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DOI: 10.21276/aimdr.2017.3.1.OR6
Original Article ISSN (O):2395-2822; ISSN (P):2395-2814
Annals of International Medical and Dental Research, Vol (3), Issue (1) Page 38
Section: Orthopaedics
Anatomical Single-Bundle Anterior Cruciate Ligament
Reconstruction Using Medial Portal Technique.
Owais Ahmed Qureshi1, Najamul Huda2
1Assistant Professor, Department of Orthopaedic Surgery, Rama Medical College, Hospital & Research Centre, Hapur.
2Professor, Department of Orthopaedic Surgery, TMU, Moradabad.
Received: November 2016
Accepted: December 2016
Copyright: © the author(s), publisher. Annals of International medical and Dental Research (AIMDR) is an
Official Publication of “Society for Health Care & Research Development”. It is an open-access article distributed
under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-
commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Variations in the arterial pattern of the upper limb are very common as observed in many cadaveric and angiographic
studies. Knowledge of variations in the origin and course of the radial artery is important because they are used for
many diagnostic procedures as well as vascular and reconstructive surgeries like coronary angiography, percutaneous
coronary intervention and coronary artery bypass surgery. During routine dissection in our institute, we observed a case
of high origin of the radial artery in a 33 year old male cadaver. It was found to be unilateral; on left side, radial artery
was taking origin from 3rd part of the axillary artery at the lower border of pectoralis minor before the origin of
subscapular artery and anterior circumflex humeral artery. It had a superficial course in the arm crossing the median
nerve from medial to lateral side. The further course of this superficial radial artery in the forearm was normal and it
terminated by forming a deep Palmar arch in hand. These variations may be of great clinical implications for vascular
and plastic surgeons and radiologists. Superficial course of radial artery makes it vulnerable to accidental injuries.
INTRODUCTION
Positioning the ACL femoral and tibial bone
tunnels at the center of the native ACL femoral and
tibial attachment is called as anatomical ACL graft
placement and is considered critical to the success
of ACL reconstruction. Non-anatomical ACL graft
placement is the most common cause leading to
recurrent instability following ACL
reconstruction.[1,2] Commonly ACL reconstruction
has been performed using a transtibial technique in
which the ACL femoral tunnel is drilled through a
tibial tunnel positioned in the posterior half of the
native ACL tibial attachment site.
Name & Address of Corresponding Author
PinkiRai
Demonstrator,
Department of Anatomy,
SHKM Govt. Medical College, Nalhar (Nuh), India.
E mail:pinkirai89@gmail.com
Positioning the ACL tibial tunnel in the posterior
half of the ACL tibial attachment site results in
ACL femoral tunnel too high and deep in the
intercondylar notch, outside of the native ACL
femoral attachment site [Figure 1]. An ACL graft
in such tunnels will be vertically oriented in both
the coronal and sagittal planes. A vertically
oriented ACL graft may resist the anterior tibial
translation, but may fail to control the pivot-shift
phenomenon.[3–6] This may lead the patient to
experiencing continued symptoms of instability and
giving-way episodes due to the pivot-shift
phenomenon.
The medial portal technique offers a number of
advantages over the transtibial technique.[7]
1. Does not require any special guides or
instrumentation.
2. The femoral tunnel can be drilled without the loss
of joint distention due to fluid extravasation out of
the tibial tunnel, giving better visualization.
3. Placement of the femoral tunnel within the native
ACL femoral footprint.
4. A longer tibial tunnel can be drilled, which
minimizes graft-tunnel length mismatch and allows
longer bone-tendon-bone grafts to be used.
5. Insertion of the femoral interference fixation screw
through the medial portal, which was used to drill
the ACL femoral tunnel, avoids screw-tunnel
divergence as seen in transtibial technique.
Surgical Technique
Name & Address of Corresponding A
uthor
Dr. Owais Ahmed Qureshi,
Assistant Professor,
Department of Orthopaedic Surgery,
Rama Medical College, Hospital & Research Centre,
Hapur.
ABSTRACT
Background: The traditional transtibial approach can limit anatomical placement of the femoral tunnel in anterior
cruciate ligament (ACL) reconstruction, Placement of an ACL graft within the anatomical femoral and tibial
attachment sites is critical to the successful clinical outcome of ACL reconstruction. Surgical Technique: The
medial portal technique was used for anatomic single bundle (SB) ACL reconstruction. Methods: Between
November 2013 and October 2015, 30 ACL reconstructions were performed using the medial portal technique.
