Transtibial ACL Femoral Tunnel Preparation Increases Odds of Repeat Ipsilateral Knee Surgery

Shelbyville Orthopaedics and Sports Medicine, 101 Stonecrest, #2, Shelbyville, KY 40065.
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 11/2013; 95(22):2035-2042. DOI: 10.2106/JBJS.M.00187
Source: PubMed


Recent efforts to improve the results of anterior cruciate ligament (ACL) reconstruction have focused on placing the femoral tunnel anatomically. Medial portal femoral tunnel techniques facilitate drilling of femoral tunnels that are more anatomic than those made with transtibial techniques. Few studies have compared the clinical outcomes of these two femoral tunnel techniques. We hypothesized that the transtibial technique is associated with decreased Knee injury and Osteoarthritis Outcome Scores (KOOS) and an increased risk of repeat surgery in the ipsilateral knee when compared with the anteromedial portal technique.
Four hundred and thirty-six patients who had undergone primary isolated autograft ACL reconstruction with a transtibial (229 patients) or anteromedial portal (207 patients) technique in 2002 or 2003 were identified in a prospective multicenter cohort. A multiple linear regression model was used to determine whether surgical technique (transtibial or anteromedial portal) was a significant predictor of KOOS at six years postoperatively, after controlling for preoperative KOOS, patient age, sex, activity level, body mass index (BMI), smoking status, graft type, and the presence of meniscal and chondral pathology at the time of reconstruction. A multiple logistic regression model was used to determine whether surgical technique was a significant predictor of repeat ipsilateral knee surgery, after controlling for patient age and activity level, graft type, and meniscal pathology at the time of reconstruction.
Postoperative KOOS were available for 387 patients (88.8%). Femoral tunnel drilling technique was not a predictor of the KOOS Quality of Life subscore (p = 0.72) or KOOS Function, Sports and Recreational Activities subscore (p = 0.36) at the six-year follow-up evaluation. Data regarding the prevalence of repeat surgery were available for 380 patients. Femoral tunnel technique was a significant predictor of subsequent ipsilateral knee surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.30 to 4.78, p = 0.006).
Patients who underwent ACL reconstruction with a transtibial technique had significantly higher odds of undergoing repeat ipsilateral knee surgery relative to those who underwent reconstruction with an anteromedial portal technique.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    ABSTRACT: The purpose of this study was to compare clinical and radiological outcomes of patients who underwent single-bundle anterior cruciate ligament (ACL) reconstruction with anteromedial portal (AMP) and transtibial (TT) techniques. Arthroscopic single-bundle ACL reconstruction was performed using AMP technique in 34 patients and TT technique in 30 patients. The patients were evaluated retrospectively. Aperture fixation was used for femoral fixation, and absorbable screws and U staples were used for tibial fixation of the graft. Pivot shift test, Lachman test, Lysholm, Tegner, and International Knee Documentation Committee (IKDC-2000) scoring systems were used in the clinical and functional evaluation of patients before and after the surgery. Time to return sports and activity level were assessed. In the radiological evaluation of non-anatomic bone tunnel placement, the criteria developed by lllingworth et al. were used. The mean duration of follow-up was 20.4 and 24.6 months in the AMP and TT groups, respectively. There was a significant difference between the AMP group (86.7 %) and the TT (14.7 %) group in terms of anatomical placement of the femoral tunnels and grafts (p < 0.001). No significant difference was observed between the two groups in terms of the Pivot shift test, Lachman test, Lysholm, Tegner, and IKDC scores, and activity level (p > 0.05). The patients in the AMP group returned to sports 1.5 months earlier on average (p < 0.001). It was shown that AMP technique was superior to the TT technique in providing anatomical placement of the graft and in recovery time to return sports; however, there was no difference between groups in early periods in terms of the clinical and functional outcomes.
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    ABSTRACT: We describe the surgical approach that we have used over the last years for anterior cruciate ligament (ACL) reconstruction, highlighting the importance of arthroscopic viewing through the anteromedial portal (AMP) and femoral tunnel drilling through an accessory anteromedial portal (AMP). The AMP allows direct view of the ACL femoral insertion site on the medial aspect of the lateral femoral condyle, does not require guides for anatomic femoral tunnel reaming, prevents an additional lateral incision in the distal third of the thigh (as would be unavoidable when the outside‐in technique is used) and also can be used for double‐bundle ACL reconstruction.
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    ABSTRACT: Purpose The purpose of this study was to compare the anterior cruciate ligament (ACL) femoral tunnel characteristics between 2 common arthroscopic portals used for ACL reconstruction, a standard anteromedial portal and a far anteromedial portal. Methods Seven cadaveric knees were used. A 1.25-mm Kirschner wire was drilled through the center of the ACL femoral footprint and through the distal femur from the standard anteromedial and far anteromedial portals at knee flexion angles of 100°, 120°, and 140°. No formal tunnels were drilled. Each tunnel exit point was marked with a colored pin. After all tunnels were created, the specimens were digitized with a MicroScribe device (Revware, Raleigh, NC) to measure the tunnel length; distance to the posterior femoral cortical wall (posterior cortical margin); and tunnel orientation in the sagittal, coronal, and axial planes. Results The standard anteromedial portal resulted in a longer tunnel length, a less horizontal tunnel in the coronal plane, and a greater posterior cortical margin compared with the far anteromedial portal at all knee flexion angles. For both portal locations, the tunnel length and posterior cortical margin increased, and the tunnel position became more horizontal in the coronal plane, more anterior in the sagittal plane, and less horizontal in the transverse plane as knee flexion increased. Conclusions Portal position affects femoral tunnel characteristics, with results favoring the more laterally positioned standard anteromedial portal at all flexion angles. Increasing the knee flexion angle leads to a longer femoral tunnel length and posterior femoral cortical margin with either portal position. Clinical Relevance Understanding how portal positioning and knee flexion angle affect femoral tunnel orientation and characteristics may lead to improved surgical outcomes after ACL reconstruction.
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