1
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Danieli MV, Molinari AVP, Suzze JVG, Abreu VD, Guerreiro JPF. Transtibial Femoral Tunnel Technique in ACL Reconstruction and Osteoarthritis Incidence. Rev Bras Ortop 2024; 59:e76-e81. [PMID: 38524708 PMCID: PMC10957279 DOI: 10.1055/s-0044-1779328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/26/2023] [Indexed: 03/26/2024] Open
Abstract
Objective : Evaluate osteoarthritis incidence in patients that undergone ACL reconstruction using the transtibial technique, with a minimum of 5 years of follow up, with isolated ACL injury. Methods : Patients who underwent ACL reconstruction by the same surgeon using the transtibial technique with hamstrings graft and with a minimum of 5 years of follow-up, without other injuries during the surgical procedure, were selected to undergo imaging exams of the operated knee to assess the incidence of osteoarthritis. The obtained data were evaluated by descriptive statistics. Results : Forty-two patients (44 knees) were evaluated, with a mean age of 31 years old (SD: 8), being 23 right knees and 28 male patients. Mean time from surgery to imaging evaluation was 94.1 months (ranging from 60 to 154 months; SD: 28). Of the evaluated knees, 37 did not have osteoarthritis (83.3%) and 7 had (16.7%). Conclusion : ACL reconstruction with femoral tunnel performed through the transtibial technique in patients without other associated injuries in the operated knee, using hamstrings graft, with a minimum of 5 years of follow up, showed an osteoarthritis incidence of 16.7% in a mean follow-up of 94.1 months. Level Of Evidence V; Case Series.
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Affiliation(s)
- Marcus Vinicius Danieli
- Uniort.e – Hospital de Ortopedia, Londrina, PR, Brasil
- Pontifícia Universidade Católica PUC, Paraná, Campus de Londrina, Londrina, PR, Brasil
| | | | | | - Victoria de Abreu
- Pontifícia Universidade Católica PUC, Paraná, Campus de Londrina, Londrina, PR, Brasil
| | - João Paulo Fernandes Guerreiro
- Uniort.e – Hospital de Ortopedia, Londrina, PR, Brasil
- Pontifícia Universidade Católica PUC, Paraná, Campus de Londrina, Londrina, PR, Brasil
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2
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Gabr A, Khan M, Kini SG, Haddad F. Anteromedial Portal versus Transtibial Drilling Techniques for Femoral Tunnel Placement in Arthroscopic Anterior Cruciate Ligament Reconstruction: Radiographic Evaluation and Functional Outcomes at 2 Years Follow-Up. J Knee Surg 2023; 36:1309-1315. [PMID: 36075229 DOI: 10.1055/s-0042-1755358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to compare the functional and radiographic outcomes of arthroscopic single-bundle anterior cruciate ligament reconstruction (ACLR) using either the anteromedial (AM) portal technique or transtibial (TT) technique. We identified 404 patients who underwent arthroscopic ACLR by a single surgeon between January 2006 and December 2016 at our institution. The TT portal was utilized in femoral tunnel drilling in 202 patients (TT group) while the AM portal was used in 202 patients (AM group). The mean postoperative follow-up duration was 26 months (range: 24-33 months). Postoperative radiographic femoral and tibial tunnel positions were assessed by two independent observers. Functional outcomes were evaluated with Tegner, Lysholm, and Knee Injury and Osteoarthritis Outcome score (KOOS) scores. On the anteroposterior plain radiographs, the mean femoral tunnel position relative to the lateral femoral condyle was 46.8% for the AM group versus 48.6% in the TT group, respectively (p=0.003). The mean graft inclination angle was 31.9° and 22° in the AM and TT groups, respectively (p<0.0001). On the lateral radiographs, the mean femoral tunnel placement across Blumensaat's line in relation to the anterior femoral cortex was 84% in the AM group while it was 78% in the TT group (p<0.0001). At 2 years postoperatively, there were no significant differences in the mean Tegner, Lysholm, and KOOS scores between the two patient groups. The graft failure rate at 2 years follow-up was 4.5% (n=9) in the AM group while it was 2.5% (n=5) in the TT group (p=0.2). Femoral tunnel placement was more anatomical with the AM portal technique compared with the TT technique. However, there was no significant difference in postoperative functional outcomes between the two patient groups. The AM portal technique appears to have a higher graft failure rate. This might be attributed to increased graft loading in an anatomical position.
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Affiliation(s)
- Ayman Gabr
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
| | - Mohsin Khan
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
| | - Sunil G Kini
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
| | - Fares Haddad
- Department of Orthopaedics, The University College of London Hospitals NHS Trust, London, United Kingdom
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3
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Vijayan S, Kyalakond H, Kulkarni MS, Aroor MN, Shetty S, Bhat V, Rao SK. Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal. Musculoskelet Surg 2023; 107:37-45. [PMID: 34389922 PMCID: PMC10020253 DOI: 10.1007/s12306-021-00727-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
Arthroscopic ACL reconstruction is the current standard care of treatment for anterior cruciate ligament (ACL) injuries. Modified transtibial (mTT) and anteromedial portal (AMP) techniques aim at the anatomical placement of femoral tunnel. Controversy existed in the literature with regard to the outcome of these techniques. Hence, we designed a retrospective comparative study to analyse the clinical and functional outcomes of mTT and AMP techniques. We hypothesized that there would be no difference between the clinical and functional outcomes in mTT and AMP techniques. This retrospective observational study was conducted in consecutive patients who underwent arthroscopic ACL reconstruction using semitendinosus-gracilis (STG) quadrupled graft in our tertiary care centre with a minimum follow-up of two years. Out of 69 patients, 37 had undergone ACL reconstruction by mTT technique and remaining by AMP technique. All the patients were assessed clinically by anterior drawer, Lachman's, pivot shift and single-legged hop test. Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) subjective knee evaluation score were used for the functional status. Knee instability was assessed objectively by KT-1000 arthrometer. There was no statistically significant difference in baseline demographic characteristics between mTT and AMP groups. At the end of 2 years, no statistically significant difference was noted in the anterior drawer and Lachman's test. Though not significant, IKDC scores and Lysholm's scores showed a better outcome in the AMP group when compared to the mTT group. AMP group showed significantly better outcome with KT-1000 arthrometer. Based on the results obtained, we presume that overall both mTT and AMP have similar functional outcome. However, as AMP technique offers significantly improved subjective rotational stability on pivot shift test, better hop limb symmetry index and KT 1000 readings compared to mTT, we suggest AMP over mTT.
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Affiliation(s)
- S. Vijayan
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - H. Kyalakond
- grid.496653.b0000 0004 1805 6782Department of Orthopedics, BVVS S Nijalingappa Medical College and HSK Hospital and Research Centre, Navanagar, Bagalkot, Karnataka 587103 India
| | - M. S. Kulkarni
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - M. N. Aroor
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - S. Shetty
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - V. Bhat
- grid.411639.80000 0001 0571 5193Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - S. K. Rao
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
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4
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Wang Z, Du Y, Chang Q, Xie Q, Wang L, Xu C. Analysis the Lateral Tunnel Position of the Bone Graft and Regeneration of Femur by CT Tunnel Localization. J BIOMATER TISS ENG 2022. [DOI: 10.1166/jbt.2022.3160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: To analyze, in a retrospective study, the lateral tunnel position of the graft femur by CT after arthroscopic ACL reconstruction via the anteromedial (AM) approach and the tunnel angle shown on X-ray. Methods and Materials: 60 patients undergoing arthroscopic
ACL reconstruction via AM approach with 4 femoral hamstring tendon grafts were investigated from October 2019 to October 2021. Postoperative orthogonal x-rays and computed tomography (CT) scans were obtained, and the position of the femoral tunnel obtained after CT reconstruction was correlated
with the Bernard-Hertel grid. The angle of the resulting femoral tunnel on the orthogonal x-ray was analyzed against the CT tunnel position. Results: In the study, the anterior–posterior orientation was forward (P = 0.001) and the high-low orientation was similar (taken
as 20%, P = 0.066) or slightly higher (taken as 21%, P = 0.025) compared to the AM beam localization in the two-beam reconstruction. Overall, the femoral tunnel angle on non-weight-bearing orthogonal x-ray was negatively correlated with the anterior–posterior (AP) position
of the femoral tunnel centre as shown on CT (P = 0.004, r =−0.368) and positively, but weakly, correlated with the high-low (HL) position (P = 0.049, r = 0.254). Conclusion: Non-weight-bearing orthogonal X-rays only can make approximate predictions
about the distribution of anatomical reconstruction, I.D.E.A.L reconstruction.
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Affiliation(s)
- Zhihui Wang
- Department of Joint Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Yuanliang Du
- Department of Joint Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Qiankun Chang
- Department of Ultrasonography, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Qiang Xie
- Department of Hand and Foot Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Liqing Wang
- Intensive Care Unit, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
| | - Cong Xu
- Department of Joint Surgery, Affiliated Hospital of ChengDe Medical University, Chengde, Hebei 067000, China
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Haroun HK, Abouelsoud MM, Allam MR, Abdelwahab MM. Transtibial versus independent femoral tunnel drilling techniques for anterior cruciate ligament reconstruction: evaluation of femoral aperture positioning. J Orthop Surg Res 2022; 17:166. [PMID: 35303903 PMCID: PMC8931956 DOI: 10.1186/s13018-022-03040-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Femoral tunnel can be drilled through tibial tunnel (TT), or independent of it (TI) by out-in (OI) technique or by anteromedial (AM) technique. No consensus has been reached on which technique achieves more proper femoral aperture position because there have been evolving concepts in the ideal place for femoral aperture placement. This meta-analysis was performed to analyze the current literature comparing femoral aperture placement by TI versus TT techniques in ACL reconstruction. Methods We performed a comprehensive systematic review and meta-analysis of English-language literature in PubMed, Cochrane, and Web of Science databases for articles comparing femoral aperture placement by TI versus TT techniques with aperture position assessed by direct measurement or by postoperative imaging, PXR and/or CT and/or MRI. Results We included 55 articles with study population of 2401 knees of whom 1252 underwent TI and 1149 underwent TT techniques. The relevant baseline characteristics, whenever compared, were comparable between both groups. There was nonsignificant difference between TI and TT techniques in the distance from aperture center to footprint center and both techniques were unable to accurately recreate the anatomic footprint position. TI technique significantly placed aperture at more posterior position than TT technique. TI technique significantly lowered position of placed aperture perpendicular to Blumensaat’s line (BL) than TT technique, and modifications to TT technique had significant effect on this intervention effect. Regarding sagittal plane aperture placement along both AP anatomical axis and BL, there was nonsignificant difference between both techniques. Conclusion Modifications to TT technique could overcome limitations in aperture placement perpendicular to BL. The more anterior placement of femoral aperture by TT technique might be considered, to some extent, a proper position according to recent concept of functional anatomical ACL reconstruction. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03040-5.