All the patients were followed for a minimum of 06 months post-operatively. Clinical evaluation was done using
the Lysholm score and International Knee Documentation Committee (IKDC) grade. Results: The mean Lysholm
and the IKDC grade showed improvement at last follow up. None of the patients had a positive pivot shift test,
anterior drawer test and Lachman test at final follow-up. Conclusion: The medial portal technique for anatomical
SB ACL reconstruction is a simple technique showing good clinical results.
Keywords: Anterior cruciate ligament, Reconstruction, Anatomical, Single-bundle, Medial Portal Technique.
Qureshi & Huda; Anterior Cruciate Ligament Reconstruction
Annals of International Medical and Dental Research, Vol (3), Issue (1) Page 39
Section: Orthopaedics
A standard anterolateral (AL) portal was placed for
diagnostic arthroscopy. After confirming the
diagnosis of ACL tear by arthroscopic examination
of the knee joint, the ipsilateral hamstring tendons
(both semitendinosus and gracilis tendons) were
harvested using a closed tendon stripper through an
oblique skin incision along the distal insertion of
the tendons on the proximal tibia and prepared as a
4-strand double loop graft. While the graft was
being prepared and sized by an assistant an
anteromedial (AM) portal was established making
sure that the instrument placed through the AM
portal would be able to reach the posterior margin
of lateral wall of the femoral notch without
damaging the medial femoral condyle. Clearing of
the notch was done to improve visualization of the
native tibial and femoral footprints of ACL [Figure
1]. A radiofrequency ablator was used to clear the
notch rather than a mechanical shaver so that bony
landmarks could be preserved and care was taken
to clear the lateral wall of the femoral notch right
till the over the top position. Any associated
meniscal and synovial pathology was addressed.
Figure 1: Femoral notch cleaned and femoral ACL
footprint identified.
Figure 2: Drill site for femoral tunnel approached
through an offset guide placed through AM portal.
Under direct arthroscopic visualization at 90°
flexion, the center of the femoral footprint was
located and marked with a microfracture awl at 10-
o clock position (right knee)/2-o clock position (left
knee), corresponding to center of the femoral ACL
footprint within the knee.[8]
Figure 3: Cannulated drill over guide wire.
Figure 4: Femoral tunnel length measured.
Arthroscopic over the top offset guides, available
with different offsets were routinely used. The
offset guide aims to preserve a 2 mm posterior wall
in the femoral tunnel. In a 10 mm diameter femoral
tunnel (5 mm radius), an offset guide of 7 mm (5+2
= 7 mm) will be adequate to maintain 2 mm of the
posterior wall. With the knee at 90° flexion,
appropriate offset guide was introduced through the
AM portal and after fixing it at the over the top
position it was rotated so that it guides the pin into
the lateral condyle at the level of the center of the
femoral footprint previously marked [Figure 2].
Just the tip of the guide pin was drilled through the
offset guide so that the entry point of the pin was
marked. With the guide pin held in the same
position, the knee was moved to 120° flexion and
the guide pin is further drilled to exit out of the skin
on the anterolateral aspect of the thigh. By using
the intraarticular marking of center of femoral ACL
footprint as guide for introducing the femoral guide
pin, there was no case in which the pin is exited too
posterior or too anterior with respect to the femoral
shaft. A 5 mm cannulated drill bit was used to drill
over the guide pin and exit out of the lateral
femoral cortex [Figure 3]. The length of this
Qureshi & Huda; Anterior Cruciate Ligament Reconstruction
Annals of International Medical and Dental Research, Vol (3), Issue (1) Page 40
Section: Orthopaedics
femoral tunnel was measured using a depth gauge
[Figure 4]. A reamer of the same size as the
femoral end graft diameter was used to create the
blind-ended femoral tunnel according to the length
of the graft to be kept inside the tunnel and at least
8mm of extra length of tunnel required to flip the
endobutton [Figure 5,6). A suture loop (#5
ethibond) was passed through the distal end of the
guide pin and pulled out of the proximal exit point,
so that one end of the suture exited from the
anterolateral aspect of the thigh and the other from
the AM portal [Figure 7]. Both ends of the suture
were held with an artery forceps, out of the surgical
field.
Figure 5,6: Femoral tunnel reamed through AM
portal to desired length.
Figure 7: Suture loop passed through femoral tunnel.
Figure 8: Tibial guide pin passed through tibial ACL
footprint.
