeSH (Medical Subject Heading): ànterior cruciate ligament´ OR ÀCL´ AND ànatomic´ OR ànatomical´ AND `reconstruction´ OR `surgery´ AND ‘1995:2009’ (See Appendix 1 for complete search string). Only articles writtincluded. Furthermore, the reference lists to identify additional s

Data Collection and Analysis Selection of studies

From the abstracts two authors independently selected relevant studies for full-text review. Studies were also included if the abstract did not provide enough data to make a correct decision. For incindependently analyzed the full texts usianalysis was not perform

isagreement between the two reviewers was resolved by consensus. Data extraction and management

The data were extracted from the included papers, according to a predefined standardized data sheet. The data sheet included a column for all the data, as well as an additional column for comments. Validation of the data extracted was performed by the first author. Statistical analysis and data synthesis

PASW Statistics (version 17.0, SPSSprocess the data. From all the

vel of Evidence was cross tabulated with the extracted surgical data to determine the influence, using chi square. This was done for Level 1 + 2, versus Level 3 + 4, versus Level 5 studies. The level of statistical significance was set at p <0.05. Post-hoc analysis was performed when a significant influence was found, using the standardized residuals.

97

Results Description of Studies Results of the search

There were 740 hits on MEDLINE and 357 on EMBASE, using the previously described search criteria (Figure 2). From these, 1097 studies, 955 were excluded on the basis of the abstracts, because they did not meet the inclusion criteria. Most of the excluded studies were either cadaveric studies, pediatric studies, not written in English or papers focusing exclusively on single-bundle reconstruction. Of the 142 remaining papers, 74 were included for final analysis. The other 68 papers were mostly excluded because they did not report that their reconstructive technique was anatomic. For example, they stated they used “anatomic fixation”.

ed studies.

include this systematicn

el of evidence in Tabl l 1 and 2 studies and a high percentage of level 5 studies. The level 5 studies mainly

nd expert o studies

Figure 2: Flow diagram of the search and the

included and exclud

Included studies A total of 74 papers were d for further analysis in

review4-53,2,54-76. The demographic data oTable 2 and the lev

f the included papers are displayed ie 3. There was a low percentage of leve

consisted of technical notes a pinions. Eleven of the included

98


described both an anatomic single- as well as a double bundle technique. However,

in these studies only the double-bundle reconstruction was analyzed. Table 3. Level of evidence of included studies Level 1 2.7% Level 2 14.9%

23.0% Level 3 Level 4 0% Level 5 59.5% Data Results

Whether the recorded surgical data were reported or not reported in the ncluded papers, is displayed in Table 4. i

Level of evidence Most of the included studies were level 5 evidence as can be seen in Table 3. Due to the low number of level 1 and 2 studies, these groups were combined into one roup for further statistical analysis. There were no level 4 studies included in this

f evidence with the reported surgical data

f navigation, tibial and femoral fixation, different MRI, CT or 3D

udies Table 2. Demographics of included stPapers 74 First authors ournal 14 ear Mean: 2007, SD: 1.9 years

SD: Stan

58 JY

dard deviation

greview. Cross tabulation of the level owas unable to show the influence due to a too small number of studies in each group for: visualization of the tibial and femoral insertion sites, visualization of the lateral intercondylar ridge and lateral bifurcate ridge, measuring of the tibial and femoral insertion site, measuring the size of the femoral intercondylar notch, performing notchplasty, placing the tunnels in the center of the tibial and femoral ACL insertion sites, proof of tunnel placement, placement of the tibial and femoral tunnels at a fixed distance from another anatomic structure, individualization of the urgery, use of fluoroscopy, use os

tension pattern for the two bundles, post operative radiographs,CT. This would have violated the statistical assumptions.

99

Table 4. Reporting of surgical data in included reviews Reported Not reported

(%) (%) Use of an accessory medial portal 51.4 48.6 Visualization of the tibial insertion site 77.0 23.0 Visualization of the femoral insertion site 70.3 29.7 Visualization of the lateral intercondylar and bifurcate ridge 12.2 87.8 Measuring the tibial insertion site 4.1 95.9 Measuring the femoral insertion site 4.1 95.9 Measuring the dimensions of the femoral intercondylar notch

1.4 95.9

Performing wall or notchplasty 12.2 87.8 Use of o’clock face for femoral tunnel position 60.8 39.2 Flexion angle during femoral drilling 59.5 40.5 Placement of the tibial tunnel in ACL footprint 85.1 14.9 Placement of the femoral tunnel in ACL footprint 81.1 18.9 Proof of tunnel placement provided† 71.6 28.4 Placement of the tibial tunnel at fixed distance from another anatomic structure

35.1

64.9

Placement of the tibial tunnel at fixed distance from another anatomic structure

35.1

64.9

Individualization of surgical technique based on patient characteristics

4.1

95.9

Graft type that was used† 91.9 8.1 Use of fluoroscopy 10.8 89.2 Use of navigation 10.8 89.2 Tibial fixation method† 89.2 10.8 Femoral fixation method† 94.6 5.4 Use of a different tension pattern for the anteromedial and posterolateral bundle graft

