Review Question - QID 4910

The clinical presentation is consistent with a mal-positioned femoral tunnel leading to a vertical graft. Vertical grafts are associated with persistently positive pivot shift and lower Lysholm satisfaction scores. The Lysholm is a commonly used brief subjective questionnaire.

Early arthroscopic single-incision transtibial ACL reconstruction often resulted in femoral tunnels which were at the top of the notch (12 o:clock position), rather than at the anatomic origin on the wall. The resulting vertical graft often improved anteroposterior laxity (as tested with the Lachman) but was less able to provide rotational stability (as tested with the Pivot shift).

Lee et al. found a significant association between vertically positioned grafts and residual (postoperative) positive pivot shift tests. They also found patients with a vertically positioned graft had lower Lysholm satisfaction scores. They conclude more oblique positioning of the graft may have advantages in rotational stability, which in turn increase subjective patient satisfaction.

Yasuda et al. noted that vertical non-anatomic tunnel placement cannot completely restore normal rotatory stability in laboratory studies.

Illustration A demonstates the difference between a vertical tunnel/graft and a more horizontal graft/tunnel. Illustration V shows a Pivot Shift Test.

Incorrect Answers:
Answer 2. An intact vertical graft is less likely to have a positive Lachman with no endpoint.
Answer 3-5. An excessively vertical graft in a patient with persistent instability is likely to have a positive pivot shift.