Figure 9: Graft pulled into femoral tunnel.
Figure 10: Position of graft after final tightening of
tibial interference screws. Large angle of divergence
seen between PCL and ACL graft.
For drilling the tibial tunnel, the knee was kept at
90° flexion and the tip pointing ACL guide was
positioned just posterior to the anterior horn of the
lateral meniscus on the antero lateral surface of the
medial tibial spine, in the middle of the tibial ACL
footprint. A guide pin was drilled into the proximal
Qureshi & Huda; Anterior Cruciate Ligament Reconstruction
Annals of International Medical and Dental Research, Vol (3), Issue (1) Page 41
Section: Orthopaedics
tibia from a point located half way between the
tibial tubercle and the posteromedial corner of the
tibia and exiting into the joint at the previously
identified site [Figure 8]. Fully extending the knee
and ensuring that there was no impingement of the
guide pin against the roof of the femoral notch
further confirmed the position of the tibial guide
pin. A cannulated reamer with the same diameter as
the tibial end of the graft was used to drill the tibial
tunnel.
Figure 11: 12 week post op X ray shows no widening
of tunnels.
An arthroscopic grasper was inserted through the
tibial tunnel and the suture loop, which was
previously positioned in the femoral tunnel, was
pulled out of the tibial tunnel. The femoral end of
the prepared quadrupled hamstring graft was
looped around the endobutton loop, (Smith and
Nephew, Andover, USA) which was pulled into the
joint through the tibial tunnel and into the femoral
tunnel under arthroscopic visualization [Figure 9].
Traction was maintained on the pulling suture of
the endobutton till it was flipped against the lateral
femoral cortex. Secure fixation of the endobutton
was confirmed by pulling on the graft causing
movement of the whole patient. The graft was
cycled and then the tibial end of the graft was fixed
with an interference screw(RCI, Smith and
Nephew, Andover, USA) while the knee was held
in 10°- 20° flexion and maximal tension was
maintained on the graft [Figure 10].
MATERIALS AND METHODS
Between November 2013 and October 2015, 30
procedures were performed using the medial portal
technique for anatomical SB ACL reconstruction
using autologous quadrupled hamstring graft. The
patients’ average age was 36years (range, 20 to 45
years). All patients were male and fall from a two-
wheeler was the most common cause of injury.
Post operatively a standard rehab protocol was
followed for all patients. All the patients were
followed for a minimum of 06 months
postoperatively. The mean follow-up period was 14
months (range, 06 to 24 months) [Table 1].
Evaluation of clinical results was done using the
Lysholm score and objective International Knee
Documentation Committee (IKDC) grade [Table
2].
Table 1: Patient Demographics
Variable Range
Number of patients 30
Age(years) 36 (20-40)
Gender Males
Coexisting Injury Medial Meniscal Tear-12
Lateral Meniscal Tear- 2
Follow –up ( months) 14 (6-24)
Table 2: Clinical Results
Characteristics Preoperative Postoperative
Modified Lysholm
Score 66.4±10.6 88.2±6.4
IKDC Grade
Normal 0 23
Nearly Normal 0 07
Abnormal 17 0
Severely abnormal 13 0
RESULTS
On clinical assessment all the patients showed good
or excellent clinical outcomes in the Lysholm score
with a median score of 88.2 at final follow-up. The
IKDC grade at final follow-up was normal in 23
patients and nearly normal in 07 patients [Table 2].
None of the patients had a positive pivot shift test,
anterior drawer test and Lachman test at final
follow-up. Radiographs done during follow up did
not show tunnel widening or implant migration in
any case [Figure 11].
DISCUSSION
ACL reconstruction is fast becoming a commonly
performed orthopaedic procedure. In USA alone
over 100,000 ACL reconstructions are performed
per year in the United States.[9] It has been
proposed that abnormal knee kinematics is one of
the primary causes of the development of
osteoarthritis (OA) after ACL reconstruction.[10,11]
It is hoped that anatomical ACL reconstruction,
which restores the normal knee kinematics in
patients with functionally unstable ACL deficient
knees will reduce the long-term incidence of OA.