52.7

47.3

se of post-operative radiography 18.9 81.1 94.6

se of post-operative CT-scan 2.7 97.3 e 3-dimensional CT-scan 2.7 97.3

† More

UUse of post-operative MRI 5.4 UUse of post-operativ

specific data are provided in additional tables

Influence of ‘level of evidence’ was found on the use of the o’clock face method for femoral tunnel location (p=0.001) and the knee flexion angle during femoral tunnel drilling (p=0.014). Post-hoc analysis showed that level 5 studies

100


used the o’clock face methods less often than level 1, 2 and 3 studies. Level 3

and anterolateral portals.

studies more often did not report the knee flexion angle during femoral tunnel among the different

f evidence in the use of the accesso edial portal (p= 0.75).

ry medial portal Of the included studies, 51.4% reported the use of an accessory medial

es used a two-portal approach with the standard anteromedial

isualization and measurement of the native ACL insertion sites Seventy-seven percent of the studies stated they visualized the tibial

sertion site, whereas 70.3% of the studies reported visualizing the femoral sertion site. The bony ridges were identified in 12.2% of the studies for

ite location. Often, this only concerned l bifurcate ridge. Only 4.1% of the

eported measuring the tibial and nsertion site dimensions and asured the dimensions of the femo rcondylar notch.

asty Of the included studies, 12.2% med notchplasty. Most authors

g it for adequate visualization. The notchplasty was often described “minimal”, or performed “when needed”34. It was also used for

ardwar 54

drilling than level 1, 2 and 5 studies. There were no differenceslevels o ry m Accesso

portal. The other studi

V

ininidentification of the femoral ACL insertion sthe lateral intercondylar ridge and not the latera

femopapers r ral iral inte1.4% me

Notchpl

perfordescribed usinas being onlyh e retrieval in revision surgery . In none of the studies performing notch-plasty, measurements of the notch were performed. No measurements of the notchplasty were reported either. O’clock face

The o’clock face was used in 60.8% of the papers to indicate the location of the femoral tunnels. Most authors used it to clarify their femoral tunnel location in addition to describing placing the tunnels in the anatomic footprint, rather than to determine the exact location of the femoral tunnels. The reported location of the AM tunnel varied from 10.00/2.00 to 11.00/1.00 o’clock. The PL tunnel was placed between the 9.00/3.00 and 9.30/ 2.30 position. Drilling of the femoral tunnel

Knee flexion angles during femoral tunnel drilling were reported in 59.5% of the studies. In the studies that reported the knee flexion angle, it varied between 90 and 135 degrees. Placing the tunnels in the ACL footprint

The tibial tunnels were reported to be placed in the center of the AM and

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PL footprints in 85.1% of the studies. The same was done in 81.1% for the femoral nnels. Seventy-six percent of the studies provided proof of this, using either a

iagram, arthroscopic pictures, radiographs, MRI, CT or 3D CT scans. Five percent tic model, cadaveric pictures

nd navigation data. Arthroscopic pictures and diagrams ed Sixty-five percent of the papers provided a combination of two or more of the

5). The tibial and femoral tunnel locations were er anatomic structure i % of the

mined the location of the tunnels and CL f int. For t ial

eau length on radiographs/ fluoroscopy, th e, posterior cruciate ligam anterior horn of

l fem condyle. the l side they used Blumensaat’s line on radiographs/fluoroscopy, or the

r notch/posterior cartilage bord

the native ACL footprint

tudused other means, such as fluoroscopic pictures, a plasa were us most often.

above mentioned proofs (Tableplaced at a fixed distance from anoth n 35.1 studies. Sometimes this fixed distance detersometimes it was used to clarify the location of the A ootpr he tibside, authors used the tibial plat e medialtibial eminence, lateral tibial spin ent,lateral meniscus, medial collateral ligament, and mediafemora

oral For

posterior edge of intercondyla er. Table 5. Proof of tunnel placement in S † No n hown

(%) t show(%)

Diagram 74.3 25.7 Arthroscopic pictures Radiographs

5 4

2 9

4 9

e these methods to show their tunnel position

5.4 4.617.6 82.4

MRI CT

.7 7.34.1 95.9

3D CT Other

.1 5.95.4 94.6

Multiple of the above 64.9 35.1 † % Of papers that us s Individualization

The surgery was individualized in 4.1% of the studies. This meant that the size ba ed on the patient’s

s or measurements of the AC sertion or in some studies individualization was im

the graft type they used for their natomic ACL reconstruction procedure. 4% used several graft types. Most of the

include

authors described that they determined graft type and individual characteristic

sL in sites

intercondylar notch. However, possible, due to randomization. Graft type

About 8% of the studies did not report a

d studies used hamstring tendon autografts (Table 6).

