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What Is the Maximum Tibial Tunnel Angle for Transtibial PCL Reconstruction? A Comparison Based on Virtual Radiographs, CT Images, and 3D Knee Models
Clinical Orthopaedics and Related Research ( IF 4.2 ) Pub Date : 2022-05-01 , DOI: 10.1097/corr.0000000000002111
Yuanjun Teng 1, 2 , Lijun Da 3 , Gengxin Jia 2 , Jie Hu 4 , Zhongcheng Liu 2 , Shifeng Zhang 1, 2 , Hua Han 1, 2 , Yayi Xia 1, 2
Affiliation  

Background 

To minimize the killer turn caused by the sharp margin of the tibial tunnel exit in transtibial PCL reconstruction, surgeons tend to maximize the angle of the tibial tunnel in relation to the tibial plateau. However, to date, no consensus has been reached regarding the maximum angle for the PCL tibial tunnel.

Questions/purposes 

In this study we sought (1) to determine the maximum tibial tunnel angle for the anteromedial and anterolateral approaches in transtibial PCL reconstruction; (2) to compare the differences in the maximum angle based on three measurement methods: virtual radiographs, CT images, and three-dimensional (3D) knee models; and (3) to conduct a correlation analysis to determine whether patient anthropomorphic factors (age, sex, height, and BMI) are associated with the maximum tibial tunnel angle.

Methods 

Between January 2018 and December 2020, 625 patients who underwent CT scanning for knee injuries were retrospectively reviewed in our institution. Inclusion criteria were patients 18 to 60 years of age with a Kellgren-Lawrence grade of knee osteoarthritis less than 1 and CT images that clearly showed the PCL tibial attachment. Exclusion criteria were patients with a history of tibial plateau fracture, PCL injuries, tumor, and deformity around the knee. Finally, 104 patients (43 males and 61 females, median age: 38 [range 24 to 56] years, height: 165 ± 9 cm, median BMI: 23 kg/cm2 [range 17 to 31]) were included for analysis. CT data were used to create virtual 3D knee models, and virtual true lateral knee radiographs were obtained by rotating the 3D knee models. Virtual 3D knee models were used as an in vitro standard method to assess the true maximum tibial tunnel angle of anteromedial and anterolateral approaches in transtibial PCL reconstruction. The tibial tunnel’s entry was placed 1.5 cm anteromedial and anterolateral to the tibial tubercle for the two approaches. To obtain the maximum angle, a 10-mm- diameter tibial tunnel was simulated by making the tibial tunnel near the posterior tibial cortex. The maximum tibial tunnel angle, tibial tunnel lengths, and perpendicular distances of the tunnel’s entry point to the tibial plateau were measured on virtual radiographs, CT images, and virtual 3D knee models. One-way ANOVA was used to compare the differences in the maximum angle among groups, and correlation analysis was performed to identify the relationship of the maximum angle and anthropomorphic factors (age, sex, height, and BMI).

Results 

The maximum angle of the PCL tibial tunnel relative to the tibial plateau was greater in the anteromedial group than the anterolateral group (58° ± 8° versus 50° ± 8°, mean difference 8° [95% CI 6° to 10°]; p < 0.001). The maximum angle of the PCL tibial tunnel was greater in the virtual radiograph group than the CT image (68° ± 6° versus 49° ± 5°, mean difference 19° [95% CI 17° to 21°]; p < 0.001), the anteromedial approach (68° ± 6° versus 58° ± 8°, mean difference 10° [95% CI 8° to 12°]; p < 0.001), and the anterolateral approach (68° ± 6° versus 50° ± 8°, mean difference 18° [95% CI 16° to 20°]; p < 0.001), but no difference was found between the CT image and the anterolateral groups (49° ± 5° versus 50° ± 8°, mean difference -1° [95% CI -4° to 1°]; p = 0.79). We found no patient anthropomorphic characteristics (age, sex, height, and BMI) that were associated with the maximum angle.

Conclusion 

Surgeons should note that the mean maximum angle of the tibial tunnel relative to the tibial plateau was greater in the anteromedial than anterolateral approach in PCL reconstruction, and the maximum angle might be overestimated on virtual radiographs and underestimated on CT images.

