Orthopedics

Feature Article 

Comparison of Modified Transtibial and Anteromedial Portal Techniques in Anatomic Single-Bundle ACL Reconstruction

Joung Kyue Han, PhD; Keun Churl Chun, MD; Seong In Lee, MD; Saintpee Kim, MD; Churl Hong Chun, MD, PhD

Abstract

The purpose of this study was to compare the clinical, 3-dimensional computed tomography, magnetic resonance imaging, and second-look arthroscopic findings of the modified transtibial technique with those of the anteromedial portal technique in single-bundle anterior cruciate ligament reconstruction (SB-ACLR). Among patients who underwent SB-ACLR from February 2012 to May 2014, 95 patients with a minimum of 36 months of follow-up were included in this retrospective study. Forty-five patients underwent a reconstruction using the modified transtibial technique. Fifty patients underwent a reconstruction using the anteromedial portal technique. Clinical scores and stabilities were recorded preoperatively and at final follow-up. All patients had postoperative computed tomography and the computed tomography parameters, including tunnel position and graft obliquity, evaluated. Additionally, postoperative magnetic resonance imaging and second-look arthroscopy were performed. On the basis of the functional and stability outcomes, all of the patients showed significant improvement after SB-ACLR, with no significant differences existing between the 2 groups (P>.05). Tunnel position and obliquity were not significantly different between the 2 groups (P>.05). There were no statistically significant differences between the 2 groups regarding the magnetic resonance imaging and second-look arthroscopy findings (P>.05). The tunnel characteristics and clinical results of the 2 techniques were comparable. Given the several advantages of the modified transtibial technique, including its simplicity and patients' greater activity level, it is suitable for anatomic SB-ACLR. [Orthopedics. 2019; 42(2):83–89.]

Abstract

The purpose of this study was to compare the clinical, 3-dimensional computed tomography, magnetic resonance imaging, and second-look arthroscopic findings of the modified transtibial technique with those of the anteromedial portal technique in single-bundle anterior cruciate ligament reconstruction (SB-ACLR). Among patients who underwent SB-ACLR from February 2012 to May 2014, 95 patients with a minimum of 36 months of follow-up were included in this retrospective study. Forty-five patients underwent a reconstruction using the modified transtibial technique. Fifty patients underwent a reconstruction using the anteromedial portal technique. Clinical scores and stabilities were recorded preoperatively and at final follow-up. All patients had postoperative computed tomography and the computed tomography parameters, including tunnel position and graft obliquity, evaluated. Additionally, postoperative magnetic resonance imaging and second-look arthroscopy were performed. On the basis of the functional and stability outcomes, all of the patients showed significant improvement after SB-ACLR, with no significant differences existing between the 2 groups (P>.05). Tunnel position and obliquity were not significantly different between the 2 groups (P>.05). There were no statistically significant differences between the 2 groups regarding the magnetic resonance imaging and second-look arthroscopy findings (P>.05). The tunnel characteristics and clinical results of the 2 techniques were comparable. Given the several advantages of the modified transtibial technique, including its simplicity and patients' greater activity level, it is suitable for anatomic SB-ACLR. [Orthopedics. 2019; 42(2):83–89.]

Key functions of the anterior cruciate ligament (ACL) include providing anteroposterior stability to the knee joint and preventing excessive hyperextension of the knee and internal rotation of the tibia.1 Therefore, an ACL injury results in both an anterior and a rotational instability. Both should be corrected.2 A traditional single-bundle ACL reconstruction (SB-ACLR) technique with graft tissue in an isometric position has been shown to be effective in restoring the anteroposterior stability of the knee joint, but it is ineffective in restoring the rotational stability.3 This is due to the nonanatomical placement of the femoral tunnel.4

This commonly used traditional transtibial technique relies on the tibial tunnel to position the femoral tunnel, making its use in anatomical ACLR difficult.5 The modified transtibial (MTT) technique and the anteromedial portal (AMP) technique have been proposed as methods to anatomically place the femoral tunnel, independently of the tibial tunnel, during ACLR.6–8 In this study, the authors analyzed the clinical outcomes of a femoral and tibial tunnel placement by using a 3-dimensional (3D) computed tomography (CT) scan for those patients who wanted to have the cancellous screw removed postoperatively. The arthroscopic results of SB-ACLR when using the MTT technique and the AMP technique were good. The purpose of this study was to evaluate the various femoral and tibial tunnel characteristics, graft obliquity, and clinical results of the 2 techniques for SB-ACLR using 3D CT, magnetic resonance imaging (MRI), and second-look arthroscopic findings. The hypothesis was that the outcomes of the MTT technique would not be significantly different from those of the AMP technique.