102


Table 6. Graft types used for anatomic ACL reconstruction Graft type Percentage Hamstring tendon 68.9

uadriceps tendon 2.Q 7 16.2 Allograft

Multiple graft types 4.1 Not reported 8.1 Intra-operative assistance in tunnel placement

he placement of their tib

ixation for the bial side and EndoButton fixation for the femoral side. An overview of the

tion methods that were used is presented in Table 7. The category ‘other’

the same knee flexion angle, this angle ranged om 15-60 degrees 34,38,39,42,47,55,63,64,68,71,73,76. When there was a

lexion angle between the AM and PL grafts, the AM flexion angle ranged

Eleven percent of the studies used fluoroscopy to assist in tial and or femoral tunnels. Another 11% used navigation to aid in tunnel

placement. Fixation technique

Of the included studies, 10.8% did not report on what method they used for tibial fixation of the grafts, whereas only 5.4% of the papers did not report on the femoral fixation methods. The majority used interference screw ftidifferent fixa

included: mini-plate, mini-swing bridge, double-spiked plate, suture disk/plate, press fit, leaving the autograft attached to its insertion and a suture over the bony bridge. Fifty-three percent of the studies reported the use of a different tension pattern for the AM and PL graft. Twenty-seven percent reported the same tension pattern for both grafts and the remaining studies did not report on this. When the bundles were secured in

6,7,13,15,29,31,frdifference in f

from 30-90 degrees and the PL ranged from 0-30 degrees2,4,5,9-11,14,16-18,20,22-

26,28,32,33,40,41,45,46,49-54,56-58,60,62,65-67. Many different combinations were reported. Table 7. Fixation methods used for anatomic ACL reconstruction Fixation method Femoral side Tibial side EndoButton 63.5% 1.4%

ost 1.4% 6.8% 1.4% 0%

Metal in

4.1% 9.5% asher lock 0% 1.4%

8.1% 14.9% Not repo

PCross pin

terference screw 4.1% 10.8% Bio-absorbable interference screw 12.2% 44.6% Staple WOther

rted 5.4% 10.8%

103

Post-operative imaging

Almost 19% of the authors reported on performing post-operative radiographs, 5.4% on post-operative MRI and 2.7% on post-operative (3D) CT. The timing of the imaging was often not reported. The studies that do report the timing, report diverse time points ranging from 1 week to 2 years after surgery. 3D CT scan was mostly performed for pre-operative planning in revision and augmentation surgery2. One study reported repeated arthroscopy of the knee to evaluate the graft47. Discussion

This systematic review aimed to investigate and assess studies published on anatomic double-bundle ACL reconstruction, which provide a description of the surgical technique. It was hypothesized that many of the recorded surgical data

ere underreported in the literature. The most important finding of the present reported in

e majority of the included studies. These included visu e ninsertion sites; placing the tunnels in the footprint, graft type and fixation od.

t were poorly reported were the measuring of the ACL insertion site oral intercondylar notch, individualizati the surg nd

e/post-operative imaging. It needs to be emphasize at idualization cannot be performed when patients are randomly allocated to r of two specific surgical procedures.

Unlike what we expected, the level of evidence did not influe he of reporting in the included studies. However, this

dies that were included, compared with level 1 and 2 studies. stly technical notes,

y is still performed by some authors (12.2%) to make the

to abnormal graft forces, graft failure80 and possible re- overgrowth of the notch in the medium/long-term81. None of the

bundle to a single-

wsystematic review was that some of the surgical factors were adequatelyth alizing th ative ACL

methData thadimensions and fem on of ery aintra-operativ d thindiveithe

nce tquality may be due the large number of level 5 stuAnother reason may be that the level 5 studies were mo

roviding very detailed surgical descriptions. pNotchplast

reconstruction easier by visualizing the posterolateral margin of the intercondylar space more clearly77. However, use of an accessory anteromedial portal allows the surgeon excellent visualization of the intercondylar space78. The disadvantage of notchplasty lies in the removal of the osseous landmarks of the femoral ACL insertion79. This can therefore compromise correct anatomic tunnel placement.

oreover, it can lead Mgrowth andstudies that performed notchplasty reported measuring the dimensions of the notch before deciding on performing notchplasty. In our concept of anatomic ACL reconstruction, we attempt to preserve the patient’s anatomy. Thus, in a patient

ith a narrow notch, we suggest converting from a doublewbundle reconstruction, or the use of a curved drill.

104


The knee flexion angle during femoral tunnel drilling is reported only in of the studies. During anatomic ACL reconstruction flexion

influences the length of th unnelslarge variation in the reported flexion angle suggests that it isnot universally applicable to the wide range of anatomic ACLniques. Therefore it should be reported by the au discrepancy in the recorded data in this syst ic review.

n and 70% of the papers report on visualizing the tibi d femoraCL insertion site, respectively, but as many as 85 and 81% report placing the