Clinical Relevance 

To perform PCL reconstruction more safely, the findings of this study suggest that the PCL drill system should be set differently for the anteromedial and anterolateral approaches, and the maximum angle measured by intraoperative fluoroscopy should be reduced 10° for the anteromedial approach and 18° for the anterolateral approach. Future clinical or cadaveric studies are needed to validate our findings.



中文翻译:

跨胫骨 PCL 重建的最大胫骨隧道角度是多少?基于虚拟射线照片、CT 图像和 3D 膝关节模型的比较

背景 

为了最大限度地减少经胫骨 PCL 重建中胫骨隧道出口锐利边缘引起的杀手转弯,外科医生倾向于最大化胫骨隧道相对于胫骨平台的角度。然而,迄今为止,对于 PCL 胫骨隧道的最大角度尚未达成共识。

问题/目的 

在本研究中,我们寻求 (1) 确定经胫骨 PCL 重建中前内侧和前外侧入路的最大胫骨隧道角度;(2)比较基于虚拟X光片、CT图像和三维(3D)膝关节模型三种测量方法的最大角度的差异;(3)进行相关性分析以确定患者拟人化因素(年龄、性别、身高和BMI)是否与最大胫骨隧道角度相关。

方法 

2018年1月至2020年12月期间,我们机构对625例因膝关节损伤接受CT扫描的患者进行了回顾性分析。纳入标准为 18 至 60 岁、Kellgren-Lawrence 膝骨关节炎分级小于 1 且 CT 图像清晰显示 PCL 胫骨附着处的患者。排除标准是有胫骨平台骨折、PCL 损伤、肿瘤和膝关节周围畸形病史的患者。最后,纳入104名患者(43名男性和61名女性,中位年龄:38[范围24至56]岁,身高:165±9cm,中位BMI:23kg/cm 2 [范围17至31])进行分析。CT数据用于创建虚拟3D膝关节模型,并通过旋转3D膝关节模型获得虚拟真实膝关节侧位X光片。虚拟 3D 膝关节模型被用作体外标准方法,用于评估经胫骨 PCL 重建中前内侧和前外侧入路的真实最大胫骨隧道角度。两种入路的胫骨隧道入口均位于胫骨结节前内侧和前外侧 1.5 cm 处。为了获得最大角度,通过在胫骨后皮质附近制作胫骨隧道来模拟直径为10毫米的胫骨隧道。通过虚拟射线照片、CT 图像和虚拟 3D 膝关节模型测量最大胫骨隧道角度、胫骨隧道长度以及隧道入口点到胫骨平台的垂直距离。采用单因素方差分析比较各组间最大角度的差异,并进行相关分析以确定最大角度与拟人化因素(年龄、性别、身高和BMI)的关系。

结果 

前内侧组的 PCL 胫骨隧道相对于胫骨平台的最大角度大于前外侧组(58° ± 8° 与 50° ± 8°,平均差异 8° [95% CI 6° 至 10°] ;p < 0.001)。虚拟 X 光片组中 PCL 胫骨隧道的最大角度大于 CT 图像(68° ± 6° 与 49° ± 5°,平均差 19° [95% CI 17° 至 21°];p < 0.001 )、前内侧入路(68° ± 6° 与 58° ± 8°,平均差 10° [95% CI 8° 至 12°];p < 0.001)和前外侧入路(68° ± 6° 与 50 ° ± 8°,平均差异 18° [95% CI 16° 至 20°];p < 0.001),但 CT 图像与前外侧组之间没有发现差异(49° ± 5° 与 50° ± 8°) ,平均差 -1° [95% CI -4° 至 1°];p = 0.79)。我们没有发现与最大角度相关的患者拟人化特征(年龄、性别、身高和体重指数)。

结论 

外科医生应注意,在 PCL 重建中,前内侧入路相对于胫骨平台的胫骨隧道相对于胫骨平台的平均最大角度大于前外侧入路,并且最大角度可能在虚拟 X 光照片上被高估,而在 CT 图像上被低估。

临床相关性 

为了更安全地进行PCL重建,本研究结果建议,PCL钻头系统应针对前内侧和前外侧入路设置不同,术中透视测量的最大角度前内侧入路应减少10°,前内侧入路应减少18°。前外侧入路。需要未来的临床或尸体研究来验证我们的发现。

更新日期:2022-05-01
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