Anteromedial Portal Versus Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? A Retrospective Comparative Study

doi:10.1016/j.arthro.2013.05.020

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 29, Issue 8, August 2013, Pages 1330-1337

https://doi.org/10.1016/j.arthro.2013.05.020 Get rights and content

Purpose

This study aimed to undertake a retrospective analysis of prospectively collected data comparing, at a minimum follow-up of 5 years (78.1 ± 5.3 months v 75.6 ± 4.8 months), the clinical, functional, and radiographic outcomes of 2 homogeneous groups of athletes who had undergone arthroscopic single-bundle autologous hamstring reconstruction of the anterior cruciate ligament (ACL) using a transtibial (TT) or an anteromedial portal (AMP) approach to drill the femoral tunnel.

Methods

Ninety-four patients were operated on in 2005 and 2006, and 88 (93.6%) (73 men, 15 women) were evaluated subjectively and objectively, using the Lysholm and International Knee Documentation Committee (IKDC) scores, manual maximum displacement test with a KT-1000 arthrometer (MEDmetric, San Diego, CA) and the Lachman test, and rotational instability with the pivot shift test. Degenerative changes were assessed on radiographs according to the Fairbank classification.

Results

The median age at operation was 29 years (20 to 43 years; SD, 5.4) in the TT group 1 and 28 years (19 to 45 years; SD, 6.1) in the AMP group 2. At the last appointment, the 2 groups had similar results for the Lysholm and IKDC scores (primary outcome). Patients who underwent the AMP approach had less glide pivot shift (P = .42) and Lachman (P = .47) phenomena, with no statistically significant intergroup difference. Radiography showed fewer, but not significantly different, degenerative changes in the AMP ACL reconstruction group at final follow-up (P = .47).

Conclusions

In our series, ACL reconstruction using a femoral tunnel drilled through an AMP provided better rotational stability and anterior translation than drilling the femoral tunnel using the TT technique. This difference likely is not relevant from a clinical and functional viewpoint. The 2 groups of patients were not significantly different in terms of development of degenerative changes seen radiographically at a minimum follow-up of 5 years.

Level of Evidence

Level III, retrospective comparative study.

Section snippets

Methods

The primary outcome was the change in the overall Lysholm²² and International Knee Documentation Committee (IKDC)²³ scores. These are reliable, valid, and relatively simple instruments to assess function and symptoms in patients with ACL instability. The secondary outcomes were (1) change in anteroposterior laxity (measured by the Lachman test and the KT-1000 arthrometer [MEDmetric, San Diego, CA] side-to-side difference), (2) restoration of rotational instability (measured by the pivot shift

Results

Of 243 consecutive patients who had undergone ACL reconstruction from January 2005 to May 2006, 94 were initially enrolled in the study. One hundred forty-nine patients were excluded because they had secondary injuries to cartilage and menisci. Eighty-eight patients (93.6%) were followed for at least 5 years from the index procedure. Forty-six consecutive patients who had undergone the TT technique for ACL reconstruction (TT, group 1; 39 male patients and 7 female patients), who were operated

Discussion

This study showed that drilling the femoral tunnel through an AMP portal and using a TT technique provide grossly comparable outcomes. Specifically, this study showed that at a minimum of 5 years after surgery, AMP and TT ACL reconstructions provide comparable functional outcomes in terms of Lysholm and IKDC scores and sport activity level. Some glide pivot shift (P = .42) and Lachman (P = .47) phenomena may occur (more frequently after TT ACL reconstruction), but the intergroup difference is

Conclusions

In our series, we found that ACL reconstruction using a femoral tunnel drilled through an AMP provides better rotational stability and anterior translation than drilling the femoral tunnel using the TT technique, but this difference is likely not relevant from a clinical and functional viewpoint. The 2 groups of patients were not significantly different in terms of the development of degenerative changes on radiographic evaluation and a return to sport at a minimum follow-up of 5 years.

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Cited by (72)