L footprint, respectively. This was often d

ACL insertion site and the tibial plateau anatomy vary considerably mong patients. Therefore, using a fixed distance from another anatomic structure

reference, provides a disservice to anatomic reconstruction method

ost-perative radiographs. When authors use post-operative radiography, the moment

is is vital for the f tunnel widening and osteoarthritic changes. Imaging is very

anatomic ACL reconstruction. For examp CT can d to rm the tunnel positions post-operatively, as well as for pre-operative planning

mes to revision surgery2. ound that a variety of surgical data we sly

ic double-bundle ACL reconstruction literature. It e concluded that not reported does not necessa ply not performed.

day, with the high level of medical research, authors should be held up ertain standard. For interpretation of the results of a published t is

know the surgical details of the procedure s studied mic

about 60% , the knee e f l t

angle is very important, as it largely emora . Furthermore, the something that is

reconstruction techThere is a

thor. emat

Seventy-seve al an l Atunnels in the center of the tibial and femoral AC

one by locating the footprint based on the distance from another anatomic structure or by using a certain predefined o’clock position. However, the size and shape of theaor a specific o’clock

s as it provides a generic formula that should not be applied universally. Anatomic ACL reconstruction is, by definition, a technique based on the individual’s anatomy. Furthermore, there are often sevrious limitations in the literature as regards reporting on knee flexion angles as well as the viewing portal when using the o’clock reference that limits standardization in terms of surgical descriptions82.

Although this review is targeted toward at anatomic ACL reconstruction, 15% of the studies do not report placing the tibial tunnels in the center of the native ACL insertion site and 19% do not report placing the femoral tunnels in the center of the native ACL insertion site. This illustrates the need for a proper definition of “anatomic ACL reconstruction”. In the present review, this is defined as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. A flowchart was recently published that is the first step in creating the definition and criteria for anatomic ACL reconstruction82,83.

Some studies do not report on post-operative imaging, but do show poat which this is done is sometimes not reported, although thinterpretation oimportant in le, 3D be useconfiwhen it co

Overall, we f re grosunderreported in current anatommay b rily imHowever, toto a c study, iimportant to that wa . Anato

105

ACL reconstruction can be and is performed in many ways. It is a relatively new ding surgical procedure. We do not know yet what is the

best w

reconstruction. Both procedures should be performed in an natomic fashion to show a potential benefit of one over the other.

verall completeness and applicability of evidence

Quality

r most surgical data, there was

and a technically demanay the execute it. As such, studies that report on an anatomic ACL

reconstruction technique should provide adequate and detailed information that allows for fair comparison and interpretation of the outcomes. A limited technique does not necessarily make a paper less valid, but it causes restrictions to the interpretation of the outcomes and the possibility of pooling the outcomes with similar studies. This is especially important in order to compare double-bundle to single-bundle ACL a O

A limitation to this review is that it was specifically focused on studies that reported on an anatomic ACL reconstruction technique. The authors had to report that their procedure was performed in an anatomic fashion for the study to be included. This was done since there is no clear cut definition available of anatomic ACL reconstruction. However, this resulted in the exclusion of studies that presented an anatomic reconstruction technique, but did not name it as such. Furthermore, the data presented in this review may not be applicable to the reporting of surgical data for overall ACL surgery. Finally, outcome data were not assessed in this systematic review due the fact that it wasn’t our goal and interest. Moreover, the heterogeneity of the studies would make any trial to report and pool outcome measures very difficult, if not impossible.

of evidence Another limitation may be that the majority of the included studies were

level 5 evidence. Only 17.6% of the included studies were level 1 and 2 evidence. Potential biases in the review process

The search was limited to English papers published on MEDLINE or EMBASE. Studies in other languages and published in other databases were therefore not included in this review. The data extraction was not performed in a blinded fashion, i.e. blacking out authors, title and so on. However, two independent reviewers selected all the papers and extracted all the data. Furthermore, the first author validated the extracted data by processing the included studies once again after data extraction. . Conclusion

In conclusion, this systematic review of surgical techniques in anatomic double-bundle ACL reconstruction focused on the reporting of important surgical data needed for the evaluation of the procedure. Fo

106


gross u

1. Oden

nderreporting which was independent of the level of evidence. To provide literature that meets the current high level of medical research, we encourage authors to report their surgical technique in a standardized and thorough manner. References

sten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 1985;67-2:257-62. 2. Shen W, Forsythe B, Ingham SM, Honkamp NJ, Fu FH. Application of the anatomic double-bundle reconstruction concept to revision and augmentation anterior cruciate ligament surgeries. Journal of Bone and Joint Surgery Series A 2008;90-SUPPL. 4:20-34. 3. Higgins JPT, Greens S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 [updated September 2009]. The Cochrane Collaboration 2008;Available from www.cochrane-handbook.org. 4. Aglietti P, Cuomo P, Giron F, Boerger TO. Double-bundle anterior cruciate ligament reconstruction: Surgical technique. Operative Techniques in Orthopaedics.15(2)()(pp 111-115), 2005.Date of Publication: Apr 2005. 2005-2:111-5. 5. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli N. Single-and double-incision double-bundle ACL reconstruction. Clin Orthop Relat Res 2007;454:108-13.

. Double-strande

nstruction. Arthroscopy 2006;22-11:1250 e1-6.