Materials and Methods

Patients

Of patients who underwent arthroscopic SB-ACLR with a fresh-frozen Achilles tendon allograft between February 2012 and May 2014, a total of 95 patients were enrolled in this study. The inclusion criteria were primary ACL injury with or without meniscal injury and a minimum follow-up of 36 months. The patients were randomly assigned to either the MTT group (45 patients) or the AMP group (50 patients) on the day of surgery by permuted block randomization, which was performed by an independent investigator (C.H.C.) who did not join the operation.

Surgery and Rehabilitation

Modified Transtibial Technique. When considering the placement of the femoral tunnel and the length of the tibial tunnel, the tibial entrance point was positioned 2 to 3 cm posteromedial to the tibial tuberosity, 1 cm superior to the attachment site of the pes anserinus, and just anterior to the medial collateral ligament. A guide pin was then inserted at an angle of 60° to the tibial plateau with the use of a tibial drill guide (C-ring Pin Guide; Arthrex, Naples, Florida) aimed midway between the ACL footprints of the anteromedial and posterolateral bundles. The tibial tunnel was created with the same diameter as the graft. Using the tibial tunnel as a reference, the femoral tunnel was reamed close to the anatomical point with the knee flexed to 60°. A varus force and an internal rotation force were applied to the proximal aspect of the tibia, while the guide was externally rotated until an anatomic femoral point was obtained (Figure 1A).

The femoral tunnel was reamed close to the anatomical point with the knee flexed to 60°, and a varus force and an internal rotation force were applied to the proximal aspect of the tibia for patients undergoing the modified transtibial technique (A). For patients undergoing the anteromedial portal technique, through the far medial portal, the femoral tunnel was created with a reamer close to the anatomical point with the knee in nearly full flexion (B).

Figure 1:

The femoral tunnel was reamed close to the anatomical point with the knee flexed to 60°, and a varus force and an internal rotation force were applied to the proximal aspect of the tibia for patients undergoing the modified transtibial technique (A). For patients undergoing the anteromedial portal technique, through the far medial portal, the femoral tunnel was created with a reamer close to the anatomical point with the knee in nearly full flexion (B).

Anteromedial Portal Technique. Similar to the MTT technique, the tibial tunnel was aimed midway between the ACL footprints of the anteromedial and posterolateral bundles with a tibial drill guide. It was created with the same diameter as the graft. Likewise, the placement was conducted with caution when the cortical bone of the tibial articular surface was detected to prevent damage to the synovial membrane. Damage to the synovial membrane was prevented when the femoral guide or the reamer was passing through to create the femoral tunnel. The far medial portal was created by using the AMP. Through the far medial portal, the femoral tunnel was created with a reamer close to the anatomical point with the knee in nearly full flexion (Figure 1B).

Graft Fixation. To fix the allograft on the femoral side, a metal interference screw (Jeil Medical, Seoul, Korea) was used. A bioabsorbable screw (OSTEOTWIN; Biomatlante, Vigneus-de-Bretagne, France) was used on the tibial side to fix the tendinous portion of the graft. For additional fixation of the tendinous portion, a cancellous screw with a spike washer (Jeil Medical) was inserted 5 mm below the tibial tunnel insertion.

Evaluation

Functional Evaluation. The Lysholm knee score and Tegner activity scale scores were assessed in the outpatient clinic before and after the surgery and on the last day of follow-up. The overall function score of patients was assessed using the subjective scale of the International Knee Documentation Committee.

Stability Assessment. The anteroposterior stress views, the Lachman test results, and the pivot shift test results were all assessed in the outpatient clinic before and after the surgery and on the last day of follow-up. Every physical examination was performed by an orthopedic surgeon (C.H.C.) who was blinded to his prior measurements. The radiological examinations of the anteroposterior stress views were performed using a Telos stress device (Arthrometer, model KT2000; MEDmetric Corporation, San Diego, California).