Femoral Tunnel Widening After Double-Bundle Anterior Cruciate Ligament Reconstruction With Hamstring Autograft Produces a Small Shift of the Tunnel Position in the Anterior and Distal Direction: Computed Tomography–Based Retrospective Cohort Analysis
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
To determine whether the femoral tunnel position remains in an anatomical footprint after tunnel widening and shifting.
Patients who underwent unilateral double-bundle anterior cruciate ligament reconstruction with hamstring autograft and performed computed tomography scan evaluation at the time of 5 days and 1 year postoperatively were included in this retrospective cohort study. Three-dimensional models of the femur and femoral tunnels were reconstructed from computed tomography scan data. The location of the tunnel center and tunnel margins in the anatomical coordinate system, and the mean shifting distance of tunnel center and margin were measured with image analysis software during the period. The change of tunnel center location in Bernard quadrant was confirmed if the tunnel center remained within the boundaries of anatomical position after tunnel widening.
A total of 56 patients satisfied the inclusion criteria. The mean shifting distance of AM and PL tunnel centers were 1.7 ± 0.9 mm and 1.6 ± 0.6 mm. The Tunnel margin of the anteromedial (AM) and posteromedial (PL) tunnels were shifted to 2.5 ± 1.3 mm and 2.6 ± 1.4 mm in the anterior direction, and 1.4 ± 0.9 mm and 1.0 ± 0.7 mm in the distal direction, respectively. Among the anatomical located tunnel, 97% (32/33) and 87.1% (27/31) of AM and PL tunnel centers remained in a range of anatomical footprint. The tunnel center was shifted from the anatomical position into a nonanatomical position in 3% (1/33) of the AM tunnel and 12.9% (4/31) of PL tunnel after tunnel widening. The tunnel location which shifted nonanatomically were relatively anterior and distal position.
Tunnel widening shifts the tunnel position to the anterior and distal direction, which could change the initial tunnel position. Nevertheless, the majority of tunnel positions remained in the anatomical position after tunnel widening and shifting.
Level III, retrospective cohort study.
Anatomical anterior cruciate ligament reconstruction (ACLR) results in fewer rates of atraumatic graft rupture, and higher rates of rotatory knee stability: A meta-analysis
2020, Journal of ISAKOS
This review highlights the differences in outcomes between anatomical and non-anatomical anterior cruciate ligament reconstruction (ACLR) techniques.
To compare clinical and functional outcomes between anatomical and non-anatomical ACLR techniques.
A search of MEDLINE, Embase and PubMed from 1 January 2000 to 24 October 2019 was conducted. Randomised and prospective primary ACLR studies using autograft and a minimum of 2 years of follow-up were included. The Anatomic Anterior Cruciate Ligament Reconstruction Checklist (AARSC) was used to categorise studies as anatomical. Outcomes analysed included failure rate, knee stability and functional outcomes. A meta-analysis using risk ratio and mean differences was conducted using a random effects model.
Thirty-six studies were included, representing 3710 patients with a follow-up range of 24–300 months. The overall failure rate was 96/1470 (6.5%) and 131/1952 (6.7%) in the anatomical group and non-anatomical group, respectively. The pooled results of the overall failure rate showed that there was no statistically significant difference between the anatomical and the non-anatomical groups (p=0.96). There were 37/60 (61.7%) and 29/67 (43.3%) traumatic failures in the anatomical and non-anatomical groups, respectively. The number of patients with the negative postoperative pivot-shift test was 995/1252 (79.5%) and 1140/1589 (71.1%) in the anatomical and non-anatomical groups, respectively. The pooled results indicated a statistically significant higher number of patients with a positive pivot shift in the non-anatomical group compared with the anatomical group (p=0.03).
This study demonstrated that the overall failure rate was similar between the anatomical and non-anatomical approaches. However, the anatomical ACLR demonstrated a significantly superior restoration of rotatory stability, as evidenced by a higher percentage with a negative postoperative pivot-shift test. Non-anatomical ACLR resulted in higher rates of atraumatic graft ruptures and persistent rotatory knee instability. Surgeons should consider anatomical ACLR when treating rotatory knee stability in patients.
II, systematic review and meta-analysis of level I and II studies.
Prevalence of patellofemoral joint osteoarthritis after anterior cruciate ligament injury and associated risk factors: A systematic review
2020, Journal of Orthopaedic Translation
The prevalence of patellofemoral joint (PFJ) osteoarthritis (OA) after anterior cruciate ligament (ACL) injury was inconsistently reported in the literature. This review summarises the reported prevalence of PFJ OA and risk factors of PFJ OA after ACL injury.
PubMed, Embase, WoS, and MEDLINE (OVID) were searched up to 1 March 2019. A modified version of the Coleman methodology score was used to assess the methodological quality of the included studies. Prevalence of PFJ OA was pooled depended on different interventions in ACL injured populations.
Thirty-eight studies were included. Five different radiographic classification methods were used: the Kellgren and Lawrence Grade 2, IKDC Grade B, Fairbank Grade 1, joint space narrowing of Grade 2 based on OARSI, and Ahlbäck Grade 1. One included study used MRI Osteoarthritis Knee Score to evaluate PFJ degenerative changes. The overall prevalence of PFJ OA after ACL injury in included studies varied between 4.5% and 80%. The large variation of PFJ OA prevalence is mainly because of different follow-up period and surgical techniques. The pooled data showed that bone-patellar tendon-bone graft, single-bundle ACL reconstruction (ACLR), and delayed ACLR are likely associated with PFJ degenerative changes after ACL injury. ACLR, delayed ACLR, body mass index (BMI), meniscectomy, patellofemoral chondral lesions, age at surgery, and TFJ OA were identified in the literature inducing PFJ OA after ACL injury.