6. Ahn JH, Lee SH. Anterior cruciate ligament double-bundle reconstruction with hamstring tendon autografts. Arthroscopy 2007;23-1:109 e1-4. 7. Asagumo H, Kimura M, Kobayashi Y, Taki M, Takagishi K. Anatomic Reconstruction of the Anterior Cruciate Ligament Using Double-Bundle Hamstring Tendons: Surgical Techniques, Clinical Outcomes, and Complications. Arthroscopy Journal of Arthroscopic and Related Surgery 2007;23-6:602-9. 8. Bellier G, Christel P, Colombet P, Djian P, Franceschi JP, Sbihi A

d hamstring graft for anterior cruciate ligament reconstruction. Arthroscopy 2004;20-8:890-4. 9. Brucker PU, Lorenz S, Imhoff AB. Anatomic fixation in double-bundle anterior cruciate ligament reconstruction. Operative Techniques in Orthopaedics 2005;15-2:135-9. 10. Brucker PU, Lorenz S, Imhoff AB. Aperture fixation in arthroscopic anterior cruciate ligament double-bundle reco

11. Brucker PU, Zelle BA, Fu FH. Intraarticular EndoButton displacement in anatomic anterior cruciate ligament double-bundle reconstruction: A case report. Operative Techniques in Orthopaedics 2005;15-2:154-7. 12. Buda R, Ferruzzi A, Vannini F, Zambelli L, Di Caprio F. Augmentation technique with semitendinosus and gracilis tendons in chronic partial lesions of the

107

ACL: clinical and arthrometric analysis. Knee Surg Sports Traumatol Arthrosc 2006;14-11:1101-7. 13. Caborn DN, Chang HC. Single femoral socket double-bundle anterior cruciate ligament reconstruction using tibialis anterior tendon: description of a new technique. Arthroscopy 2005;21-10:1273. 14. Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy 2005;21-10:1275. 15. Cho S, Muneta T, Ito S, Yagishita K, Ichinose S. Electron microscopic evaluation of two-bundle anatomically reconstructed anterior cruciate ligament

raft. Journal of Orthopaedic Science.9(3)()(pp 296-301), 2004.Date of

16. Ch

tal. Arthroscopy Journal of rthroscopic and Related Surgery 2007;23-3.

man JB, Fu FH. Anatomical double-bundle anterior cruciate ligamen

. wo-bundle, four-tunnel anterior cruciate ligament reconstruction. Knee Surg

9-36. 22. Co

. Anatomic anterior cruciate gament double-bundle reconstruction using 2 tibial and 2 femoral tunnels.

Orthopaedics 2005;20-3:218-23. 5. Frank DA, Altman GT, Re P. Hybrid anterior cruciate ligament

reconst

gPublication: 2004. 2004-3:296-301.

ristel P, Franceschi JP, Sbihi A, Colombet P, Djian P, Bellier G. Anatomic anterior cruciate ligament reconstruction: The French experience. Operative Techniques in Orthopaedics 2005;15-2:103-10. 17. Christel P, Sahasrabudhe A, Basdekis G. Double-Bundle Anterior Cruciate Ligament Reconstruction with the Anatomic Director Set. Operative Techniques in Sports Medicine 2008;16-3:131-7. 18. Christel P, Sahasrabudhe A, Basdekis G. Anatomic double-bundle anterior cruciate ligament reconstruction with anatomic aimers. Arthroscopy 2008;24-10:1146-51. 19. Cohen SB, Fu FH. Three-Portal Technique for Anterior Cruciate Ligament Reconstruction: Use of a Central Medial PorA20. Cohen SB, Star

t reconstruction. Techniques in Knee Surgery 2006;5-2:99-106. 21. Colombet P, Robinson J, Jambou S, Allard M, Bousquet V, de Lavigne CTSports Traumatol Arthrosc 2006;14-7:62

lombet PD, Robinson JR. Computer-assisted, anatomic, double-bundle anterior cruciate ligament reconstruction. Arthroscopy 2008;24-10:1152-60. 23. Espejo-Baena A, Serrano-Fernandez JM, de la Torre-Solis F, Irizar-Jimenez S. Anatomic double-bundle ACL reconstruction with femoral cortical bone bridge support using hamstrings. Knee Surg Sports Traumatol Arthrosc 2009;17-2:157-61. 24. Ferretti M, Zelle BA, Chhabra A, Fu FHliTechniques in2

ruction: introduction of a new technique for anatomic anterior cruciate ligament reconstruction. Arthroscopy 2007;23-12:1354 e1-5. 26. Fu FH, Shen W, Starman JS, Okeke N, Irrgang JJ. Primary anatomic

108


double-bundle anterior cruciate ligament reconstruction: a preliminary 2-year prospective study. Am J Sports Med 2008;36-7:1263-74. 27. Ishibashi Y, Tsuda E, Fukuda A, Tsukada H, Toh S. Intraoperative

iomechanical evaluation of anatomic anterior cruciate ligament reconstruction igation system: comparison of hamstring tendon and bone-patellar

ndon-bone graft. Am J Sports Med 2008;36-10:1903-12.