Evaluation of the Femoral and the Tibial Tunnel Positions and the Obliquity via a 3D CT Scan. A 3D CT scan (Somatom Definition Flash; Siemens, Berlin, Germany) was obtained 3 weeks postoperatively. A 3D CT scan was used for placement of the femoral tunnel, and the data were analyzed according to the quadrant method reported by Bernard et al.9 The side views were obtained via a 3D CT scan and by using picture archiving and communication system (PiViewSTAR 5.0; INFINITT, Seoul, Korea) technology. The distance (t) from the femoral condyle to the center of the femoral tunnel was measured. This line was parallel to the Blumensaat line. The distance (h) from the line perpendicular to the Blumensaat line was estimated and expressed as a percentage (Figure 2A). The placement of the tibial tunnel was estimated according to the method reported by Tsukada et al.10 A measurable rectangular frame was made up of the tibial plateau's medial tangential line (B), the lateral tangential line, the anterior tangential line (D), and the posterior tangential line. The distance from the center of the tunnel to the anterior tangential line (A) and the medial tangential line (C) was estimated. The ratio between the distance from A to B to the distance from C to D was then calculated and expressed as a percentage (Figure 2B). The coronal obliquity of the femoral tunnel was measured with coronal placement of the 3D CT scan by using the angle between the line parallel to the femoral tunnel and the line halving the femoral shaft. The sagittal obliquity was measured with the sagittal plane of the CT scan (Figure 3). Femoral and tibial tunnel positions were measured by 3 orthopedic surgeons who were blinded to the patient information (K.C.C., S.I.L., S.K.). Interobserver reliability was assessed with the kappa value, which was found to be 0.91.

On the lateral femoral side of a 3-dimensional computed tomography scan, the location of the femoral tunnel aperture centers was established within a 4×4 grid, which was oriented along the most anterior edge of the notch roof (h=line perpendicular to the Blumensaat line; t=line parallel to the Blumensaat line) (A). The central points of the tibial tunnel from the anterior edge and the medial edge of the tibial plateau were calculated as A/B and C/D, respectively (A=the distance from the center of the tunnel to the anterior tangential line; B=medial tangential line; C=the distance from the center of the tunnel to the medial tangential line; D=anterior tangential line) (B).

Figure 2:

On the lateral femoral side of a 3-dimensional computed tomography scan, the location of the femoral tunnel aperture centers was established within a 4×4 grid, which was oriented along the most anterior edge of the notch roof (h=line perpendicular to the Blumensaat line; t=line parallel to the Blumensaat line) (A). The central points of the tibial tunnel from the anterior edge and the medial edge of the tibial plateau were calculated as A/B and C/D, respectively (A=the distance from the center of the tunnel to the anterior tangential line; B=medial tangential line; C=the distance from the center of the tunnel to the medial tangential line; D=anterior tangential line) (B).

A line parallel to the axis of the femoral tunnel and a line bisecting the femoral shaft were used to calculate the coronal inclination of the femoral tunnel on coronal computed tomography scans (A). The sagittal inclination of the femoral tunnel was calculated relative to a line bisecting the femoral shaft in the lateral views of sagittal computed tomography scans (B).

Figure 3:

A line parallel to the axis of the femoral tunnel and a line bisecting the femoral shaft were used to calculate the coronal inclination of the femoral tunnel on coronal computed tomography scans (A). The sagittal inclination of the femoral tunnel was calculated relative to a line bisecting the femoral shaft in the lateral views of sagittal computed tomography scans (B).

Magnetic Resonance Imaging and Second-Look Arthroscopic Findings. For the coronal oblique MRI view that tilted in the direction of the ACL, the authors classified the grade by the amount of ACL rupture. Grade 1 was a partial rupture of less than 50%, grade 2 was a partial rupture of greater than 50%, and grade 3 was a complete rupture. Laxity was divided into 3 categories, with a value equal to or less than 2 mm considered normal, 3 to 5 mm considered lax, and greater than 5 mm considered a partial or complete tear. Synovial coverage of the grafts was classified as good (>80% of the graft), fair (50% to 80%), or poor (<50%) (Figure 4).11

Arthroscopic findings of anterior cruciate ligament reconstruction using the modified transtibial technique (A) and the anteromedial technique (B). Anterior cruciate ligament reconstruction using an Achilles tendon allograft (1) and second-look arthroscopic findings (2).