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Affiliation(s)
- Haitham K Haroun
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt.
| | - Maged M Abouelsoud
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt
| | | | - Mahmoud M Abdelwahab
- Orthopedic Department, Faculty of Medicine, Ain Shams University, Al-Abbasya District, Cairo, Egypt
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6
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Cinque ME, Kunze KN, Williams BT, Moatshe G, LaPrade RF, Chahla J. Higher Incidence of Radiographic Posttraumatic Osteoarthritis With Transtibial Femoral Tunnel Positioning Compared With Anteromedial Femoral Tunnel Positioning During Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:255-263. [PMID: 33769902 DOI: 10.1177/0363546521993818] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anteromedial (AM) femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) has been reported by some authors to yield superior clinical and functional outcomes compared with the transtibial (TT) approach; however, differences in the subsequent rates of posttraumatic osteoarthritis (PTOA) are not clear. PURPOSE To perform a systematic review and meta-analysis of the literature to evaluate the influence of femoral tunnel positioning during primary ACLR on the development of radiographic PTOA. STUDY DESIGN Systematic review and Meta-analysis. METHODS The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019) were queried for all studies describing the development of PTOA after TT or AM ACLR. Data pertaining to patient demographics, ACLR technique, and radiographic PTOA were extracted. A meta-analysis utilizing the DerSimonian-Laird method for random effects was used to compare the weighted proportion of PTOA after ACLR between the TT and AM approaches. RESULTS There were 16 studies identified for inclusion with a total of 1546 patients. The mean follow-up across all studies was 10.9 years (range, 5.4-17.8 years). The mean follow-up in the AM and TT groups was 10.8 years (range, 5.4-17 years) and 11.4 years (range, 6-17.8 years), respectively. A total of 783 (50.6%) patients underwent TT ACLR. Of these patients, 401 (weighted mean, 49.3%) developed radiographic PTOA. A total of 763 (49.4%) patients underwent AM ACLR. Of these patients, 166 (mean, 21.8%) went on to develop radiographic PTOA. The meta-analysis demonstrated a significantly greater rate of PTOA after ACLR using a TT technique compared with an AM technique overall (49.3% vs 25.4%, respectively; P < .001) and when studies were stratified by 5- to 10-year (53.7% vs 14.2%, respectively; P < .001) and greater than 10-year (45.6% vs 31.2%, respectively; P < .0001) follow-up. CONCLUSION TT ACLR was associated with higher overall rates of radiographic PTOA compared with the AM ACLR approach. The rates of radiographic PTOA after ACLR with a TT approach were also significantly higher than using an AM approach when stratified by length of follow-up (5- to 10-year and >10-year follow-up).
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Affiliation(s)
- Mark E Cinque
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Brady T Williams
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Jorge Chahla
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Bhimani R, Shahriarirad R, Ranjbar K, Erfani A, Ashkani-Esfahani S. Transportal versus all-inside techniques of anterior cruciate ligament reconstruction: a systematic review. J Orthop Surg Res 2021; 16:734. [PMID: 34949188 PMCID: PMC8705139 DOI: 10.1186/s13018-021-02872-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/05/2021] [Indexed: 01/10/2023] Open
Abstract
Background Transportal (TP) and all-inside techniques (AIT) are the most commonly used anterior cruciate ligament (ACL) reconstruction procedures in current clinical practice. However, there is an ongoing debate over which procedure is superior. Therefore, the purpose of this systematic review was to evaluate and compare the clinical outcomes and complications of these two techniques to propose recommendations for future application. Our primary hypothesis was that AIT is a superior ACLR technique compared to TP. Methods A systematic literature review, using PRISMA guidelines, was conducted using PubMed, Medline, Google Scholar, and EMBASE, up to February 2021 to identify studies focusing on AIT and TP techniques of ACL reconstruction. We excluded animal experiments, cadaveric studies, retrospective studies, case reports, technical notes, and studies without quantitative data. Patients’ characteristics, surgical technical features, along with postoperative follow-up and complications were extracted and reported accordingly. Methodological quality of the included studies was assessed using the Modified Coleman Methodology Score (MCMS). Results A total of 44 studies were selected for this review, of which four were comparative studies. A total of 923 patients underwent AIT and 1678 patients underwent the TP technique for ACLR. A single semitendinosus graft was commonly used in the AIT compard to combined semitendinosus and gracilis graft in the TP group. The postoperative increase in International Knee Documentation Committee (IKDC), Lysholm, KT-1000, and Short Form-12 (physical and mental) scores were similar in the AIT group and the TP group. Contrastingly, the VAS pain score was significantly lower in the AIT group compared to the TP group. Furthermore, the pooled complication rates from all studies were similar between the two groups (AIT: 54 patients, 8.26% vs. PT: 55 patients, 6.62%). However, the four studies that prospectively compared AIT and TP techniques showed lesser complications in the AIT group than the TP group. Conclusion Since the future trend in orthopedic surgery is toward less invasive and patients’ satisfaction with good outcomes, AIT is a good alternative method considering preserving bony tissue and gracilis tendon with less post-operative pain, along with more knee flexor strength and equal outcomes compared to conventional ACL reconstruction surgery. Level of Evidence II. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02872-x.
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Affiliation(s)
- Rohan Bhimani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirhossein Erfani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran. .,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Soheil Ashkani-Esfahani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Lee DK, Kim JH, Lee BH, Kim H, Jang MJ, Lee SS, Wang JH. Influence of Graft Bending Angle on Femoral Tunnel Widening After Double-Bundle ACL Reconstruction: Comparison of Transportal and Outside-In Techniques. Orthop J Sports Med 2021; 9:23259671211035780. [PMID: 34708137 PMCID: PMC8543726 DOI: 10.1177/23259671211035780] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Previous studies have suggested that increased mechanical stress due to acute
graft bending angle (GBA) is associated with tunnel widening and graft
failure after anterior cruciate ligament (ACL) reconstruction. Few studies
have compared the GBA between the outside-in (OI) and the transportal (TP)
techniques. Purpose: To evaluate the influence of GBA on clinical outcomes and tunnel widening
after ACL reconstruction with OI versus TP technique. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the study were 56 patients who underwent double-bundle ACL
reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical
outcomes (Lysholm, International Knee Documentation Committee, Tegner score,
and knee laxity) 1 year postoperatively were evaluated. Computed tomography
scans at 5 days and 1 year postoperatively were used for imaging
measurements, and the femoral tunnel was divided into the proximal third,
middle, and aperture sections. The GBA and cross-sectional area (CSA) were
measured using image analysis software and were compared between groups. A
correlation analysis was performed to determine if the GBA affected clinical
outcomes or tunnel widening. Results: No significant difference was observed in clinical outcomes between the
groups. The GBA of both the anteromedial (AM) and posterolateral bundles
were more acute in the OI group compared with the TP group
(P < .05). The CSA at the AM tunnel aperture
increased significantly in the OI group (84.2% ± 64.3%) compared with the TP
group (51.4% ± 36.7%) (P = .04). However, there were no
differences in the other sections. In the Pearson correlation test, GBA was
not correlated with tunnel widening or clinical outcomes. Conclusion: Regardless of technique, the GBA did not have a significant influence on
tunnel widening or clinical outcomes. Considering a wider AM tunnel
aperture, a more proximal and posterior AM tunnel position might be
appropriate with the OI technique.
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Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, South Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Hyeonsoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Min Jae Jang
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Health Science and Technology and Department of Medical Device Management and Research, SAIHST (Samsung Advanced Institute for Health Sciences & Technology), Sungkyunkwan University, Seoul, South Korea
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9
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Lee DK, Kim JH, Lee SS, Lee BH, Kim H, Kim J, Wang JH. 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. Arthroscopy 2021; 37:2554-2563.e1. [PMID: 33745939 DOI: 10.1016/j.arthro.2021.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the femoral tunnel position remains in an anatomical footprint after tunnel widening and shifting. METHODS 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. RESULTS 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. CONCLUSIONS 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 OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Korea
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyeonsoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jinwoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Health Science and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea; Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
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10
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Loucas M, Loucas R, D'Ambrosi R, Hantes ME. Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211024591. [PMID: 34277881 PMCID: PMC8255613 DOI: 10.1177/23259671211024591] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/28/2021] [Indexed: 01/14/2023] Open
Abstract
Background: The drilling technique used to make a femoral tunnel is critically important for determining outcomes after anterior cruciate ligament (ACL) reconstruction. The 2 most common methods are the transtibial (TT) and anteromedial (AM) techniques. Purpose: To determine whether graft orientation and placement affect clinical outcomes by comparing clinical and radiological outcomes after single-bundle ACL reconstruction with the AM versus TT technique. Study Design: Systematic review; Level of evidence, 3. Methods: Articles in PubMed, EMBASE, the Cochrane Library, ISI Web of Science, Scopus, and MEDLINE were searched from inception until April 25, 2020, using the following Boolean operators: transtibial OR trans-tibial AND (anteromedial OR trans-portal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament. Results: Of 1270 studies retrieved, 39 studies involving 11,207 patients were included. Of these studies, 14 were clinical, 13 were radiological, and 12 were mixed. Results suggested that compared with the TT technique, the AM technique led to significantly improved anteroposterior and rotational knee stability, International Knee Documentation Committee (IKDC) scores, and recovery time from surgery. A higher proportion of negative Lachman (P = .0005) and pivot-shift test (P = .0001) results, lower KT-1000 arthrometer maximum manual displacement (P = .00001), higher Lysholm score (P = .001), a higher incidence of IKDC grade A/B (P = .05), and better visual analog scale score for satisfaction (P = .00001) were observed with the AM technique compared with the TT technique. The AM drilling technique demonstrated a significantly shorter tunnel length (P = .00001). Significant differences were seen between the femoral and tibial graft angles in both techniques. Low overall complication and revision rates were observed for ACL reconstruction with the AM drilling technique, similar to the TT drilling technique. Conclusion: In single-bundle ACL reconstruction, the AM drilling technique was superior to the TT drilling technique based on physical examination, scoring systems, and radiographic results. The AM portal technique provided a more reproducible anatomic graft placement compared with the TT technique.
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Affiliation(s)
- Marios Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Rafael Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Michael Elias Hantes
- Department of Orthopedic Surgery, Faculty of Medicine, University of Thessaly, Larissa, Greece
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Li R, Li T, Zhang Q, Fu W, Li J. Comparison of Clinical Outcomes between Anteromedial and Transtibial Techniques of Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. JOURNAL OF SPORTS SCIENCE AND MEDICINE 2021; 20:237-249. [PMID: 34211316 DOI: 10.52082/jssm.2021.237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/04/2021] [Indexed: 02/05/2023]
Abstract
This study compared clinical outcomes obtained after single-bundle anterior cruciate ligament (ACL) reconstruction using the anteromedial (AM) and transtibial (TT) techniques, which comprise the conventional transtibial (cTT) and modified transtibial (mTT) techniques. This study included clinical randomized controlled trials and prospective and retrospective controlled trials with AM and TT techniques from the PubMed and Embase databases and the Cochrane Library. All databases were searched from January 2010 to July 2020. Two independent evaluators verified the quality of the included studies using the Cochrane Collaboration's risk of bias tool and the Newcastle-Ottawa Scale (NOS). Outcome measures analysed included the Lachman test, pivot-shift test, side-to-side difference (SSD), Lysholm score, Tegner activity scale, International Knee Documentation Committee (IKDC) grade and score. Ten randomized controlled trials (RCTs) and 16 prospective and retrospective controlled trials were included with a total of 2202 patients. There were 1180 patients and 1022 patients in the AM and TT groups, respectively. Compared to the cTT group, superior postoperative results were observed in the AM group based on the negative rate of the Lachman test and the pivot-shift test, IKDC grade and score, Lysholm score, Tegner activity scale and SSD (p < 0.05). However, there was no significant difference between the AM and mTT groups (p > 0.05). Compared to the conventional TT technique, the AM technique exhibited superior clinical outcomes. Nevertheless, the modified TT and AM techniques had comparable results. With neither of the techniques (mTT or AM) producing significantly superior outcomes, surgeons can choose either of them depending on their preferences.
