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Editorial Commentary: Does Anybody Really Know What Time It Is? Does Anybody Really Care?
Editorial Commentary: Does Anybody Really Know What Time It Is? Does Anybody Really Care? Mark D. Miller, M.D.
Abstract: The use of a “clock-face” to describe the anterior cruciate ligament femoral tunnel position is fraught with difficulties. Much work has been done to promote “anatomic” anterior cruciate ligament femoral tunnel positioning, and more research and clinical follow-up studies are necessary to further clarify this concept.
See related article on page 394
F
irst of all, I sincerely thank the Arthroscopy Editors and Dr. Lubowitz in particular for the opportunity to discuss this paper and the critical importance of anatomic tunnel placement in anterior cruciate ligament (ACL) reconstruction. I read “Inter- and Intrarater Reliability of the Femoral Tunnel Clock-Face Grading System During Anterior Cruciate Ligament Reconstruction” by Mehta, Petsche, and Rawal1 with interest and congratulate the authors for putting “one more nail in the coffin” of characterizing the ACL femoral tunnel position based on the “clock-face.” At some point near the dawn of the 21st century, we finally realized that transtibial ACL reconstruction with vertical femoral tunnel placement was not as successful as we convinced ourselves it was. This led to surgical modifications that attempted to place femoral tunnels more horizontally. Because the femoral notch is basically semicircular, it is not difficult to understand how the clock-face was adopted to describe femoral tunnel positioning. Woo et al., in an award winning paper published in this journal,2 attempted to clarify the clock-face nomenclature in an illustration (Fig 1). Interestingly, this description did not account for the anteroposterior position of the tunnel, and Dr. Woo later shared with me a modified version of this illustration (Fig 2). Cadaveric research in our lab used the concept of the clock-face to study different options for more horizontal femoral tunnel positioning,3 and many surgeons modified their techniques accordingly.
University of Virginia, Charlottesville Ó 2016 by the Arthroscopy Association of North America 0749-8063/161138/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.11.014
398
Fig 1. Anterior cruciate ligament clock-face illustration as originally published in this journal.2 Reprinted with permission.
Subsequently, Fu et al.4 extensively studied ACL insertion site anatomy, and the concept of “anatomic” ACL reconstruction was born. Like others, we quickly realized that transtibial techniques did not consistently result in anatomic and/or more horizontal femoral tunnels,5 and this led to the popularity of “independent” femoral tunnel drilling. Although we are now in closer agreement regarding ideal femoral tunnel placement, some differences of opinion still exist. Further evidence regarding this concept is presented in this paper. We cannot even seem to agree where the tunnel is located amongst ourselves! The time has come to abandon the clock-face and embrace anatomy. As we continue to refine a procedure that we thought we had “mastered” in the 20th century, I recommend the following:
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 2 (February), 2017: pp 398-399
399
EDITORIAL COMMENTARY
4. Drill the femoral tunnel using an independent technique (accessory medial portal with hyperflexion, flexible reamer, or outside in). 5. Follow your patients closely and keep up with the literature. Thank you for the opportunity to share these thoughts with you and we all look forward to further advances in anatomic ACL reconstruction.
References
Fig 2. Modified anterior cruciate ligament clock-face illustration (courtesy of Dr. Woo, circa 2010).
1. Carefully locate the center of the ACL femoral footprint while viewing from the medial portal (or viewing from the lateral portal with a 70 arthroscope). 2. Place the guide pin in this location and confirm that it is where you intended. 3. Consider retrograding the pin back to the aperture and check it with a lateral fluoroscopic radiograph (I believe that it should be below Blumensaat’s line and at the junction of the third and fourth anteroposterior quadrants).
1. Mehta V, Petsche T, Rawal AM. Inter- and intrarater reliability of the femoral tunnel clock-face grading system during anterior cruciate ligament reconstruction. Arthroscopy 2017;33:394-397. 2. Loh JC, Yukihisa F, Tsuda E, Steadman R, Fu FH, Woo S. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy 2003;19:297-304. 3. Golish SR, Baumfeld JA, Schoderbek RJ, Miller MD. The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: A cadaveric study. Arthroscopy 2007;13:1187-1192. 4. Forsythe B, Kopf S, Wong A, et al. J Bone Joint Surg Am 2010;92:1418-1426. 5. Tompkins M, Milewski MD, Brockmeier SF, Gaskin CM, Hart JM, Miller MD. Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: Use of an accessory medial portal versus traditional transtibial drilling. Am J Sports Med 2012;40:1313-1321.