Large variations of PFJ OA after ACL injury are associated with different follow-up period and surgical techniques. ACL reconstructed population with bone-patellar tendon-bone graft, single-bundle reconstruction, and delayed operation time has a high prevalence of PFJ OA.
This review focuses more on the effect of surgical technique factors on the degenerative changes on PFJ. The results reveal that BPTB, single-bundle reconstruction, and delayed ACLR are more likely associated with PFJ degenerative changes after ACL injury. These findings imply that awareness of PFJ problems after surgical intervention will remind of surgeons taking PFJ into consideration in operations, which is likely to reduce the incidences of anterior knee pain, patellar maltracking, and over-constrained patella in the early stage after surgery.
Positioning Technique of the Fixed Knee in Hyperflexion for the Transportal Femoral Tunnel During Reconstruction of the Anterior Cruciate Ligament
2020, Arthroscopy Techniques
During reconstruction surgery of the anterior cruciate ligament, the evolution of the femoral tunnel from the transtibial to the transportal path provides greater accuracy in reaching the desired anatomic point. However, there are also some new challenges, such as correct execution, reproducibility, and minimizing the risk of iatrogenic injury from its use. In an effort to overcome these challenges, we have proposed the use of a positioner, which was developed by our group and allows the leg to stay in the desired position, without variations in the operation or aid from a medical assistant. This manuscript presents our femoral tunnel preparation technique and its application in clinical practice.
Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury – Secondary publication
2020, Journal of Orthopaedic Science
Citation Excerpt :
There is limited evidence supporting that in patients undergoing ACL reconstructions, the surgeon should use a tibial independent approach for femoral tunnel placement (either a trans-portal or outside-in technique), because the approach is readily accepted for the anatomy of the ACL, although clinical and measured outcomes are similar (Recommendation 2, Agreement ratio 71.4%, Level C). This recommendation was based on three systematic reviews [157–159], seven interventional studies [160–166], and 8 observation studies [167–174] about the CQ (Figs. 29–35). When comparing the clinical results between the trans-portal and trans-tibial technique, it was controversial which method was superior.
This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).
The JOA ACL guideline committee revised the previous guideline based on “Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014”, which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of “the balance of benefit and harm” was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.
We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.
This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
Outcome of posterior wall blowout in anterior cruciate ligament (ACL) reconstruction via anteromedial portal approach: A retrospective research in 20 patients with 6 years follow-up
2019, Chinese Journal of Traumatology - English Edition
To evaluate the clinical outcome in patients who received anterior cruciate ligament (ACL) reconstruction via anteromedial portal with or without posterior wall blowout.
Twenty patients with ruptured ACL, who have received ACL reconstruction via anteromedial portal between Apr 2012 and Oct 2013 were enrolled. According to the conditions of posterior wall, the patients were divided into 2 groups: posterior wall blowout group (10 patients) and posterior wall intact group (10 patients). The median follow up time were 63 (range 19–75) months and 60.5 (range 25–64) months in the 2 groups respectively. The clinical outcome was evaluated by knee joint physical examination, magnetic resonance imaging (MRI), the International Knee Documentation Committee (IKDC) 2000 subjective score, Lysholm score, Tenger score, difference of thigh circumference, KT-2000 and Biodex isokinetic dynamometer system.
No significant differences were found in terms of the IKDC score, Lysholm score, Tegner score, Lachman test positive rate or Pivot Shift test positive rate between the two groups. In KT-2000 and Biodex isokinetic dynamometer tests, the difference of muscle strength between affected knees and unaffected knees in posterior wall blowout group was not significant less than that of posterior wall intact group (p > 0.05). In addition, there is no statistical difference between the two groups in signal/noise quotient (SNQ) of the graft (p > 0.05) in post operative MRI.
Blowout of posterior wall in ACL reconstruction via anteromedial portal does not affect the clinical outcome as long as reliable fixation has been taken intraoperatively.

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: The authors report that they have no conflicts of interest in the authorship and publication of this article.

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Original ArticleAnteromedial Portal Versus Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? A Retrospective Comparative Study

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Results

Discussion

Conclusions

Arthroscopy

Surgeon

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Knee

Knee

Arthroscopy

Knee

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Anterior cruciate ligament reconstruction with double bundle versus single bundle: Experimental study

Clinics (Sao Paulo)

ACL graft can replicate the normal ligament's tension curve

Knee Surg Sports Traumatol Arthrosc

Rotational instability of the knee: Internal tibial rotation under a simulated pivot shift test

Arch Orthop Trauma Surg

Biomechanical comparison of single-tunnel-double-bundle and single-bundle anterior cruciate ligament reconstructions

Am J Sports Med

Systematic review on cadaveric studies of anatomic anterior cruciate ligament reconstruction

Knee Surg Sports Traumatol Arthrosc

Original Article
Anteromedial Portal Versus Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? A Retrospective Comparative Study