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Affiliation(s)
- Ran Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University
| | - Tao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University
| | - Qiuping Zhang
- Rheumatism Immunology Laboratory, West China Hospital, Sichuan University
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University
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Stone AV, Chahla J, Manderle BJ, Beletsky A, Bush-Joseph CA, Verma NN. ACL Reconstruction Graft Angle and Outcomes: Transtibial vs Anteromedial Reconstruction. HSS J 2020; 16:256-263. [PMID: 33380955 PMCID: PMC7749890 DOI: 10.1007/s11420-019-09707-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The importance of creating an anatomic anterior cruciate ligament (ACL) reconstruction has been receiving significant attention. The best technique by which to achieve this anatomic reconstruction continues to be debated. The two most common methods are the transtibial (TT) and anteromedial (AM) techniques. Each has its advantages and disadvantages, and the literature comparing the two remains uncertain. QUESTIONS/PURPOSES In this prospective comparative study, we aimed to compare the ACL graft and tunnel angles achieved using the anatomic transtibial (TT) and anteromedial (AM) techniques; compare the ACL graft and tunnel angles in knees that have undergone ACL reconstruction and knees with intact ACLs; and determine whether differences in the graft or tunnel angle produce differences in clinical outcomes, as measured using both physical exam and patient-reported outcomes, after ACL reconstruction. METHODS Patients who underwent primary ACL reconstruction with bone-tendon-bone grafts using a TT or AM technique were included. Femoral graft angle (FGA), tibial graft angle (TGA), and sagittal orientation of the reconstructed ACL and contralateral native ACL were measured on post-operative magnetic resonance imaging. Post-operatively, patients underwent measurement of knee stability and completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) survey. RESULTS Twenty-nine patients were enrolled (AM group, 14; TT group, 15); at follow-up, KOOS data were available for 26 patients (13 in each group). There were no differences in sagittal ACL graft angle between groups or in comparison with the normal knee. The FGA was more vertical after TT reconstructions; the TGA was comparable between groups. There were no significant differences in 2-year post-operative physical exam measurements or in KOOS scores. CONCLUSION Anatomic ACL angle was restored after reconstruction with both the TT and AM techniques, despite different FGAs. No significant differences in clinical outcome were noted between groups on physical exam or KOOS at 2 years after surgery. These results suggest that TT reconstruction results in a graft position similar to that seen in AM reconstruction and that the location of the intra-articular tunnel aperture matters more than the orientation of the tunnel.
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Affiliation(s)
- Austin V. Stone
- grid.266539.d0000 0004 1936 8438Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY USA
| | - Jorge Chahla
- grid.240684.c0000 0001 0705 3621Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St., Chicago, IL 60616 USA
| | - Brandon J. Manderle
- grid.240684.c0000 0001 0705 3621Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St., Chicago, IL 60616 USA
| | - Alexander Beletsky
- grid.240684.c0000 0001 0705 3621Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St., Chicago, IL 60616 USA
| | - Charles A. Bush-Joseph
- grid.240684.c0000 0001 0705 3621Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St., Chicago, IL 60616 USA
| | - Nikhil N. Verma
- grid.240684.c0000 0001 0705 3621Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St., Chicago, IL 60616 USA
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13
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Eliya Y, Nawar K, Rothrauff BB, Lesniak BP, Musahl V, de SA D. Anatomical anterior cruciate ligament reconstruction (ACLR) results in fewer rates of atraumatic graft rupture, and higher rates of rotatory knee stability: a meta-analysis. J ISAKOS 2020. [DOI: 10.1136/jisakos-2020-000476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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14
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Porter A, Yang S, Chauhan A, Early S, Challa S, D'Angelo J, Keefe D, Hoenecke H, Fronek J. Professional Advancement and Performance of Amateur Baseball Players Selected in the Major League Baseball Draft With Previous Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2020; 48:581-587. [PMID: 31990575 DOI: 10.1177/0363546519898194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect that an anterior cruciate ligament injury requiring reconstructive surgery has on the professional advancement and performance of amateur baseball players selected in the Major League Baseball draft is not known. Return to sports after anterior cruciate ligament reconstruction (ACLR) in professional athletes has been shown to be high, but mixed results with regard to performance and return to preinjury level have been demonstrated in other sports. PURPOSE To (1) investigate the highest level of professional advancement among Major League Baseball draftees with a history of ACLR before entering the draft, (2) examine how much time these players spent on the disabled list (DL) and determine if it was related to the knee, and (3) compare the batting and pitching performance of these players against healthy matched controls. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Predraft medical records of all players selected in the Major League Baseball draft from 2004 to 2008 were reviewed. Players with a documented anterior cruciate ligament injury treated with ACLR before the draft were included. For each study player, 3 controls were identified. Data were accumulated from the time when players were drafted through the 2015 season. Outcome variables included highest professional level of advancement, DL time, and batting and pitching performance. RESULTS Forty draftees with a history of ACLR (22 pitchers, 18 position players) were identified and matched to 120 controls (66 pitchers, 54 position players). The difference in the highest level of professional advancement between the groups was not statistically significant (P = .488). The mean total number of times and the mean total number of days on the DL were similar between the groups (1.83 vs 1.47, P = .297; 121.54 vs 109.62, P = .955); however, the mean number of times on the DL because of a knee injury was significantly different (0.28 vs 0.11, P = .004), as was the mean number of days on the DL because of a knee injury (17.36 vs 7.72, P = .009). Among pitchers, there were no differences in performance. Similarly, there were no differences among position players in batting performance. CONCLUSION There was no difference between draftees with a history of ACLR and their controls in terms of advancement from the minor to the major leagues. Additionally, pitching and batting performance were similar. Although the 2 groups spent similar time on the DL, the ACLR group spent more time on the DL because of a knee injury than the control group.
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Affiliation(s)
- Anthony Porter
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Shawn Yang
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Aakash Chauhan
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Samuel Early
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Sravya Challa
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
| | | | - Daniel Keefe
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Heinz Hoenecke
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Jan Fronek
- Division of Sports Medicine, Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California, USA
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15
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Ishibashi Y, Adachi N, Koga H, Kondo E, Kuroda R, Mae T, Uchio Y. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication. J Orthop Sci 2020; 25:6-45. [PMID: 31843222 DOI: 10.1016/j.jos.2019.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND 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). METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Shimane University School of Medicine, Japan
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16
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Rocha de Faria JL, Pavão DM, Werneck FC, de Castro Moreirão M, Labronici PJ, de Paula Mozella A, Branco de Sousa E. Positioning Technique of the Fixed Knee in Hyperflexion for the Transportal Femoral Tunnel During Reconstruction of the Anterior Cruciate Ligament. Arthrosc Tech 2019; 9:e131-e135. [PMID: 32021786 PMCID: PMC6993486 DOI: 10.1016/j.eats.2019.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/12/2019] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- José Leonardo Rocha de Faria
- Knee Surgery Center of the National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil,Address correspondence to José Leonardo Rocha de Faria, M.D., Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad – Av. Brasil, Rio de Janeiro – RJ – Brazil.
| | - Douglas Melo Pavão
- Knee Surgery Center of the National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
| | | | - Marcos de Castro Moreirão
- Knee Surgery Center of the National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
| | | | - Alan de Paula Mozella
- Knee Surgery Center of the National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
| | - Eduardo Branco de Sousa
- Knee Surgery Center of the National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
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Erickson BJ, Chalmers PN, D'Angelo J, Ma K, Dahm DL, Romeo AA, Ahmad CS. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in Professional Baseball Players. Orthop J Sports Med 2019; 7:2325967119878431. [PMID: 31696134 PMCID: PMC6822199 DOI: 10.1177/2325967119878431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for ACL tears to allow baseball players to return to sport (RTS). The optimal graft type and femoral tunnel drilling technique are currently unknown. Hypothesis: There is a high rate of RTS in professional baseball players after ACLR, with no significant difference in RTS rates or performance between cases and controls or between graft types or femoral drilling techniques. Study Design: Cohort study; Level of evidence, 3. Methods: All professional baseball players who underwent ACLR between 2010 and 2015 were included. Demographic and performance data (pre- and postoperative) for each player were recorded. Performance metrics were then compared between cases and matched controls. Results: A total of 124 players (mean age, 23.7 ± 4.1 years; 83% minor league players) underwent ACLR. Of these, 80% returned to sport (73% to the same or higher level) at a mean 310 ± 109 days overall and 333 ± 126 days at the same or higher level. The most common graft type was an ipsilateral bone–patellar tendon–bone (BTB) autograft (n = 87; 70%). A total of 91 players underwent concomitant meniscal debridement or repair. No significant difference in any of the primary performance metrics existed from before to after ACLR. Compared with matched controls, no significant difference existed in RTS rates or any performance metrics after ACLR. No significant difference existed in RTS rates or primary performance outcome measures between graft types or femoral drilling techniques. Conclusion: The RTS rate for professional baseball players after ACLR was 80%. No significant difference in performance metrics existed between BTB and hamstring autografts or between femoral drilling techniques. Furthermore, no significant difference in performance or RTS rates existed between cases and matched controls. Femoral drilling technique and graft type did not affect performance and RTS rates in professional baseball players after ACLR.
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Affiliation(s)
| | - Peter N Chalmers
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - John D'Angelo
- Major League Baseball Commissioner's Office, New York, New York, USA
| | - Kevin Ma
- Major League Baseball Commissioner's Office, New York, New York, USA
| | - Diane L Dahm
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
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18
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Huang W, Ong TY, Fu SC, Yung SH. Prevalence of patellofemoral joint osteoarthritis after anterior cruciate ligament injury and associated risk factors: A systematic review. J Orthop Translat 2019; 22:14-25. [PMID: 32440495 PMCID: PMC7231960 DOI: 10.1016/j.jot.2019.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/23/2019] [Accepted: 07/09/2019] [Indexed: 01/17/2023] Open
Abstract
Background 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. Methods 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. Results 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. Conclusions 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. The translational potential of this article 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.
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Key Words
- ACL, Anterior Cruciate Ligament
- ACLR, Anterior Cruciate Ligament Reconstruction
- Anterior cruciate ligament injury
- BPTB, Bone-Patellar Tendon-Bone
- CI, Confidence Interval
- CMS, Coleman methodology score
- HS, Hamstring
- IKDC, International Knee Documentation Committee
- JSN, Joint Space Narrowing
- KL, Kellgren and Lawrence
- MOAKS, MRI Osteoarthritis Knee Score
- OA, Osteoarthritis
- OARSI, Osteoarthritis Research Society International
- ORs, odd ratios
- PFJ, Patellofemoral Joint
- Patellofemoral joint osteoarthritis
- Prevalence
- Risk factors
- TFJ, Tibiofemoral Joint
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Affiliation(s)
- Wenhan Huang
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Tim-Yun Ong
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Sai-Chuen Fu
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Shu-Hang Yung
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
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Wein F, Osemont B, Goetzmann T, Jacquot A, Valluy J, Saffarini M, Molé D. Anteversion and length of the femoral tunnel in ACL reconstruction: in-vivo comparison between rigid and flexible instrumentation. J Exp Orthop 2019; 6:26. [PMID: 31230152 PMCID: PMC6589149 DOI: 10.1186/s40634-019-0198-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/14/2019] [Indexed: 01/12/2023] Open
Abstract
Background Due to it being tangential to the distal femoral axis, the anteromedial portal presents significant risk of causing iatrogenic damage, and of producing tunnels that are too short for optimal osseointegration. Flexible reamers were developed to eliminate the need for knee hyperflexion and offer better-controlled orientation of the femoral tunnel. We aimed to compare the anteversion and length of femoral tunnels drilled using flexible reamers to those drilled using rigid reamers. Methods Between May 2012 and December 2013, all patients receiving ACL reconstruction performed by one surgeon were operated on using either a rigid or a flexible reamer from the same supplier (Versi-Tomic® system, Stryker, Kalamazoo, Michigan). The height of each patient was recorded, and the length and anteversion of the femoral tunnels were measured intra-operatively and on true lateral radiographs, respectively. Results Thirty-seven patients underwent operations using the rigid instrumentation, and 43 using the flexible instrumentation. There was no statistically significant difference between the two groups in either sex or height (p = n.s.). The patients operated on using the rigid instrumentation had tunnels anteverted by 18.6° ± 6° and 33.6 ± 2.9 mm long. Those operated on using the flexible instrumentation had tunnels anteverted by 40° ± 2° and 41.1 ± 3.57 mm long. Both anteversion and tunnel length were significantly greater for tunnels drilled using the flexible instrumentation (p < 0.001). Conclusions This study demonstrated that flexible reamers produce significantly more anteverted and longer femoral tunnels during ACL reconstruction than rigid reamers. Clinical studies remain necessary to assess the outcomes of ACL reconstruction using flexible reamers.