Abstract: The use of a “clock-face” to describe the anterior cruciate ligament femoral tunnel position is fraught with difficulties. Much work has been done to promote “anatomic” anterior cruciate ligament femoral tunnel positioning, and more research and clinical follow-up studies are necessary to further clarify this concept.
See related article on page 394
F
irst of all, I sincerely thank the Arthroscopy Editors and Dr. Lubowitz in particular for the opportunity to discuss this paper and the critical importance of anatomic tunnel placement in anterior cruciate ligament (ACL) reconstruction. I read “Inter- and Intrarater Reliability of the Femoral Tunnel Clock-Face Grading System During Anterior Cruciate Ligament Reconstruction” by Mehta, Petsche, and Rawal1 with interest and congratulate the authors for putting “one more nail in the coffin” of characterizing the ACL femoral tunnel position based on the “clock-face.” At some point near the dawn of the 21st century, we finally realized that transtibial ACL reconstruction with vertical femoral tunnel placement was not as successful as we convinced ourselves it was. This led to surgical modifications that attempted to place femoral tunnels more horizontally. Because the femoral notch is basically semicircular, it is not difficult to understand how the clock-face was adopted to describe femoral tunnel positioning. Woo et al., in an award winning paper published in this journal,2 attempted to clarify the clock-face nomenclature in an illustration (Fig 1). Interestingly, this description did not account for the anteroposterior position of the tunnel, and Dr. Woo later shared with me a modified version of this illustration (Fig 2). Cadaveric research in our lab used the concept of the clock-face to study different options for more horizontal femoral tunnel positioning,3 and many surgeons modified their techniques accordingly.
University of Virginia, Charlottesville Ó 2016 by the Arthroscopy Association of North America 0749-8063/161138/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.11.014
398
Fig 1. Anterior cruciate ligament clock-face illustration as originally published in this journal.2 Reprinted with permission.
Subsequently, Fu et al.4 extensively studied ACL insertion site anatomy, and the concept of “anatomic” ACL reconstruction was born. Like others, we quickly realized that transtibial techniques did not consistently result in anatomic and/or more horizontal femoral tunnels,5 and this led to the popularity of “independent” femoral tunnel drilling. Although we are now in closer agreement regarding ideal femoral tunnel placement, some differences of opinion still exist. Further evidence regarding this concept is presented in this paper. We cannot even seem to agree where the tunnel is located amongst ourselves! The time has come to abandon the clock-face and embrace anatomy. As we continue to refine a procedure that we thought we had “mastered” in the 20th century, I recommend the following:
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 2 (February), 2017: pp 398-399
399
EDITORIAL COMMENTARY
4. Drill the femoral tunnel using an independent technique (accessory medial portal with hyperflexion, flexible reamer, or outside in). 5. Follow your patients closely and keep up with the literature. Thank you for the opportunity to share these thoughts with you and we all look forward to further advances in anatomic ACL reconstruction.
References
Fig 2. Modified anterior cruciate ligament clock-face illustration (courtesy of Dr. Woo, circa 2010).
1. Carefully locate the center of the ACL femoral footprint while viewing from the medial portal (or viewing from the lateral portal with a 70 arthroscope). 2. Place the guide pin in this location and confirm that it is where you intended. 3. Consider retrograding the pin back to the aperture and check it with a lateral fluoroscopic radiograph (I believe that it should be below Blumensaat’s line and at the junction of the third and fourth anteroposterior quadrants).
1. Mehta V, Petsche T, Rawal AM. Inter- and intrarater reliability of the femoral tunnel clock-face grading system during anterior cruciate ligament reconstruction. Arthroscopy 2017;33:394-397. 2. Loh JC, Yukihisa F, Tsuda E, Steadman R, Fu FH, Woo S. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy 2003;19:297-304. 3. Golish SR, Baumfeld JA, Schoderbek RJ, Miller MD. The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: A cadaveric study. Arthroscopy 2007;13:1187-1192. 4. Forsythe B, Kopf S, Wong A, et al. J Bone Joint Surg Am 2010;92:1418-1426. 5. Tompkins M, Milewski MD, Brockmeier SF, Gaskin CM, Hart JM, Miller MD. Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: Use of an accessory medial portal versus traditional transtibial drilling. Am J Sports Med 2012;40:1313-1321.