Figure 4:

Arthroscopic findings of anterior cruciate ligament reconstruction using the modified transtibial technique (A) and the anteromedial technique (B). Anterior cruciate ligament reconstruction using an Achilles tendon allograft (1) and second-look arthroscopic findings (2).

Statistical Analysis. All of the statistical analyses were performed using SPSS version 12.0 software (SPSS Inc, Chicago, Illinois). Student's t tests and chi-square tests were used for the analysis of clinical and radiological data. P<.05 was considered significant.

Results

Functional and Stability Assessment

Preoperative functional scores (Lysholm knee score, International Knee Documentation Committee score, and Tegner activity score) of both groups were better than those at last follow-up. However, there was no significant difference between the 2 groups at final follow-up. Stress view, Lachman test, and pivot shift test also showed excellent results at final follow-up in both groups. There was no statistically significant difference in stability between the 2 groups at last follow-up (Table 1).

Comparison of Functional Outcome and Stability Between the 2 Groups

Table 1:

Comparison of Functional Outcome and Stability Between the 2 Groups

Evaluation of the Femoral and the Tibial Tunnel Positions and the Obliquity via a 3D CT Scan

The mean distance (t) of the line parallel to the Blumensaat line from the femoral posterior condylar surface to the center of the femoral tunnel was 30.4%±1.2% for the patients receiving the MTT technique and 31.4%±1.6% for the patients receiving the AMP technique. The mean distance (h) of the line perpendicular to the Blumensaat line was 39.2%±2.0% for the patients receiving the MTT technique and 41.2%±1.8% for the patients receiving the AMP technique. There were no statistically significant differences between the 2 groups. The mean distance from the center of the tibia to the anterior tangential line was 42.8%±2.6% for the patients receiving the MTT technique and 43.2%±2.4% for the patients receiving the AMP technique. The mean distance from the center of the tibia to the medial tangential line was 47.2%±2.9% for the patients receiving the MTT technique and 47.8%±3.1% for the patients receiving the AMP technique. No statistically significant differences were found between the 2 groups. The mean coronal obliquity (42.2°±6.2° vs 43.7°±6.4°) and the mean sagittal obliquity (41.7°±5.7° vs 42.9°±5.4°) were similar between the 2 groups. There were no statistically significant differences between the 2 groups (Table 2).

Comparison of Tunnel Position and Obliquity Between the 2 Groups

Table 2:

Comparison of Tunnel Position and Obliquity Between the 2 Groups

Magnetic Resonance Imaging and Second-Look Arthroscopic Findings

At the follow-up MRI examination, the graft tendons were in good condition and showed signal intensities similar to those of the surrounding normal cartilage in all cases. No statistically significant differences were found between the 2 groups regarding the graft tensions and the synovial coverage (Table 3).

Comparison of Graft Tension and Synovial Coverage Between the 2 Groups

Table 3:

Comparison of Graft Tension and Synovial Coverage Between the 2 Groups

Discussion

The key finding of this study was that anatomic ACLR performed with the use of the MTT technique was not significantly different from that performed with the use of the AMP technique in terms of tunnel positions, widening of the tunnels, graft obliquity, and clinical results.

Based on recent anatomical and biomechanical studies, the anatomical placement of the femoral tunnel for the graft was as recommended. In particular, there have been reports of poor clinical results with an inaccurate placement of the femoral tunnel in the sagittal plane,12 and more biomechanical studies are emerging and emphasizing the importance of coronal placement of the femoral tunnel.13 However, there are many different opinions regarding the possibility of an accurate anatomical placement of the femoral tunnel when using the traditional transtibial technique and when using a conventional ACLR with graft tissue in an isometric position.13–15 Arnold et al5 and Chhabra et al16 both reported that the anatomical placement of the femoral tunnel was not possible with the transtibial technique because it places the tunnel between the 11 and 12 o'clock positions. Yasuda et al17 reported that the transtibial technique results in a perpendicular placement of the graft, which is known to be associated with anterior stability but also with clinical rotational instability. Recently, many biomechanical studies have shown that the placement of the femoral tunnel close to the coronal plane results in rotational stability of the knee and internal rotational stability of the tibia.12,18 Rue et al19 showed that a laterally oriented transtibial technique produced a femoral tunnel located at the femoral footprints of the ACL bundles. However, all of these studies were mainly focused on the modification of tibial tunnel obliquity. In the current study, the authors performed the MTT technique by applying a varus force and an internal rotation force to the proximal aspect of the tibia and then inserting the femoral guide pin. Applying a varus force and an internal rotation force to the proximal aspect of the tibia with the thigh tied to the leg holder provided a lateral knee-joint opening, which helped in the anatomical positioning of the femoral guide.