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Affiliation(s)
- Frank Wein
- Centre Artics, Clinique Louis Pasteur, Nancy, France
| | | | | | | | - Jeremy Valluy
- ReSurg S.A, Rue Saint-Jean 22, 1260, Nyon, Switzerland
| | - Mo Saffarini
- ReSurg S.A, Rue Saint-Jean 22, 1260, Nyon, Switzerland.
| | - Daniel Molé
- Centre Artics, Clinique Louis Pasteur, Nancy, France
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20
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Mehta A, Lin CC, Campbell RA, Chin G, McGarry MH, Lee TQ, Adamson GJ. Effects of Anteromedial Portal versus Transtibial ACL Tunnel Preparation on Contact Characteristics of the Graft and the Tibial Tunnel Aperture. Clin Orthop Surg 2019; 11:52-59. [PMID: 30838108 PMCID: PMC6389531 DOI: 10.4055/cios.2019.11.1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/27/2018] [Indexed: 12/24/2022] Open
Abstract
Background The purpose of this study was to compare the tibial tunnel aperture contact characteristics simulating an anteromedial and transtibial anterior cruciate ligament (ACL) tunnel preparation. Methods Seven matched pairs of cadaveric knees were tested. From each knee, a 10-mm quadriceps ACL graft was prepared. The native ACL was arthroscopically removed and tibial tunnels were drilled. In one knee, a transtibial technique was performed with femoral tunnel drilling approached through the tibial tunnel. For the anteromedial technique on the contralateral knee, the posterior tibial tunnel was chamfered with a rasp. The knees were then disarticulated and tibial tunnel aperture geometry was measured. A pressure sensor was placed between the graft and the posterior aspect of the tibial tunnel and the graft was secured with an interference screw. Contact force, contact area, contact pressure, peak contact pressure, hysteresis and stiffness were measured at cyclic loads of 50 N, 100 N, 150 N, and 200 N. Results Tibial tunnel aperture area, diameter and deviation from a circle were significantly larger with the transtibial technique (p < 0.05). There was no significant difference in hysteresis, stiffness, contact area, contact force and mean contact pressure. The peak contact pressure between the ACL graft and the tibial tunnel was significantly higher with the anteromedial technique for 100 N (p = 0.04), 150 N (p = 0.01), and 200 N (p = 0.002) cyclic loading. Conclusions Increased peak contact pressure on the graft at the tibial aperture with the anteromedial technique may increase the stress on the graft and possibly lead to failure following ACL reconstruction.
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Affiliation(s)
- Akshay Mehta
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Charles C Lin
- Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Ronald A Campbell
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Garwin Chin
- Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA.,Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA.,Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA.,Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center, Long Beach, CA, USA.,Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Gregory J Adamson
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
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21
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Ra HJ, Celik H, Kim HJ, Lee DH. Femoral tunnel widening is similar between anteromedial portal and transtibial techniques following single-bundle anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2019; 27:626-635. [PMID: 30306239 DOI: 10.1007/s00167-018-5204-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE In anterior cruciate ligament (ACL) reconstruction, there is concern regarding the potential risk of femoral tunnel widening in the anteromedial portal (AMP) technique due to the acute graft-bending angle at the aperture and the more elliptical aperture shape of the femoral tunnel compared to the transtibial (TT) techniques. Therefore, the aim of the current systematic review and meta-analysis was to compare the femoral tunnel widening between the AMP and TT techniques in patients who underwent ACL reconstruction. METHODS It should be included the studies that reported on femoral tunnel widening in patients who underwent single-bundle ACL reconstruction, using soft-tissue tendon graft, with AMP and/or TT techniques. Two reviewers independently recorded data from each study, including the sample size and magnitude of tunnel widening after ACL reconstruction. RESULTS Twenty-one studies were finally included in this meta-analysis. The pooled changes of absolute millimeters of tunnel widening from the immediate postoperative status to the last follow-up did not differ significantly between the AMP and TT techniques at both the aperture [3.31 mm, 95% confidence interval (CI) 1.7-5.0. mm versus 2.9 mm, 95% CI 2.4-3.4 mm, P = n.s.] and the midportion (3.5 mm, 95% CI 0.8-6.3 mm versus 3.0 mm, 95% CI 2.2-3.9 mm, P = n.s.) of the femoral tunnel. No significant difference was observed between the two techniques in the relative percentage of femoral tunnel widening (AMP; 28.8%, 95% CI 14.8-42.9% vs. TT; 29.7%, 95% CI 15.6-43.7%, P = n.s.). CONCLUSION No significant difference in femoral tunnel widening was observed between the AMP and TT techniques, both in absolute millimeter and relative percentage, in patients who underwent single-bundle ACL reconstruction. This finding could alleviate the potential concerns associated with femoral tunnels being wider for the AMP than for the TT technique. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ho Jong Ra
- Department of Orthopaedic Surgery, College of Medicine, Gangneung Asan Hospital, Ulsan University, Gangneung, Republic of Korea
| | - Haluk Celik
- Department of Orthopaedic Surgery, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Hyun-Jun Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu, 06351, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu, 06351, Seoul, South Korea.
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22
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Jiang XD, Zheng HL, Yang YP. 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. Chin J Traumatol 2019; 22:24-28. [PMID: 30744941 PMCID: PMC6529363 DOI: 10.1016/j.cjtee.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/25/2018] [Accepted: 01/03/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate the clinical outcome in patients who received anterior cruciate ligament (ACL) reconstruction via anteromedial portal with or without posterior wall blowout. METHODS 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. RESULTS 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. CONCLUSION Blowout of posterior wall in ACL reconstruction via anteromedial portal does not affect the clinical outcome as long as reliable fixation is taken intraoperatively.
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Affiliation(s)
- Xu-Dong Jiang
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, China
| | - Han-Long Zheng
- Orthopaedic Department, Beijing Jishuitan Hospital, Beijing, China
| | - Yu-Ping Yang
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, China,Corresponding author.
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23
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Eysturoy NH, Nielsen TG, Lind MC. Anteromedial Portal Drilling Yielded Better Survivorship of Anterior Cruciate Ligament Reconstructions When Comparing Recent Versus Early Surgeries With This Technique. Arthroscopy 2019; 35:182-189. [PMID: 30611349 DOI: 10.1016/j.arthro.2018.08.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare anteromedial (AM) and transtibial (TT) femoral drilling hole techniques in primary anterior cruciate ligament reconstruction, using the Danish Knee Ligament Reconstruction Register, comparing revision rates and clinical outcomes from 2 time periods, 2007 to 2010 and 2012 to 2015. METHODS A total of 8,386 primary anterior cruciate ligament reconstructions were registered between January 2007 to December 2010 and 8,818 in the period January 2012 to December 2015. Revision ACL was the primary endpoint. Secondary endpoints were the objective and subjective clinical outcomes. Crude and adjusted relative risks (RRs) with 95% confidence interval (CIs) were calculated. RESULTS The adjusted RR for revision surgery in the AM (2007-10) group compared with the TT (2007-10) group was 1.45 (95% CI, 1.17-1.78; P < .05), but when comparing the AM (2012-15) group with TT (2012-15) group, the RR was 0.99 (95% CI, 0.68-1.45; P = .96). One-year postoperative objective stability testing showed an RR = 1.38 (95% CI, 1.19-1.60; P < .01) for rotational stability and an RR = 1.37 (95% CI, 0.99-1.89; P < .01) for sagittal stability when comparing AM (2007-10) to TT (2007-10). No significant difference in objective stability was found in the more recent period. Lastly, comparing the subjective scores, the AM (2012-15) had a significantly higher Tegner score 1 year postoperatively compared with the TT-group (2012-15). CONCLUSIONS This study found an increased RR of revision anterior cruciate ligament and rotational and sagittal instability 1 year postoperatively for the AM technique in the period from 2007 to 2010. However, there was no significant difference in revision surgery and objective measures between the techniques from 2012 to 2015. Nevertheless, a higher activity level was found in the AM group. The results could indicate that the results found in the period 2007 to 2010 may have been caused by a learning curve when introducing a new and more complex procedure (AM). LEVEL OF EVIDENCE Level III, retrospective comparative trial.
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Affiliation(s)
| | - Torsten G Nielsen
- Division of Sports Trauma, Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark
| | - Martin C Lind
- Division of Sports Trauma, Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark.
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24
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Geng Y, Gai P. Comparison of 2 femoral tunnel drilling techniques in anterior cruciate ligament reconstruction. A prospective randomized comparative study. BMC Musculoskelet Disord 2018; 19:454. [PMID: 30579352 PMCID: PMC6303949 DOI: 10.1186/s12891-018-2376-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 12/10/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To evaluate the length and position of femoral tunnel,and exam whether knee stability and clinical functional outcomes are superior in AMP method. METHODS From August 2014 to February 2015, we prospectively recruited 104 patients undergoing anterior cruciate ligament reconstruction. They were randomized to anteromedial portal or transtibial method. All patients underwent Lysholm score, International Knee Documentation Committee score,Tegner score at pre-operative and last follow-up point as subjective assessment of clinical function. The Lachman test, the Pivot-shift test and KT-1000 were performed at the last follow-up as a evaluation of knee joint stability. We measured the length of femoral tunnel intraoperatively and at 1 week post-operatively, CT-based three-dimensional reconstruction was used to assess femoral tunnel location. RESULTS The average follow-up time of anteromedial portal group was 25.7 ± 6.8 months (range:12-36.5 months), and the average follow-up time of the transtibial group was 24.9 ± 6.0 months (range:12-37 months). There was no significant difference between the groups pre-operative Lysholm score, IKDC score and Tegner scores. Both groups showed significantly improvement in these clinical function scores at follow up for their ACL reconstruction. However, there was no significant difference in the function scores between the two groups at last follow up. However, the mean femoral tunnel length in the anteromedial portal group was significantly shorter than that in the transtibial group. And tunnel location was significantly lower and deeper with the anteromedial portal technique than with the transtibial technique. CONCLUSION The use of anteromedial portal method resulted in a significantly lower and deeper placement of the femoral tunnel, and a shorter tunnel length compared to the transtibial method. However, there was no statistical difference in terms of clinical function and knee joint stability between the anteromedial portal method and the transtibial method. TRIAL REGISTRATION Name of the registry: Chinese Clinical Trial Registry. The registration number: ChiCTR1800014874 . The date of registration: 12 February, 2018. The study is retrospectively registered.