Clinical and biomechanical studies have
conclusively demonstrated that a vertically placed
graft may restore anterior tibial translation but
shows a less effective resistance to rotatory load
compared to a lower and more horizontally
oriented graft.[12]
Recent biomechanical studies have suggested that a
femoral tunnel placed centrally within the native
ACL and posteriorly on the lateral wall of
intercondylar notch by the trans-AM portal
technique can restore both anterior and rotational
Qureshi & Huda; Anterior Cruciate Ligament Reconstruction
Annals of International Medical and Dental Research, Vol (3), Issue (1) Page 42
Section: Orthopaedics
stability of the knee leading to superior clinical
outcomes than the traditionally oriented femoral
tunnels.[5]
The key to anatomical ACL reconstruction is
accurate identification of anatomy of the ACL
origin.[13-15] Although the lateral intercondylar ridge
and lateral bifurcate ridge have been described,
they can be difficult to visualize.[16] The center of
the ACL has been as being within 2 mm of an
arthroscopic reference point located at the junction
of a line drawn distally from the most proximal
corner of the articular margin on the lateral wall of
the notch and a perpendicular line drawn to the
most posterior point of the condyle.[17] Other
techniques have also been described, which bring
the femoral tunnel lower down on the wall of the
lateral femoral condyle near the anatomic
attachment of the ACL.[18-21]
On the tibial side the anteromedial bundle is
located at 30% and the posterolateral bundle 44%
from anterior to posterior.[22] Use of 3D CT has
been used to validate the femoral and tibial tunnel
positions post operatively.[23-25]
The use of intra-operative fluoroscopy to locate the
tunnel starting points has been described but it is
time consuming and makes the rest of the surgery
more difficult due to cumbersome radiation
protection gowns.[26] It also adds additional cost to
the procedure.
Drilling through the AM portal has made the low
placement of the femoral tunnel on the wall of the
lateral femoral condyle easier.[27] If done carefully
one can avoid contact of the drill with the articular
surface of the medial femoral condyle. The use of
flexible drilling systems has improved the safety of
this procedure.[28] Some surgeons may use two
anteromedial portals: a high portal close to the
patella tendon providing visualization and a second
more medial portal just above the meniscus for
instrumentation. These independent drilling
methods have been shown to produce tunnels with
superior function compared with tunnels produced
by conventional transtibial drilling methods.[29-32]
There is still a lot of controversy regarding creating
of anatomical tunnels using transtibial tunnel
drilling.[33] Recently a comparision of two tibial
entry points to determine whether the anatomical
femoral origin of the ACL could be reached using a
transtibial technique showed that a more proximal
and medial entry point 15.9 mm distal to the joint
line and 9.8 mm medial to the tibial tubercle
allowed the insertion site to be reached. These
authors concluded that femoral tunnels could be
positioned in an anatomic manner however the
starting point offers little margin for error.[34]
Others have established that the use of a transtibial
drilling technique resulted in a non-anatomic
superior and posterior femoral tunnel.[35]
On comparison of transtibial and anteromedial
drilling techniques, the transtibial tunnels were
significantly more anterior and there was
significantly more angulation towards the lateral
condylar cortex as compared to anteromedial portal
drilling. These authors concluded that AM portal
drilling results in tunnels, which allow stabilization
for both anterior tibial translation and rotational
instability.[36]
Another advantage that an anatomic approach to
primary, revision and augmentation anterior
cruciate ligament reconstruction offers is that it
allows an intact bundle to be preserved so that only
reconstruction of the deficient bundle may be
performed.[37]
A recently emerging concept is that of complete
footprint restoration. It is based on the hypothesis
that restoration of the biomechanical function of an
ACL restored knee is a function of the
reconstructed ACL insertion site area. There are
natural variations in insertion site morphology with
length measurement between 8– 21 mm. Small
footprints up to 13 mm can be restored using
anatomical single bundle reconstruction whereas
larger double bundle grafts may be required for
footprints of 16 mm or more.[38]
The major limitation of this study includes the
small number of patients and the lack of any direct
comparison with traditional techniques. Studies
with a larger number of patients need to be
performed to establish the superiority of this
technique over the traditional techniques.
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How to cite this article:Das A, Rai P, Das S, Mehrotra N.
High Origin of Radial Artery- A Cadaveric Case Report.
Ann. Int. Med. Den. Res. 2016; 2(5):??:??.
Source of Support: Nil, Conflict of Interest: None declared
How to cite
this article:
Qureshi OA, Huda N. Anatomical
Single-Bundle Anterior Cruciate Ligament Reconstruction
Using Medial Portal Technique. Ann. Int. Med. Den. Res.
2017; 3(1):OR38-OR43.
Source of Support: Nil, Conflict of Interest: None declared