There have been concerns that when the tunnels are created in an anatomic position using the transtibial technique, the starting point of the tibial tunnel is unacceptably close to the joint line, resulting in a too-short tibial tunnel length for proper fixation.16,20 Heming et al14 showed that an attempt at an anatomical placement of the femoral tunnel with the transtibial technique may result in the femoral tunnel being positioned 14 mm below the tibial articular surface. This can cause shortening of the tibial tunnel, as well as misalignment between the tunnel and the graft tissue. Therefore, other techniques that create a femoral tunnel at an anatomical attachment site have been introduced. These include the AMP technique and the MTT technique.6–8 The MTT technique was a rather simple surgical procedure, and the patients had a greater activity level at midterm and long-term follow-up compared with the AMP technique.21,22 The AMP technique had some disadvantages. It was technically demanding and had a limited visibility. Further, excessive angulation in the sagittal plane may lead to tunnel enlargement from erosion, posterior-wall blowout and potential damage to posterior articular cartilage and portal tightening in hyperflexion, iatrogenic damage to cartilage of the medial femoral condyle, higher graft failure rates, and risk for revision compared with the transtibial technique.23,24 It was suggested that the latter finding could be explained by technical failures resulting from the introduction of a new and more complex procedure or by the hypothesis of prior studies that stated that compared with a nonanatomic graft placement, a greater force is carried by the anatomic ACLR and hence there is a concomitant higher risk for ACL rupture.21 If the surgeon is concerned about any of the mentioned conditions that could occur when performing the AMP technique, the MTT technique could be a secure option.

Bernard et al9 suggested using the quadrant method to estimate the anatomical position of the bone tunnel. In the current study, the anatomical placement of the femoral tunnel after ACLR when using either the MTT technique or the AMP technique was analyzed with a 3D CT scan by using the quadrant method as suggested by Bernard et al.9 According to Kopf et al,25 the traditional transtibial technique estimated the femoral tunnel position to have a mean distance (t) parallel to the Blumensaat line of 37.2%±5.5% and a mean distance (h) perpendicular to the Blumensaat line of 11.3%±6.6%, which are greater than those at the anatomical position. According to Colombet et al,26 the anatomical placement of the femoral tunnel when using the quadrant method had a mean distance (t) of 29.35% and a mean distance (h) of 36.45%. The results of this study are similar to those of previous studies, with relatively anatomical placements of the femoral and tibial tunnels being shown.

In the current study, the authors performed the MTT technique by applying anterior drawer force, a varus force, and an external rotation force when creating the femoral tunnel to locate the femoral tunnel more inferiorly and posteriorly. At each step, the location was checked with fluoroscopy, resulting in the creation of a femoral tunnel similar to the anatomical footprint, which has led to a good result.

Conclusion

Both the MTT technique and the AMP technique led to good clinical results with an anatomical placement of the femoral and tibial tunnels after SB-ACLR. There were no significant differences in the clinical parameters that were produced by these 2 techniques. Given its several advantages, such as its simplicity and patients' greater activity level, the MTT technique is suitable for anatomic SB-ACLR.