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Affiliation(s)
- Yunhang Geng
- Qingdao University Medical College, Qingdao, China.,Department of Orthopaedic Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, People's Republic of China
| | - Pengzhou Gai
- Department of Orthopaedic Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, People's Republic of China.
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25
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Liu C, Wang Y, Li Z, Li J, Zhang H, Fu Y, Zhang K. Tibiofemoral joint contact area and stress after single-bundle anterior cruciate ligament reconstruction with transtibial versus anteromedial portal drilling techniques. J Orthop Surg Res 2018; 13:247. [PMID: 30286774 PMCID: PMC6172839 DOI: 10.1186/s13018-018-0956-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023] Open
Abstract
Background During single-bundle ACLR, femoral tunnel location plays an important role in restoring the intact knee mechanisms, whereas malplacement of the tunnel was cited as the most common cause of knee instability. The objective of this study is to evaluate, objectively, the tibiofemoral contact area and stress after single-bundle (SB) anterior cruciate ligament reconstruction (ACLR) with femoral tunnel positions drilled by transtibial (TT) or anteromedial (AM) portal techniques. Methods Seven fresh human cadaveric knees underwent ACLR by the use of TT or AM portal techniques in a randomized order. These specimens were reused for ACL-R (TT and AM). The tibiofemoral contact area and stresses were gauged by an electronic stress-sensitive film inserted into the joint space. The knee was under the femoral axial compressive load of 1000 N using a biomechanics testing machine at 0°, 10°, 20°, and 30° of flexion. Three conditions were compared: (1) intact ACL, (2) ACLR by the use of the TT method, and (3) ACLR by the use of the AM portal method. Results Compared with AM portal ACL-reconstructed knees, a significantly decreased tibiofemoral contact area on the medial compartment was detected in the TT ACL-reconstructed knees at 20°of knee flexion (P = .047). Compared with the intact group, the TT ACLR group showed a higher mean stress at 20° and 30° of flexion on the medial compartments (P = .001, P = .003, respectively), while the AM portal ACLR group showed no significant differences at 30° of flexion (P = .073). The TT ACLR group also showed a higher mean maximum stress at 20° of flexion on the medial compartments (P = .047), while the AM portal ACLR group showed no significant differences at this angle(P = .319). Discussion The alternation of the tibiofemoral joint contact area and stress in reconstructed knees may be caused by the mismatch of the tibiofemoral joint during knee movement procedures compared with intact knees. Conclusions SB ACLR by the use of the AM portal method and TT method both alter the tibiofemoral contact area and stress when compared with the intact knee. When compared with the TT technique, ACLR by the AM portal technique more closely restores the intact tibiofemoral contact area and stress at low flexion angles.
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Affiliation(s)
- Chunhui Liu
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yingpeng Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, 100069, China
| | - Zhongli Li
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Ji Li
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Hao Zhang
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yangmu Fu
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Kuan Zhang
- School of Biomedical Engineering, Capital Medical University, Beijing, 100069, China
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The transportal technique shows better clinical results than the transtibial techniques for single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:2371-2380. [PMID: 29189882 DOI: 10.1007/s00167-017-4786-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/30/2017] [Indexed: 01/29/2023]
Abstract
PURPOSE Although anatomical and independent drilling techniques, such as transportal (TP) technique, have become more popular in anterior cruciate ligament (ACL) reconstruction, the TP technique has not been shown to yield superior clinical or functional outcomes compared to the transtibial (TT) technique. The aim of the current meta-analysis was to compare clinical outcomes of the TP and TT techniques, as determined by patient-reported outcome scores and knee joint laxity tests. It was hypothesized that the TP and TT techniques of ACL reconstruction would yield similar patient-reported functional outcomes and similar results on knee joint laxity tests. METHODS Studies were included if they reported at least one of the following clinical outcomes: IKDC score, IKDC examination, Lysholm knee score, and Tegner activity score. Knee stability was evaluated by single or multiple parameters of the following knee laxity examinations: the Lachman test, the pivot shift test, and side-to-side difference on the instrumented knee laxity test. RESULTS Sixteen studies were finally included in this meta-analysis. The proportions of patients with normal grade on the IKDC examination [odds ratio (OR) 2.23; 95% confidence interval (CI) 1.41-3.53; P = 0.0006] and Lysholm score (mean difference 1.27; 95% CI 0.23-2.31; P = 0.02) after surgery were higher with the TP than with the TT technique, but there were no differences in IKDC and Tegner scores. The postoperative proportion of normal knee joint stability was significantly higher with the TP than the TT technique, on both Lachman (OR 2.29; 95% CI 1.35-3.92; P = 0.002) and pivot shift (OR 2.13; 95% CI 1.12-4.05; P = 0.02) tests. The pooled mean side-to-side difference was 0.73 mm lower with the TP than the TT technique (95% CI - 1.14 to - 0.32 mm; P = 0.0005). CONCLUSION This meta-analysis showed that the clinical outcomes of ACL reconstruction were better with the TP than the TT technique, both on knee functional outcome scales and knee laxity tests. The findings thus suggest that the TP technique would be a better option for single-bundle ACL reconstruction compared to the TT technique. LEVEL OF EVIDENCE III.
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27
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Zhang Q, Kou Y, Yuan Z. A meta-analysis on anterior cruciate ligament reconstruction: Is modified transtibial technique inferior to independent drilling techniques? Exp Ther Med 2018; 16:1790-1799. [PMID: 30186403 PMCID: PMC6122342 DOI: 10.3892/etm.2018.6395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/26/2018] [Indexed: 02/07/2023] Open
Abstract
This report respectively compared the standard transtibial (sTT) technique to the independent drilling (ID) techniques applied to anterior cruciate ligament (ACL) reconstruction. It also made a comparison between the clinical results of the modified transtibial (mTT) technique and of the ID techniques. Prospective studies on transtibial (TT) and ID techniques for ACL reconstruction were retrieved from several databases and a subgroup analysis was performed to compare the sTT technique with the ID techniques and the mTT with the ID techniques. Furthermore, comparison of the Lachman test, pivot-shift test, International Knee Documentation Committee (IKDC) subjective and objective evaluations, Lysholm score and Tegner activity scale were conducted. This report included 12 clinical studies that involved 681 patients having received ACL reconstruction. The study results indicated that in comparison between the sTT and ID techniques, the ID techniques outperformed the sTT technique in the IKDC subjective score (P=0.01) and laxity (P=0.0004). However, there was no significant difference in the IKDC objective score (P=0.34), pivot-shift test (P=0.24), Lachman test (P=0.21), Lysholm score (P=0.14) and Tegner activity scale (P=0.66). The comparison between the new mTT technique and the ID techniques suggested no significant difference in the IKDC objective and subjective scores (P=0.86), laxity (P=0.38), pivot-shift test (P=0.66), Lachman test (P=0.10), Lysholm score (P=0.10) and Tegner activity scale (P=0.55). Compared to the sTT technique, the mTT and ID techniques are more suitable for ACL reconstruction because they can present better subjective feelings. Moreover, considering that the TT technique is familiar to surgeons and the mTT technique can bring favorable subjective feelings and objective clinical outcomes, the mTT technique shows greater utilization potential.
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Affiliation(s)
- Qunhu Zhang
- Department of Orthopedics, Shuyang Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Suqian Jiangsu 223600, P.R. China
| | - Yu Kou
- Medical College of Soochow University, Suzhou Jiangsu 215123, P.R. China
| | - Zhen Yuan
- Center of Sports Medicine and Rehabilitation, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu 215001, P.R. China
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Bombaci H, Aykanat F. Drilling through anteromedial portal with a femoral aiming device ensures a sufficient length and a proper graft position, and prevents posterior wall breakage during anterior cruciate ligament reconstruction. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1403-1409. [PMID: 29705911 DOI: 10.1007/s00590-018-2211-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/14/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the characteristics of the femoral tunnel (FT) which was drilled through the AM portal by using a femoral aimer device and AP stability of the knee. METHODS Thirty-eight patients, with the mean age 29.6 (range: 20-43) years, were evaluated after ACL reconstruction. The mean follow-up time was 31.9 (range: 16-57) months. The FT was drilled using a femoral aimer with different offset according to the graft size measured, through the AM portal. The semitendinous and gracilis tendon autograft was used for reconstruction. The angles of FT and the exit point on the lateral condyle were measured on AP views of the knee. AP stability of the knee was measured with the KT-2000. RESULTS The mean angle of FT was 46.5° (± 8.4°), on the AP view. The mean distance between the exit point of FT and the most distal end of the femoral condyles was 46.7 (± 4.9) mm. The mean FT length was 36.1 (± 3.1) mm. The mean difference of anterior translation compared to the intact knee was 1.9 (± 1.6) mm. Except the three patients, with "one positive" pivot shift test, in the remaining 35 knees stability was equal to the healthy knee. CONCLUSIONS Femoral drilling by using a femoral aimer device through AM portal provided long enough FT for safe graft fixation and appropriate coronal plan obliquity. The exit point was far proximal from the insertion site of the popliteus tendon and lateral collateral ligament. Furthermore, the AM portal technique significantly improved AP stability of the knee.
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Affiliation(s)
- Hasan Bombaci
- Orthopaedics and Traumatology Department, Haydarpasa Numune Education and Research Hospital, Tibbiye Cad., 34671, Üsküdar, Istanbul, Turkey.
| | - Faruk Aykanat
- Sani Konukoglu Hospital, Sanko University, Gaziantep, Turkey
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Chen H, Tie K, Qi Y, Li B, Chen B, Chen L. Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials. J Orthop Surg Res 2017; 12:167. [PMID: 29115973 PMCID: PMC5678560 DOI: 10.1186/s13018-017-0671-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 10/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study was to compare the clinical outcome and postoperative complication between single-bundle anterior cruciate ligament (ACL) reconstruction with an anteromedial (AM) technique and a transtibial (TT) technique. Methods The study includes clinical randomized controlled trials comparing the clinical outcomes of ACL reconstruction using the autologous hamstring tendon with an AM method and a TT method published up to September 2017 were retrieved from PubMed, Cochrane Library, and Embase databases. Relevant data were extracted and the Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality. Stata/SE 12.0 was used to perform a meta-analysis of the clinical outcome. Results Five RCTs were included, with a total of 479 patients: 239 patients and 240 patients in the AM group and the TT group, respectively. Assessing postoperative stability, better results were found in the AM group for the negative rate of the Lachman test (P < 0.05), the negative rate of the pivot-shift test (P < 0.05) and the side-to-side difference (P < 0.05). Assessing postoperative functional outcome, the AM group yielded superior results in proportion with International Knee Documentation Committee (IKDC) grade A (P < 0.05) and the Lysholm scores (P < 0.05) but had a comparable IKDC score (P > 0.05). In terms of postoperative complication, no significant difference was found between the AM group and the TT group (P > 0.05). Conclusions The outcome of single-bundle ACL reconstruction with the AM technique is better than that with the TT technique in terms of postoperative stability and functional recovery of the knee.