ografts

. Second-look arthroscopic evaluations of anatomic

pective clinical

o E, Yasuda K, Ichiyama H, Azuma C, Tohyama H. Radiologic

nstruction. Arthroscopy Journal of Arthroscopic and Related Surgery

oshiya S. Double-

edics

ction with the tibial-remnant preserving technique using a

ignozzi S, Zaffagnini S, Giordano G, Irrgang JJ, Fu FH,

ndle Anterior Cruciate Ligament Reconstruction. Operative Techniques in

5-1:95-101.

busing a navte28. Jarvela T, Moisala AS, Sihvonen R, Jarvela S, Kannus P, Jarvinen M. Double-bundle anterior cruciate ligament reconstruction using hamstring autand bioabsorbable interference screw fixation: Prospective, randomized, clinical study with 2-year results. American Journal of Sports Medicine.36(2)()(pp 290-297), 2008.Date of Publication: Feb 2008. 2008-2:290-7. 29. Kondo E, Yasuda Kdouble-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability. Arthroscopy 2007;23-11:1198-209. 30. Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T. Proscomparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med 2008;36-9:1675-87. 31. KondEvaluation of Femoral and Tibial Tunnels Created With the Transtibial Tunnel Technique for Anatomic Double-Bundle Anterior Cruciate Ligament Reco2007;23-8:869-76. 32. Kurosaka M, Kuroda R, Kubo S, Hoshino Y, Araki D, YBundle Anatomic Anterior Cruciate Ligament Reconstruction: The Technique and Clinical Experience. Operative Techniques in Sports Medicine 2008;16-3:125-30. 33. Lattermann C, Zelle BA, Ferretti M, Chhabra A, Fu FH. Anatomic double-bundle anterior cruciate ligament reconstruction. Techniques in Orthopa2008;23-3:192-8. 34. Lee BI, Min KD, Choi HS, Kim JB, Kim ST. Arthroscopic anterior cruciate ligament reconstruhamstring graft. Arthroscopy Journal of Arthroscopic and Related Surgery 2006;22-3. 35. Lopomo N, BMarcacci M. Quantitative Correlation Between IKDC Score, Static Laxity, and Pivot-Shift Test: A Kinematic Analysis of Knee Stability in Anatomic Double-BuOrthopaedics 2008;18-3:185-9. 36. Lubowitz JH. Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy 2009;237. Mae T, Shino K, Matsumoto N, Hamada M, Yoneda M, Nakata K. Anatomical two-bundle versus Rosenberg's isometric bi-socket ACL

109

reconstruction: a biomechanical comparison in laxity match pretension. Knee Surg Sports Traumatol Arthrosc 2007;15-4:328-34.

l Arthrosc 2006;14-6:505-9.

5-10:1168-74.

iques. Techniques in Orthopaedics 2005;20-

econstruction of the anterior cruciate ligament using semitendinosus

Nakayama S, Fukai A, Kachi Y,

ligament

ndle reconstruction technique: two

NM.

o K, Nakamura N, Nakata K, Nakagawa S, Koyanagi M.

2008;16-4:420-6.

38. Mae T, Shino K, Matsumoto N, Nakata K, Nakamura N, Iwahashi T. Force sharing between two grafts in the anatomical two-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumato39. Marcacci M, Molgora AP, Zaffagnini S, Vascellari A, Iacono F, Lo Presti M. Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings. Arthroscopy Journal of Arthroscopic and Related Surgery 2003;19-5:540-6. 40. Martins CAQ, Kropf EJ, Shen W, van Eck CF, Fu FH. The Concept of Anatomic Anterior Cruciate Ligament Reconstruction. Operative Techniques in Sports Medicine 2008;16-3:104-15. 41. Monaco E, Labianca L, Conteduca F, De Carli A, Ferretti A. Double-bundle or single-bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study. Knee Surg Sports Traumatol Arthrosc 2007;142. Morgan CD, Caborn D. Anatomic graft fixation using a retrograde biointerference screw for endoscopic anterior cruciate ligament reconstruction: Single-bundle and 2-bundle techn3:297-302. 43. Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K. Two-bundle rtendon with endobuttons: operative technique and preliminary results. Arthroscopy 1999;15-6:618-24. 44. Nakagawa T, Takeda H, Nakajima K, Kawano H, Miura T, Nakamura K. Intraoperative 3-dimensional imaging-based navigation-assisted anatomic double-bundle anterior cruciate reconstruction. Arthroscopy 2008;24-10:1161-7. 45. Noh HK, Wang JH, Bada LP, Ahn JH, Yoo JC, Nha KW, Lee YS. Trantibial anterior cruciate ligament double-butibial bundle in one tibial tunnel. Arch Orthop Trauma Surg 2008;128-11:1245-50. 46. Nyland J, Landes S, Crawford C, Chang HC, Nawab A, Caborn DAnatomical double-bundle anterior cruciate ligament reconstruction: Maximizing benefits while minimizing complexity: A balanced potential approach. Techniques in Knee Surgery 2007;6-3:191-203. 47. Otsubo H, ShinArthroscopic evaluation of ACL grafts reconstructed with the anatomical two-bundle technique using hamstring tendon autograft. Knee Surg Sports Traumatol Arthrosc 2007;15-6:720-8. 48. Papachristou G, Sourlas J, Plessas S, Papachristou K. Arthroscopic ACL reconstruction with Delta plasty: an innovative approach with hamstrings' transfer and double tibial tunnel. Knee Surg Sports Traumatol Arthrosc49. Pederzini L, Adriani E, Botticella C, Tosi M. Technical note: double tibial

