Improvement of Accuracy of Femoral Tunnel Positioning in ACL Surgery for Low-Volume Surgeons Using Intraoperative Fluoroscopy.

Abstract

Background: Less experienced surgeons have an increased risk for tunnel malpositioning as a predominant risk factor for failure of anterior cruciate ligament reconstruction (ACLR). Fluoroscopic guidance can improve the precision of tunnel positioning.

Purpose: To investigate whether low-volume surgeons can achieve precise femoral tunnel placement in ACLR under fluoroscopic control comparable to that of experienced mid- and high-volume surgeons.

Study design: Cohort study; Level of evidence, 3.

Methods: This study retrospectively included 150 patients who underwent primary ACLR between January 2021 and March 2023 and were prospectively enrolled in an in-clinic registry. Three groups were defined: high-volume surgeon (1 surgeon with >100 ACLRs per year; 50 images), mid-volume surgeon (1 surgeon with >10 to <50 ACLRs per year; 50 images), and low-volume surgeon (5 surgeons with ≤10 ACLRs per year; 50 images). The analysis of the femoral tunnel position was performed digitally on strictly lateral fluoroscopic images by determining the depth and height relations according to the quadrant method of Bernard and Hertel.

Results: All surgeons, regardless of experience, achieved high precision of femoral tunnel placement (depth relation: SD, 3.41% [1.58 mm]; height relation: SD, 5.33% [1.33 mm]). The variances of the tunnel placements did not show significant differences between the 3 groups with the Brown-Forsythe test (depth relation: probability (Pr) > F = 0.332; height relation: Pr > F = 0.081; P < .05). The precision of the high-volume surgeon (depth relation: SD, 3.29%; height relation: SD, 4.92%) was comparable to that of the mid-volume surgeon (depth relation: SD, 2.98%; height relation: SD, 5.9%) and low-volume surgeon (depth relation: SD, 3.58%; height relation: SD, 4.62%).

Conclusion: In this study, fluoroscopically guided tunnel placement allowed low-volume surgeons to achieve a level of precision comparable to that of the experienced surgeons. Fluoroscopy might especially help low-volume surgeons to achieve a standardized and highly reproducible femoral tunnel position and thus avoid tunnel malpositioning.