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Affiliation(s)
- Haitao Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Kai Tie
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yongjian Qi
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Bin Li
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Biao Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Liaobin Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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Clinical outcomes of transtibial versus anteromedial drilling techniques to prepare the femoral tunnel during anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:2751-2759. [PMID: 26077285 DOI: 10.1007/s00167-015-3672-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 06/04/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE The clinical outcomes of transtibial (TT) and anteromedial (AM) drilling techniques for anterior cruciate ligament reconstruction in preparing the femoral tunnel were directly compared by using a systematic literature review. METHODS PubMed, EMBASE, the Cochrane Library, and the ISI Web of Science were searched until 10 May 2014, using the following Boolean operators: transtibial AND (anteromedial OR transportal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament. All prospective and retrospective controlled trials directly comparing physical examination and scoring system results between TT and AM techniques were retrieved. No language or publication year limitations were used in our analysis. RESULTS Of 504 studies retrieved, nine studies involving 769 patients were included. Results suggested that the AM was superior to the TT technique for preparing the femoral tunnel independent of the International Knee Documentation Committee (IKDC) Score (n.s.). A higher proportion of negative Lachman (p = 0.002) and pivot-shift test (p = 0.01) results, lower manual maximum displacement by KT-1000 (p = 0.004), higher Lysholm scores (p = 0.034), a higher incidence of IKDC grade A/B (p = 0.04), and higher visual analogue scale scores (p = 0.00) were observed with the AM compared with the TT technique. CONCLUSION Although the increases in these scores were below the minimal clinically important difference, this systematic review indicated that the AM was superior to the TT drilling technique based on physical examination and scoring system results. LEVEL OF EVIDENCE Therapeutic study (systematic review), Level III.
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Open versus arthroscopic anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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da Silva RR, Matos MA, Costa VCNB, de Morais VHAA, Lago de Castro LE. Tomographic Study of Femoral Positioning in Anterior Cruciate Ligament Reconstruction Using the Transtibial Technique. Knee Surg Relat Res 2017; 29:195-202. [PMID: 28854765 PMCID: PMC5596402 DOI: 10.5792/ksrr.16.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/28/2017] [Accepted: 04/28/2017] [Indexed: 01/01/2023] Open
Abstract
Purpose To analyze the location of the femoral tunnel by three-dimensional computed tomography (3D CT) of the lateral condyle in patients who underwent arthroscopic single-bundle anterior cruciate ligament (ACL) reconstruction, performed using a modified transtibial technique, and to compare the results with data from the literature. Materials and Methods Seventeen patients with ACL lesions underwent modified transtibial ACL reconstruction. Postoperatively, 3D CT examinations were performed and the images were analyzed by the quadrant system described by Bernard and Hertel to define the femoral tunnel coordinates. Results The mean value of femoral tunnel location coordinates was 37.1±5.9 in the horizontal plane and 23.9±7.5 in the vertical plane. Compared with other studies using the transtibial or transportal technique, femoral positioning was improved in the vertical plane. The outside-in technique provided the best results both in the vertical and horizontal planes. Conclusions The modified transtibial technique was not effective for systematically anatomic femoral tunnel positioning; however, it was relatively better than the conventional transtibial technique.
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Affiliation(s)
| | - Marcos Almeida Matos
- Department of Pos-Graduation, Bahiana School of Medicine and Public Health, Salvador, Brazil
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Lacey M, Lamplot J, Walley KC, DeAngelis JP, Ramappa AJ. Technical note: Anterior cruciate ligament reconstruction in the presence of an intramedullary femoral nail using anteromedial drilling. World J Orthop 2017; 8:379-384. [PMID: 28567341 PMCID: PMC5434344 DOI: 10.5312/wjo.v8.i5.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/03/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe an approach to anterior cruciate ligament (ACL) reconstruction using autologous hamstring by drilling via the anteromedial portal in the presence of an intramedullary (IM) femoral nail.
METHODS Once preoperative imagining has characterized the proposed location of the femoral tunnel preparations are made to remove all of the hardware (locking bolts and IM nail). A diagnostic arthroscopy is performed in the usual fashion addressing all intra-articular pathology. The ACL remnant and lateral wall soft tissues are removed from the intercondylar, to provide adequate visualization of the ACL footprint. Femoral tunnel placement is performed using a transportal ACL guide with desired offset and the knee flexed to 2.09 rad. The Beath pin is placed through the guide starting at the ACL’s anatomic footprint using arthroscopic visualization and/or fluoroscopic guidance. If resistance is met while placing the Beath pin, the arthroscopy should be discontinued and the obstructing hardware should be removed under fluoroscopic guidance. When the Beath pin is successfully placed through the lateral femur, it is overdrilled with a 4.5 mm Endobutton drill. If the Endobutton drill is obstructed, the obstructing hardware should be removed under fluoroscopic guidance. In this case, the obstruction is more likely during Endobutton drilling due to its larger diameter and increased rigidity compared to the Beath pin. The femoral tunnel is then drilled using a best approximation of the graft’s outer diameter. We recommend at least 7 mm diameter to minimize the risk of graft failure. Autologous hamstring grafts are generally between 6.8 and 8.6 mm in diameter. After reaming, the knee is flexed to 1.57 rad, the arthroscope placed through the anteromedial portal to confirm the femoral tunnel position, referencing the posterior wall and lateral cortex. For a quadrupled hamstring graft, the gracilis and semitendinosus tendons are then harvested in the standard fashion. The tendons are whip stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient’s autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference.
RESULTS The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft.
CONCLUSION This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.
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Cury RDPL, Sprey JWC, Bragatto ALL, Mansano MV, Moscovici HF, Guglielmetti LGB. Comparative evaluation of the results of three techniques in the reconstruction of the anterior cruciate ligament, with a minimum follow-up of two years. Rev Bras Ortop 2017; 52:319-324. [PMID: 28702391 PMCID: PMC5497004 DOI: 10.1016/j.rboe.2017.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/12/2016] [Indexed: 01/17/2023] Open
Abstract
Objective To compare the clinical results of the reconstruction of the anterior cruciate ligament by transtibial, transportal, and outside-in techniques. Methods This was a retrospective study on 90 patients (ACL reconstruction with autologous flexor tendons) operated between August 2009 and June 2012, by the medial transportal (30), transtibial (30), and “outside-in” (30) techniques. The following parameters were assessed: objective and subjective IKDC, Lysholm, KT1000, Lachman test, Pivot-Shift and anterior drawer test. Results On physical examination, the Lachman test and Pivot-Shift indicated a slight superiority of the outside-in technique, but without statistical significance (p = 0.132 and p = 0.186 respectively). The anterior drawer, KT1000, subjective IKDC, Lysholm, and objective IKDC tests showed similar results in the groups studied. A higher number of complications were observed in the medial transportal technique (p = 0.033). Conclusion There were no statistically significant differences in the clinical results of patients undergoing reconstruction of the anterior cruciate ligament by transtibial, medial transportal, and outside-in techniques.
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Affiliation(s)
- Ricardo de Paula Leite Cury
- Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia de Joelho, São Paulo, SP, Brazil
| | - Jan Willem Cerf Sprey
- Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia de Joelho, São Paulo, SP, Brazil
| | - André Luiz Lima Bragatto
- Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia de Joelho, São Paulo, SP, Brazil
| | - Marcelo Valentim Mansano
- Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia de Joelho, São Paulo, SP, Brazil
| | - Herman Fabian Moscovici
- Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia de Joelho, São Paulo, SP, Brazil
| | - Luiz Gabriel Betoni Guglielmetti
- Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo, Departamento de Ortopedia e Traumatologia, Grupo de Cirurgia de Joelho, São Paulo, SP, Brazil
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Avaliação comparativa dos resultados de três técnicas na reconstrução do ligamento cruzado anterior com seguimento mínimo de dois anos. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Ciccotti MC, Secrist E, Tjoumakaris F, Ciccotti MG, Freedman KB. Anatomic Anterior Cruciate Ligament Reconstruction via Independent Tunnel Drilling: A Systematic Review of Randomized Controlled Trials Comparing Patellar Tendon and Hamstring Autografts. Arthroscopy 2017; 33:1062-1071.e5. [PMID: 28359669 DOI: 10.1016/j.arthro.2017.01.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/29/2016] [Accepted: 01/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To collect the highest level of evidence comparing anatomic anterior cruciate ligament (ACL) reconstruction via independent tunnel drilling using bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts in terms of clinical outcome and failure rate. METHODS We performed a systematic review of clinical trials that randomized patients to ACL reconstruction with either BTB or HT autografts with a minimum 2-year follow-up. Only trials using independent tunnel drilling, including outside-in and anteromedial portal techniques, for both autografts were eligible for inclusion, whereas all transtibial studies were excluded. Study design, demographics, surgical technique, rehabilitation protocol, and clinical outcomes were compiled. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Quality assessment was performed using the Coleman Methodological Scale (CMS). RESULTS Six published studies reporting on 5 randomized controlled trials (RCTs) met the inclusion criteria. No study reported a difference in rerupture rate between BTB and HT. BTB-reconstructed knees experienced a greater incidence of anterior knee pain or crepitus in 2/7 trials and radiographic evidence of degenerative change in 3/7 trials. HT-reconstructed knees had increased instrumented laxity in 2/7 trials and less knee flexion strength postoperatively. CONCLUSIONS This study collects all available Level I and II evidence for anatomic ACL reconstruction using BTB and HT grafts. According to the data presented in these studies, clinical outcome scores and failure rates showed no differences for anatomic reconstruction using either autograft. However, in some studies, BTB-reconstructed knees experienced a greater incidence of anterior knee pain and radiographic evidence of degenerative change, and in others, HT-reconstructed knees had increased laxity and less knee flexion strength. In our opinion, both BTB and HT autografts remain valid options for ACL reconstruction when using anatomic drilling techniques, providing a stable knee with reliable return to activity. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.
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Affiliation(s)
| | - Eric Secrist
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Fotios Tjoumakaris
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Michael G Ciccotti
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Kevin B Freedman
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A..
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Lai CCH, Ardern CL, Feller JA, Webster KE. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med 2017; 52:128-138. [DOI: 10.1136/bjsports-2016-096836] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 01/10/2023]
Abstract
ObjectivesThe primary objective was to calculate the rate of return to sport (RTS) following anterior cruciate ligament (ACL) reconstruction in elite athletes. Secondary objectives were to estimate the time taken to RTS, calculate rates of ACL graft rupture, evaluate postsurgical athletic performance and identify determinants of RTS.DesignPooled RTS and graft rupture rates were calculated using random effects proportion meta-analysis. Time to RTS, performance data and determinants of RTS were synthesised descriptively.Data sourcesMEDLINE, EMBASE, AMED, CINAHL, AMI, PEDro, SPORTDiscus and The Cochrane Library were searched from inception to 19 January 2016. Hand searching of 10 sports medicine journals and reference checking were also performed.Eligibility criteria for selecting studiesStudies were included if they reported the ratio of elite athletes who returned to their preinjury level of sport following ACL reconstruction. Twenty-four studies were included.ResultsThe pooled RTS rate was 83% (95% CI 77% to 88%). The mean time to RTS ranged from 6 to 13 months. The pooled graft rupture rate was 5.2% (95% CI 2.8% to 8.3%). Six out of nine studies that included a noninjured control group found no significant deterioration in athletic performance following ACL reconstruction. Indicators of greater athletic skill or value to the team were associated with RTS.Summary and conclusionsEighty-three per cent of elite athletes returned to sport following ACL reconstruction, while 5.2% sustained a graft rupture. Most athletes who returned to sport performed comparably with matched, uninjured controls. This information may assist in guiding expectations of athletes and clinicians following ACL reconstruction.