110


tunnel using quadriceps tendon in anterior cruciate ligament reconstruction. Arthroscopy 2000;16-5:E9. 50. Pombo MW, Shen W, Fu FH. Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy 2008;24-10:1168-77. 51. Royalty RN, Junkin DM, Jr., Johnson DL. Anatomic double-bundle revision anterior cruciate ligament surgery using fresh-frozen allograft tissue. Clin Sports

o SG, Lee JJ, Kim MS.

ta K, Nakamura N, Mae T, Ohtsubo H, Iwahashi T,

igament Reconstruction. Arthroscopy Journal of Arthroscopic

.

paio R. Anatomic ACL reconstruction: does the platelet-rich

249 e1-4.

, Watanabe S, Yamamoto H. Laser-Guided

nd Related

Med 2009;28-2:311-26, ix. 52. Seon JK, Park SJ, Lee KB, Yoon TR, Seo HY, Song EK. Stability comparison of anterior cruciate ligament between double- and single-bundle reconstructions. Int Orthop 2008. 53. Seon JK, Song EK, Bae BH, Park SJ, Yoon TR, ChKinematic study following double-bundle, anterior cruciate ligament reconstruction. International Orthopaedics.31(5)()(pp 623-628), 2007.Date of Publication: Oct 2007. 2007-5:623-8. 54. Shaver JC, Johnson DL. Revision Anatomic Double-Bundle Anterior Cruciate Ligament Surgery. Operative Techniques in Sports Medicine 2008;16-3:157-64. 55. Shino K, NakaNakagawa S. Anatomic anterior cruciate ligament reconstruction using two double-looped hamstring tendon grafts via twin femoral and triple tibial tunnels. Operative Techniques in Orthopaedics 2005;15-2:130-4. 56. Siebold R. Observations on Bone Tunnel Enlargement After Double-Bundle Anterior Cruciate Land Related Surgery 2007;23-3:291-8. 57. Siebold R, Dehler C, Ellert T. Prospective Randomized Comparison of Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament ReconstructionArthroscopy - Journal of Arthroscopic and Related Surgery.24(2)()(pp 137-145), 2008.Date of Publication: Feb 2008. 2008-2:137-45. 58. Silva A, Samplasma accelerate tendon healing? Knee Surg Sports Traumatol Arthrosc 2009. 59. Sonnery-Cottet B, Chambat P. Anatomic double-bundle: a new concept in anterior cruciate ligament reconstruction using the quadriceps tendon. Arthroscopy 2006;22-11:160. Streich NA, Friedrich K, Gotterbarm T, Schmitt H. Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc 2008;16-3:232-8. 61. Takahashi T, Takeda HPlacement of the Tibial Guide in the Transtibial Technique for Anterior Cruciate Ligament Reconstruction. Arthroscopy Journal of Arthroscopic aSurgery 2009;25-2:212-4. 62. Tjoumakaris FP, Buoncristiani A, Starman JS, Fu FH. Anatomic Double-

111

Bundle Anterior Cruciate Ligament Reconstruction Using Tibialis Anterior Allograft. Operative Techniques in Sports Medicine 2007;15-2:62-7.

AF, Brucker PU, Fu FH. Anatomic double-bundle anterior cruciate

K, Yoshiya S, Kurosaka M. Double-bundle

oto Y, Ishibashi Y, Tsuda E, Tsukada H, Toh S. Single- Versus

yama H, Kondo E, Miyatake S, Inoue M, Tanabe Y. An In

-84.

t.