References

  1. Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006;14(3):204–213. doi:10.1007/s00167-005-0679-9 [CrossRef]
  2. Colombet P, Robinson J, Christel P, Franceschi JP, Djian P. Using navigation to measure rotation kinematics during ACL reconstruction. Clin Orthop Relat Res. 2007;454:59–65. doi:10.1097/BLO.0b013e31802baf56 [CrossRef]
  3. Fu FH, van Eck CF, Tashman S, Irrgang JJ, Moreland MS. Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc. 2015;23(3):640–648. doi:10.1007/s00167-014-3209-9 [CrossRef]
  4. Kanamori A, Zeminski J, Rudy TW, Li G, Fu FH, Woo SL. The effect of axial tibial torque on the function of the anterior cruciate ligament: a biomechanical study of a simulated pivot shift test. Arthroscopy. 2002;18(4):394–398. doi:10.1053/jars.2002.30638 [CrossRef]
  5. Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc. 2001;9(4):194–199. doi:10.1007/s001670100198 [CrossRef]
  6. Lubowitz JH, Akhavan S, Waterman BR, Aalami-Harandi A, Konicek J. Technique for creating the anterior cruciate ligament femoral socket: optimizing femoral footprint anatomic restoration using outside-in drilling. Arthroscopy. 2013;29(3):522–528. doi:10.1016/j.arthro.2012.10.007 [CrossRef]
  7. Noh JH, Roh YH, Yang BG, Yi SR, Lee SY. Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: transtibial technique versus anteromedial portal technique. Arthroscopy. 2013;29(5):882–890. doi:10.1016/j.arthro.2013.01.025 [CrossRef]
  8. Robin BN, Jani SS, Marvil SC, Reid JB, Schillhammer CK, Lubowitz JH. Advantages and disadvantages of transtibial, anteromedial portal, and outside-in femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction: a systematic review. Arthroscopy. 2015;31(7):1412–1417. doi:10.1016/j.arthro.2015.01.018 [CrossRef]
  9. Bernard M, Hertel P, Hornung H, Cierpinski T. Femoral insertion of the ACL: radiographic quadrant method. Am J Knee Surg. 1997;10(1):14–21.
  10. Tsukada H, Ishibashi Y, Tsuda E, Fukuda A, Toh S. Anatomical analysis of the anterior cruciate ligament femoral and tibial footprints. J Orthop Sci. 2008;13(2):122–129. doi:10.1007/s00776-007-1203-5 [CrossRef]
  11. Kinugasa K, Mae T, Matsumoto N, Nakagawa S, Yoneda M, Shino K. Effect of patient age on morphology of anterior cruciate ligament grafts at second-look arthroscopy. Arthroscopy. 2011;27(1):38–45. doi:10.1016/j.arthro.2010.05.021 [CrossRef]
  12. Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett WE Jr, . Reconstruction technique affects femoral tunnel placement in ACL reconstruction. Clin Orthop Relat Res. 2008;466(6):1467–1474. doi:10.1007/s11999-008-0238-z [CrossRef]
  13. Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 2002 Richard O'Connor Award paper. Arthroscopy. 2003;19(3):297–304. doi:10.1053/jars.2003.50084 [CrossRef]
  14. Heming JF, Rand J, Steiner ME. Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med. 2007;35(10):1708–1715. doi:10.1177/0363546507304137 [CrossRef]
  15. Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy. 2008;24(1):113–115. doi:10.1016/j.arthro.2007.07.019 [CrossRef]
  16. Chhabra A, Kline AJ, Nilles KM, Harner CD. Tunnel expansion after anterior cruciate ligament reconstruction with autogenous hamstrings: a comparison of the medial portal and transtibial techniques. Arthroscopy. 2006;22(10):1107–1112. doi:10.1016/j.arthro.2006.05.019 [CrossRef]
  17. Yasuda K, van Eck CF, Hoshino Y, Fu FH, Tashman S. Anatomic single- and double-bundle anterior cruciate ligament reconstruction: Part 1. Basic science. Am J Sports Med. 2011;39(8):1789–1799. doi:10.1177/0363546511402659 [CrossRef]
  18. Simmons R, Howell SM, Hull ML. Effect of the angle of the femoral and tibial tunnels in the coronal plane and incremental excision of the posterior cruciate ligament on tension of an anterior cruciate ligament graft: an in vitro study. J Bone Joint Surg Am. 2003;85(6):1018–1029. doi:10.2106/00004623-200306000-00006 [CrossRef]
  19. Rue JP, Ghodadra N, Bach BR Jr, . Femoral tunnel placement in single-bundle anterior cruciate ligament reconstruction: a cadaveric study relating transtibial lateralized femoral tunnel position to the anteromedial and posterolateral bundle femoral origins of the anterior cruciate ligament. Am J Sports Med. 2008;36(1):73–79. doi:10.1177/0363546507311093 [CrossRef]
  20. Piasecki DP, Bach BR Jr, Espinoza Orias AA, Verma NN. Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique?Am J Sports Med.2011;39(6):1306–1315. doi:10.1177/0363546510397170 [CrossRef]
  21. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC. Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy. 2013;29(1):98–105. doi:10.1016/j.arthro.2012.09.009 [CrossRef]
  22. Alentorn-Geli E, Lajara F, Samitier G, Cugat R. The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18(8):1013–1037. doi:10.1007/s00167-009-0964-0 [CrossRef]
  23. Gavriilidis I, Motsis EK, Pakos EE, Georgoulis AD, Mitsionis G, Xenakis TA. Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study. Knee. 2008;15(5):364–367. doi:10.1016/j.knee.2008.05.004 [CrossRef]
  24. Lubowitz JH. Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy. 2009;25(1):95–101. doi:10.1016/j.arthro.2008.10.012 [CrossRef]
  25. Kopf S, Forsythe B, Wong AK, et al. Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. J Bone Joint Surg Am. 2010;92(6):1427–1431. doi:10.2106/JBJS.I.00655 [CrossRef]
  26. Colombet P, Robinson J, Christel P, et al. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy. 2006;22(9):984–992. doi:10.1016/j.arthro.2006.04.102 [CrossRef]