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Shamah S, Kaplan D, Strauss EJ, Singh B. Anteromedial Portal Anterior Cruciate Ligament Reconstruction With Tibialis Anterior Allograft. Arthrosc Tech 2017; 6:e93-e106. [PMID: 28373946 PMCID: PMC5368166 DOI: 10.1016/j.eats.2016.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/09/2016] [Indexed: 02/03/2023] Open
Abstract
In an effort to better restore normal joint function and kinematics, recent emphasis has been placed on surgical techniques that provide a more anatomic reconstruction of the anterior cruciate ligament (ACL). With femoral tunnel placement shown to play a vital role in the biomechanics, stability, and clinical outcomes after ACL reconstruction, approaches that better approximate the ACL's native femoral origin have been adopted. The independent anteromedial portal technique is thought to better position the femoral tunnel within the native ACL footprint and leave the graft more posteroinferior on the wall of the lateral femoral condyle than the more traditional transtibial approach. This article outlines the surgical technique for an anteromedial portal ACL reconstruction with a tibialis anterior allograft fixed with the Mitek Femoral and Tibial Intrafix sheath and screw system (DePuy Synthes, Raynham, MA).
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Affiliation(s)
| | | | | | - Brian Singh
- Address correspondence to Brian Singh, B.S., Department of Orthopaedic Surgery, Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003, U.S.A.Department of Orthopaedic SurgeryHospital for Joint Diseases301 E 17th StNew YorkNY10003U.S.A.
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Kumar C, Gupta AK, Singh SK, Jain R. Transportal Anterior Cruciate Ligament Reconstruction with Quadrupled Hamstring Tendon Graft: A Prospective Outcome Study. Indian J Orthop 2017; 51:600-605. [PMID: 28966383 PMCID: PMC5609381 DOI: 10.4103/ortho.ijortho_57_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction has been one of the most commonly performed procedures throughout the world. Unsatisfactory outcome with conventional ACL reconstruction has been attributed to nonanatomic graft placement. Researchers have advised placing the graft in the native footprint of ACL to avoid nonanatomic graft placement. The goal of this study was to analyze the outcome of anatomic single bundle ACL reconstruction using transportal technique. MATERIALS AND METHODS This was a prospective outcome study conducted on 85 consecutive patients of ACL reconstruction of which 62 patients met inclusion and exclusion criteria and were analyzed for final results. All the patients underwent ACL reconstruction by quadrupled hamstring tendon graft using transportal technique and the accessory anteromedial (AAM) portal for femoral tunnel creation. The graft was fixed with endobutton on femoral side and bioabsorbable screw on the tibial side. Patients were evaluated for range of motion, International Knee Documentation Committee (IKDC) score, and Lysholm scores at a minimum followup period of 2 years. The mean pre- and postoperative scores were compared using Wilcoxon signed-rank test. RESULTS The mean Lysholm and IKDC scores improved significantly (P < 0.0001) from preoperative value. According to IKDC score, 90.3% (n = 56) were either normal or near normal at final followup. According to Lysholm score, 75.8% of patients had excellent and 13.3% had good results. Preoperatively, pivot shift was present in 85.5% (n = 53) of patients which reduced to 4.8% (n = 3) postoperatively. Infection and knee stiffness occurred in two patients, and femoral tunnel blowout and graft re-rupture occurred in one patient each. CONCLUSION Anatomic ACL reconstruction by AAM portal is a reproducible technique which gives good clinical outcome at short-term followup.
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Affiliation(s)
- Chandan Kumar
- Department of Orthopaedics, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India
| | - Anil Kumar Gupta
- Department of Orthopaedics, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India,Address for correspondence: Dr. Anil Kumar Gupta, Department of Orthopaedics, G.S.V.M. Medical College, P-6, Medical College Campus, Kanpur - 208 002, Uttar Pradesh, India. E-mail:
| | - Santosh Kumar Singh
- Department of Orthopaedics, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India
| | - Rohit Jain
- Department of Orthopaedics, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India
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Koga H, Engebretsen L, Fu FH, Muneta T. Revision anterior cruciate ligament surgery: state of the art. J ISAKOS 2016. [DOI: 10.1136/jisakos-2016-000071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Capo J, Shamah SD, Jazrawi L, Strauss E. Clinical outcomes of ACL reconstruction with tibialis anterior allograft using an anteromedial portal approach. Knee 2016; 23:1089-1092. [PMID: 27836690 DOI: 10.1016/j.knee.2016.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 06/07/2016] [Accepted: 06/12/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Jason Capo
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003, USA
| | - Steven D Shamah
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003, USA.
| | - Laith Jazrawi
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003, USA
| | - Eric Strauss
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003, USA
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Guglielmetti LGB, Cury RDPL, Oliveira VMD, Camargo OPAD, Severino FR, Severino NR, Fucs PMDMB. TRANSTIBIAL VERSUS ANTEROMEDIAL PORTAL TECHNIQUES IN ACL RECONSTRUCTION. REV BRAS MED ESPORTE 2016. [DOI: 10.1590/1517-869220162205159722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Introduction: Although the results of anterior cruciate ligament (ACL) reconstruction are well documented in many studies, with good to excellent outcomes in most cases, some issues like tunnel positioning are still discussed and studied. Objective: To compare the objective and subjective clinical outcomes of ACL reconstruction using the transtibial and anteromedial portal techniques. Methods: Prospective randomized study of 80 patients undergoing anterior cruciate ligament reconstruction by the same surgeon, with 40 patients operated by the transtibial technique and 40 by anteromedial portal technique. The patients, 34 in the transtibial group and 37 in the anteromedial portal group (nine dropouts), were reassessed during a 2-year follow-up period. The clinical assessment consisted of physical examination, KT-1000TM evaluation, Lysholm score, and objective and subjective International Knee Documentation Committee - IKDC scores. Results: Regarding the Lachman and pivot shift tests, we observed more cases of instability in the transtibial group, but with no statistical significance (p=0.300 and p=0.634, respectively). Regarding the anterior drawer test, the groups presented similar results (p=0.977). Regarding KT-1000TM evaluation, the mean results were 1.44 for the transtibial group and 1.23 for the anteromedial portal group, with no statistical significance (p=0.548). We separated the objective IKDC scores into two groups: Group 1, IKDC A, and Group 2, IKDC B, C, or D, with no statistical significance (p=0.208). Concerning the Lysholm score, the transtibial group had a mean score of 91.32, and the anteromedial portal group had a mean score of 92.81. The mean subjective IKDC scores were 90.65 for the transtibial group and 92.65 for the anteromedial portal group. Three re-ruptures were encountered in the transtibial group and three in the anteromedial portal group. Conclusions: There were no significant differences in the subjective and objective clinical assessments among patients submitted to anterior cruciate ligament reconstruction using the transtibial or anteromedial portal techniques.
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Transportal femoral drilling creates more horizontal ACL graft orientation compared to transtibial drilling: A 3D CT imaging study. Knee 2016; 23:412-9. [PMID: 27012637 DOI: 10.1016/j.knee.2016.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 02/08/2016] [Accepted: 02/22/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The principle of anatomic anterior cruciate ligament (ACL) reconstruction is to create a femoral and tibial tunnel that resembles the insertion of the native ACL. Anatomic reconstruction leads to a more horizontal graft orientation that provides more rotational stability. The aim of this study is to investigate the best method to achieve anatomical reconstruction of femoral insertion of the ACL and thus, a more horizontal orientation of the ACL. We compared tunnel position and orientation between transportal femoral drilling technique and transtibial technique. METHODS Thirty-two patients were included. Post-operative CT scans were obtained and femur, tibia and ACL tunnels were reconstructed. The position and orientation of tibial and femoral tunnels were quantified using the quadrant method, and femoral tunnel length, ellipticity and posterior wall breakage were assessed. We also investigated clinical outcome. RESULTS Analyses show that transportal drilled femoral tunnels were situated significantly lower than transtibial drilled tunnels (p<0.0001), resulting in a significantly more horizontal oriented ACL in the transportal group in coronal (p<0.0001) and sagittal plane (p=0.01). No differences were observed in depth of femoral tunnel position (p=0.44). Femoral tunnel length was shorter in the transportal group (p=0.01) with a more ellipsoidal femoral aperture (p=0.01). There were no differences between both groups in tibial position. There were no differences in clinical outcome measure between the transportal and transtibial groups. CONCLUSION This study indicates that transportal drilling of the femoral tunnel leads to a more horizontal graft orientation of the ACL, without differences in clinical outcome.
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Gabler CM, Jacobs CA, Howard JS, Mattacola CG, Johnson DL. Comparison of Graft Failure Rate Between Autografts Placed via an Anatomic Anterior Cruciate Ligament Reconstruction Technique: A Systematic Review, Meta-analysis, and Meta-regression. Am J Sports Med 2016; 44:1069-79. [PMID: 25999439 DOI: 10.1177/0363546515584043] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent data from the Danish anterior cruciate ligament (ACL) registry demonstrated increased reoperation rates for hamstring tendon autografts when an anatomic ACL reconstruction is performed. This is consistent with reports of greater time needed for hamstring tendon autografts to mature compared with other autografts. PURPOSE To review the literature comparing graft failure rate between patellar and hamstring tendon autografts placed anatomically and to determine if there are differences in return to preinjury activity levels between autografts. STUDY DESIGN Systematic review with meta-analysis and meta-regression. METHODS The PubMed, MEDLINE, SPORTDiscus, and CINAHL databases were used to identify studies published from January 1, 2000, through March 7, 2014. To compare postoperative outcomes between patellar tendon and hamstring tendon autografts, summary event rates for graft failure and return to preinjury activity level were calculated. A meta-analysis was performed to calculate a summary odds ratio (OR) for graft failure between autografts using the studies that directly compared the 2 autografts. Meta-regression analyses were performed to assess the influence of postoperative follow-up time on graft failure rate. RESULTS A total of 28 studies reported graft failures for patellar tendon (6 studies) and hamstring tendon (26 studies) autografts used with anatomic ACL reconstruction; 4 of the 28 were comparison studies. Graft failure rate was not significantly different between patellar tendon (7.0% [95% CI, 4.6%-10.5%]) and hamstring tendon autografts (3.9% [95% CI, 2.7%-5.6%]). The odds of graft failure were slightly higher for hamstring tendon autografts (OR, 1.21 [95% CI, 0.63-2.33]), but this difference was not significant (P = .57). The rate of patients returning to preinjury activity levels was not significantly different between patellar (n = 1 study; 58.1% [95% CI, 40.4%-73.9%]) and hamstring tendon autografts (n = 5 studies; 75.6% [95% CI, 43.7%-92.5%]). Overall graft failure rate was positively associated with postoperative follow-up time, but this effect was only significant with hamstring tendon autografts (P < .05). CONCLUSION Differences in graft failure rate between patellar tendon and hamstring tendon autografts were not significant. Although follow-up time was only found to have a significant influence on hamstring tendon graft failure rates, this was likely due to the smaller sample of studies assessing patellar tendon graft failures. Differences in return to preinjury activity levels could not be determined due to the lack of studies assessing that outcome. Both patellar and hamstring tendon autografts demonstrate a low risk of failure and moderately high return to activity level after anatomic ACL reconstruction.
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Affiliation(s)
- Conrad M Gabler
- Department of Rehabilitation Sciences, Athletic Training Program, University of Kentucky, Lexington, Kentucky, USA
| | - Cale A Jacobs
- Department of Orthopedics & Sports Medicine, Lexington Clinic, Lexington, Kentucky, USA
| | - Jennifer Sebert Howard
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Carl G Mattacola
- Department of Rehabilitation Sciences, Athletic Training Program, University of Kentucky, Lexington, Kentucky, USA
| | - Darren L Johnson
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
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Hohmann E. Editorial Commentary: Anatomic Femoral Tunnel Drilling: Does It Really Matter? Arthroscopy 2016; 32:151-2. [PMID: 26743417 DOI: 10.1016/j.arthro.2015.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 10/30/2015] [Indexed: 02/02/2023]
Abstract
An anatomic anteromedial portal and outside-in technique for creating the anterior cruciate ligament femoral tunnel may improve rotational stability but shows no published differences in clinical outcomes.