63. Toritsuka Y, Amano H, Kuwano M, Iwai T, Mae T, Ohzono K, Shino K. Outcome of double-bundle ACL reconstruction using hamstring tendons. Knee Surg Sports Traumatol Arthrosc 2009. 64. Tsuda E, Ishibashi Y. Computer-Navigated Double-Bundle Anterior Cruciate Ligament Reconstruction. Operative Techniques in Sports Medicine 2008;16-3:165-70. 65. Vidalligament reconstruction using tibialis anterior tendon allografts. Operative Techniques in Orthopaedics 2005;15-2:140-5. 66. Yagi M, Kuroda R, NagamuneACL reconstruction can improve rotational stability. Clinical Orthopaedics and Related Research.(454)()(pp 100-107), 2007.Date of Publication: Jan 2007. 2007-454:100-7. 67. Yagi M, Kuroda R, Yoshiya S, Kurosaka M. Anatomic anterior cruciate ligament reconstruction: The Japanese experience. Operative Techniques in Orthopaedics 2005;15-2:116-22. 68. YamamDouble-Bundle Anterior Cruciate Ligament Reconstruction Results Using Navigation: The Japanese Experience. Operative Techniques in Orthopaedics 2008;18-3:173-80. 69. Yasuda K, IchiVivo Biomechanical Study on the Tension-Versus-Knee Flexion Angle Curves of 2 Grafts in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: Effects of Initial Tension and Internal Tibial Rotation. Arthroscopy Journal of Arthroscopic and Related Surgery 2008;24-3:27670. Yasuda K, Kondo E. Anatomic double-bundle anterior cruciate ligament reconstruction: Our surgical technique. Tecniche Chirurgiche in Ortopedia e Traumatologia 2006;4-2:91-5. 71. Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama H, Minami A. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 2004;20-10:1015-25. 72. Yasuda K, Tomita F, Yamazaki S, Minami A, Tohyama H. The effect of growth factors on biomechanical properties of the bone-patellar tendon-bone graft after anterior cruciate ligament reconstruction: a canine model study. Am J Sports Med 2004;32-4:870-80. 73. Yonetani Y, Toritsuka Y, Yamada Y, Iwahashi T, Yoshikawa H, Shino K. Graft length changes in the bi-socket anterior cruciate ligament reconstruction: comparison between isometric and anatomic femoral tunnel placemenArthroscopy 2005;21-11:1317-22.

112


113

M. Double-Bundle Anterior Cruciate Ligament

ma Surg 2008;128-11:1287-94.

of Publication: Jan 2006. 2006-1:36-41.

ortal. Arthroscopy 2007;23-3:325 e1-5.

lf KL, Hame SL, Hunter DM, Oakes D, Gause P. Biomechanical

y. AJR Am J Roentgenol

roscopy 2009;25-9:943-6.

ND

s, operative"[MeSH Terms] OR ("surgical"[All Fields]

uciate ligament"[MeSH Terms]

rms] OR "anatomy"[All Fields] OR "anatomical"[All

74. Zaffagnini S, Bruni D, Alessandro R, Marcheggiani Muccioli GM, Giordano G, Marcacci Reconstruction: The Italian Experience. Operative Techniques in Sports Medicine 2008;16-3:138-47. 75. Zantop T, Petersen W. Double-bundle revision of a malplaced single-bundle vertical ACL reconstruction: ACL revision surgery using a two femoral tunnel technique. Arch Orthop Trau76. Zhao J, Peng X, He Y, Wang J. Two-bundle anterior cruciate ligament reconstruction with eight-stranded hamstring tendons: Four-tunnel technique. Knee.13(1)()(pp 36-41), 2006.Date77. Asahina S, Muneta T, Ezura Y. Notchplasty in anterior cruciate ligament reconstruction: an experimental animal study. Arthroscopy 2000;16-2:165-72. 78. Cohen SB, Fu FH. Three-portal technique for anterior cruciate ligament reconstruction: use of a central medial p79. van Eck CF, Morse KR, Fu FH. The anteromedial portal for anterior cruciate ligament reconstruction. Arthroscopy 2009;25-10:1062-4; author reply 4-5. 80. Markoeffects of femoral notchplasty in anterior cruciate ligament reconstruction. Am J Sports Med 2002;30-1:83-9. 81. May DA, Snearly WN, Bents R, Jones R. MR imaging findings in anterior cruciate ligament reconstruction: evaluation of notchplast1997;169-1:217-22. 82. van Eck CF, Romanowski JR, Fu FH. Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Arth83. van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction Flowchart. Arthroscopy 2010;26-2:258-68. Appendix 1. Search string: ((("reconstructive surgical procedures"[MeSH Terms] OR ("reconstructive"[All Fields] AND "surgical"[All Fields] A"procedures"[All Fields]) OR "reconstructive surgical procedures"[All Fields] OR "reconstruction"[All Fields]) OR ("surgery"[Subheading] OR "surgery"[All Fields] OR "surgical procedureAND "procedures"[All Fields] AND "operative"[All Fields]) OR "operative surgical procedures"[All Fields] OR "surgery"[All Fields] OR "general surgery"[MeSH Terms] OR ("general"[All Fields] AND "surgery"[All Fields]) OR "general surgery"[All Fields])) AND (("anterior crOR ("anterior"[All Fields] AND "cruciate"[All Fields] AND "ligament"[All Fields]) OR "anterior cruciate ligament"[All Fields]) OR ACL[All Fields])) AND (("anatomy"[MeSH Terms] OR "anatomy"[All Fields] OR "anatomic"[All Fields]) OR ("anatomy"[MeSH TeFields])) AND ("1995"[PDAT] : "2009"[PDAT])

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Anatomic Anterior Cruciate Ligament Reconstruction- A ... · otprint Use of post-operative 3-dimensional CT-scan fo. The year . 1995 was chosen as the starting date, since we are