Comparison of Functional Outcome and Stability Between the 2 Groups

VariableModified Transtibial Technique GroupAnteromedial Portal Technique GroupP


PreoperativeLast Follow-upPreoperativeLast Follow-up
Lysholm knee score, mean±SD47.6±2.287.6±5.148.2±0.987.4±1.1.585
International Knee Documentation Committee subjective score, mean±SD11.2±9.875.4±10.311.4±10.275.7±10.7.746
Tegner activity score, mean±SD4.8±1.17.4±1.04.9±1.27.5±1.1.546
Stress view, mean±SDa, mm6.5±0.72.7±0.66.7±0.62.6±0.8.748
Lachman test result, No. (%).751
  Negative3 (6.7)38 (84.4)4 (8.0)41 (82.0)
  Grade I5 (11.1)7 (15.6)8 (16.0)9 (18.0)
  Grade II31 (68.9)0 (0)30 (60.0)0 (0)
  Grade III6 (13.3)0 (0)8 (16.0)0 (0)
Pivot shift test result, No. (%).735
  Negative8 (17.8)43 (95.6)9 (18.0)47 (94.0)
  Grade I15 (33.3)2 (4.4)19 (38.0)3 (6.0)
  Grade II17 (37.8)0 (0)18 (36.0)0 (0)
  Grade III5 (11.1)0 (0)4 (8.0)0 (0)

Comparison of Tunnel Position and Obliquity Between the 2 Groups

VariableMean±SDP

Modified Transtibial Technique GroupAnteromedial Portal Technique Group
Tunnel position
  Femur
    Parallel to Blumensaat line (line t)30.4%±1.2%31.4%±1.6%.143
    Perpendicular to Blumensaat line (line h)39.2%±2.0%41.2%±1.8%.187
  Tibia
    Anterior to posterior42.8%± 2.6%43.2%± 2.4%.163
    Medial to lateral47.2%± 2.9%47.8%± 3.1%.117
Obliquity
  Coronal42.2°± 6.2°43.7°± 6.4°.257
  Sagittal41.7°± 5.7°42.9°± 5.4°.313

Comparison of Graft Tension and Synovial Coverage Between the 2 Groups

VariableNo. (%)P

Modified Transtibial Technique GroupAnteromedial Portal Technique Group
Graft tension.084
  Normal31 (68.9)36 (72.0)
  Lax12 (26.7)11 (22.0)
  Partial tear2 (4.4)3 (6.0)
Synovial coverage.057
  Good30 (66.7)31 (62.0)
  Fair13 (28.9)16 (32.0)
  Poor2 (4.4)3 (6.0)
Authors

The authors are from the College of Sports Science (JKH), Chung-Ang University, Anseong, the Department of Orthopedic Surgery (KCC, SIL, SK, CHC), Wonkwang University Hospital, Iksan, and the Department of Orthopedic Surgery (KCC), Hankook Hospital, Mokpo, Korea.

The authors have no relevant financial relationships to disclose.

This manuscript was supported by the Wonk-wang University in 2018.

Correspondence should be addressed to: Churl Hong Chun, MD, PhD, Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Korea ( cch@wonkwang.ac.kr).

Received: November 12, 2018
Accepted: December 31, 2018
Posted Online: February 14, 2019

10.3928/01477447-20190211-04

Sign up to receive

Journal E-contents