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Mathai NJ, Amaravathi RS, Pavan KV, Sekaran P, Sharma G, Codanda B. Functional and computed tomography correlation of femoral and tibial tunnels in single-bundle anterior cruciate ligament reconstruction: Use of accessory anteromedial portal. Indian J Orthop 2016; 50:655-660. [PMID: 27904222 PMCID: PMC5122262 DOI: 10.4103/0019-5413.193490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND An accessory anteromedial portal (AAMP) has been shown to be effective in placing an anatomically ideal femoral tunnel. It is well known that this is due to the independent femoral drilling which is possible with the AAMP. However very little is known regarding the significance of this reconstruction technique in influencing the functional outcomes of anatomic anterior cruciate ligament reconstruction (ACLR). This study documents the influence of tibial and femoral tunnel positions on functional outcomes of anatomic ACLR using the AAMP. MATERIALS AND METHODS 41 patients who underwent anatomic ACLR between 2011 and 2013 were included in this prospective cohort study. The primary outcome involved the documentation of femoral and tibial tunnel positions with volume rendering imaging using a three-dimensional computed tomography (3D-CT) done at the end of 1 year. The tunnel position evaluations from the CT images were performed by an independent observer specializing in radiodiagnosis. Functional outcome measures included preoperative and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores (subjective) documented by an independent investigator who was not involved with the surgical procedure, at the end of 1 year. RESULTS The minimum followup was 1 year. All patients achieved good clinical and functional outcomes postoperatively with no reported complications. Tunnel position evaluations with 3D-CT revealed the average tibial tunnel distance to be 15.5 mm (standard deviation [SD] =2.52) from the anterior border of the tibial plateau and the average femoral tunnel distance to be 14.33 mm (SD = 2.6) from the inferior margin of the medial surface of lateral femoral condyle and 13.72 mm (SD = 2.8) from the posterior margin of the medial surface of lateral femoral condyle. The average tunnel diameters were found to be 7.9 mm (SD = 0.72) for the tibial tunnels and 8.6 mm (SD = 1.07) for the femoral tunnels. Statistically significant correlation between the tibial tunnel distance and the IKDC scores with anterior placement of tibial tunnel were found; however, no such statistical relationship were found between the femoral tunnel positions and the functional outcome measures. CONCLUSION AAMP gives an ideal approach to drill the femoral tunnel independently. However, the influence of this tunnel placement on long term functional outcomes of ACLR needs to be assessed on larger cohort of patients.
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Affiliation(s)
- Naveen Joseph Mathai
- Department of Orthopaedics, KMC, Manipal, Karnataka, India,Address for correspondence: Dr. Naveen Joseph Mathai, Department of Orthopaedics, KMC, Manipal, Karnataka, India. E-mail:
| | | | - KV Pavan
- Department of Radiodiagnosis, St Johns Medical College, Bengaluru, Karnataka, India
| | | | - Gaurav Sharma
- Department of Orthopaedics, St Johns Medical College, Bengaluru, Karnataka, India
| | - Belliappa Codanda
- Deptartment of Orthopaedics, Sakra World Hospital, Bengaluru, Karnataka, India
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47
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Vaishya R, Agarwal AK, Ingole S, Vijay V. Current Trends in Anterior Cruciate Ligament Reconstruction: A Review. Cureus 2015; 7:e378. [PMID: 26697280 PMCID: PMC4684270 DOI: 10.7759/cureus.378] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Anterior cruciate ligament reconstruction (ACLR) is an accepted and established surgical technique for anterior cruciate ligament (ACL) injuries and is now being practiced across the globe in increasing numbers. Although most patients get good to excellent results in the short-term after ACLR, its consequences in the long-term in prevention or acceleration of knee osteoarthritis (OA) are not yet well-defined. Still, there are many debatable issues related to ACLR, such as the appropriate timing of surgery, graft selection, fixation methods of the graft, operative techniques, rehabilitation after surgery, and healing augmentation techniques. Most surgeons prefer not to wait long after an ACL injury to do an ACLR, as delayed reconstruction is associated with secondary damages to the intra- and periarticular structures of the knee. Autografts are the preferred choice of graft in primary ACLR, and hamstring tendons are the most popular amongst surgeons. Single bundle ACLR is being practiced by the majority, but double bundle ACLR is getting popular due to its theoretical advantage of providing more anatomical reconstruction. A preferred construct is the interference fixation (Bio-screw) at the tibial site and the suspensory method of fixation at the femoral site. In a single bundle hamstring graft, a transportal approach for creating a femoral tunnel has recently become more popular than the trans-tibial technique. Various healing augmentation techniques, including the platelet rich plasma (PRP), have been tried after ACLR, but there is still no conclusive proof of their efficacy. Accelerated rehabilitation is seemingly more accepted immediately after ACLR.
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48
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Galdi B, Reyes A, Brabston EW, Levine WN. Autologous Hamstring Anterior Cruciate Ligament Graft Failure Using the Anteromedial Portal Technique With Suspensory Femoral Fixation: A Case Series of 7 Patients. Orthop J Sports Med 2015; 3:2325967114566599. [PMID: 26535370 PMCID: PMC4555582 DOI: 10.1177/2325967114566599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint. Furthermore, suspensory fixation of soft tissue grafts has become popularized because of complications associated with cross-pin fixation. Concerns regarding the use of both have recently arisen. PURPOSE To raise awareness of the increased risk of graft failure when using the anteromedial portal technique with suspensory femoral fixation during ACL reconstruction. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS From November 1998 to August 2012, a total of 465 primary ACL reconstructions were performed using quadrupled hamstring autograft tendons, with drilling of the femoral tunnel performed via the transtibial portal. Graft fixation on the femur was achieved with cross-pin fixation, while interference screw fixation was used on the tibia. From September 2012 to October 2013, there were 69 reconstructions performed through an anteromedial portal. While there was no change in graft choice, a change was made to using suspensory femoral fixation. No other surgical or postoperative rehabilitation changes were made. RESULTS During the 14-year period in which ACL reconstructions were performed via the transtibial portal and with cross-pin fixation, 2 graft failures (0.4% failure rate) were reported. After switching to the anteromedial portal with suspensory fixation, 7 graft failures (10.1% failure rate) were reported over a 13-month period. These were 5 male and 2 female patients, with a mean age of 18.8 years-all elite athletes. The same surgical technique was used in all patients, and all patients had at least an 8 mm-diameter graft. Patients were cleared to return to sport at an average of 8.4 months postoperatively, after completing functional performance tests. Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition. The final patient sustained a rerupture 10 months after being cleared to play. CONCLUSION Compared with the transtibial technique with cross-pin graft fixation, there is an increased risk of graft failure when performing autologous hamstring ACL reconstructions using the anteromedial portal technique with cortical suspensory fixation.
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Affiliation(s)
- Balazs Galdi
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Allan Reyes
- New York Presbyterian/Columbia University Medical Center, New York, New York, USA
| | | | - William N Levine
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, New York, USA
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49
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Tudisco C, Bisicchia S, Cosentino A, Chiozzi F, Piva M. Knee stability, athletic performance and sport-specific tasks in non-professional soccer players after ACL reconstruction: comparing trans-tibial and antero-medial portal techniques. Muscles Ligaments Tendons J 2015; 5:175-80. [PMID: 26605191 DOI: 10.11138/mltj/2015.5.3.175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND a wrong position of bone tunnels, in particular on the femur, is one of the most frequent causes of a failed anterior cruciate ligament (ACL) reconstruction. Several studies demonstrated that drilling the femoral tunnel through the antero-medial portal (AMP) allows a more anatomical placement on the lateral femoral condyle and higher knee stability, compared to trans-tibial (TT) technique. The aim of this study was to retrospectively evaluate two groups of soccer players operated on for ACL reconstruction according to either one of these two techniques. METHODS two groups of non-professional soccer players operated on for a single bundle ACL reconstruction with hamstrings autograft using either a TT (20 patients) or an AMP (23 patients) technique were retrospectively evaluated with KT-1000 arthrometer, manual pivot shift test, isokinetic test, the incremental treadmill-running test, athletic and sport specific tasks, and knee scores (IKDC, Lysholm and KOOS). RESULTS the AMP group showed better results at pivot shift test and KOOS, but lower flexion angles at single leg squat test. There were no differences in all the other considered outcomes. CONCLUSIONS the better rotational stability of the knee achieved in AMP group did not lead to significantly better clinical and functional results in our patients. LEVEL OF EVIDENCE III TREATMENT STUDY Case-control study.
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Affiliation(s)
- Cosimo Tudisco
- Department of Orthopaedic Surgery, University of Rome Tor Vergata, Italy
| | | | - Andrea Cosentino
- Department of Orthopaedic Surgery, University of Rome Tor Vergata, Italy
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50
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Makhni EC, Padaki AS, Petridis PD, Steinhaus ME, Ahmad CS, Cole BJ, Bach BR. High Variability in Outcome Reporting Patterns in High-Impact ACL Literature. J Bone Joint Surg Am 2015; 97:1529-42. [PMID: 26378269 DOI: 10.2106/jbjs.o.00155] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND ACL (anterior cruciate ligament) reconstruction is one of the most commonly performed and studied procedures in modern sports medicine. A multitude of objective and subjective patient outcome measures exists; however, nonstandardized reporting patterns of these metrics may create challenges in objectively analyzing pooled results from different studies. The goal of this study was to document the variability in outcome reporting patterns in high-impact orthopaedic studies of ACL reconstruction. METHODS All clinical studies pertaining to ACL reconstruction in four high-impact-factor orthopaedic journals over a five-year period were reviewed. Biomechanical, basic science, and imaging studies were excluded, as were studies with fewer than fifty patients, yielding 119 studies for review. Incorporation of various objective and subjective outcomes was noted for each study. RESULTS Substantial variability in reporting of both objective and subjective measures was noted in the study cohort. Although a majority of studies reported instrumented laxity findings, there was substantial variability in the type and method of laxity reporting. Most other objective outcomes, including range of motion, strength, and complications, were reported in <50% of all studies. Return to pre-injury level of activity was infrequently reported (24% of studies), as were patient satisfaction and pain assessment following surgery (8% and 13%, respectively). Of the patient-reported outcomes, the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores were most often reported (71%, 63%, and 42%, respectively). CONCLUSIONS Substantial variability in outcome reporting patterns exists among high-impact studies of ACL reconstruction. Such variability may create challenges in interpreting results and pooling them across different studies.
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Affiliation(s)
- Eric C Makhni
- Departments of Orthopaedics and Sports Medicine, Rush University Medical Center, 1611 West Harrison, Suite 300, Chicago, IL 60612. E-mail address for E.C. Makhni:
| | - Ajay S Padaki
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032
| | - Petros D Petridis
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032
| | | | - Christopher S Ahmad
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032
| | - Brian J Cole
- Departments of Orthopaedics and Sports Medicine, Rush University Medical Center, 1611 West Harrison, Suite 300, Chicago, IL 60612. E-mail address for E.C. Makhni:
| | - Bernard R Bach
- Departments of Orthopaedics and Sports Medicine, Rush University Medical Center, 1611 West Harrison, Suite 300, Chicago, IL 60612. E-mail address for E.C. Makhni:
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