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Alessio-Mazzola M, Tradati D, Slongo M, Belluati A, Placella G, Salini V. Transtibial versus anteromedial transportal femoral tunnel in single-bundle anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized controlled trials. Musculoskelet Surg 2024:10.1007/s12306-024-00823-3. [PMID: 38814430 DOI: 10.1007/s12306-024-00823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 05/03/2024] [Indexed: 05/31/2024]
Abstract
The purpose of this study was to systematically review and meta-analyze randomized controlled trials (RCTs) reporting the comparative clinical and functional outcomes, postoperative complications, and radiological outcomes of single-bundle anterior cruciate ligament reconstruction (ACLR) performed using the transtibial (TT) approach or anteromedial (AM) technique. A systematic review of the literature was performed according to Cochrane and PRISMA guidelines. RCTs comparing TT and AM techniques were considered only. The quality of the studies was defined using the GRADE system, and the risk of bias was assessed with the RoB 2 tool. The primary endpoint was to systematically review and meta-analyze the clinical outcomes, residual laxity and failure rate of both AM and TT techniques. In the current meta-analysis 13 RCTs involving 989 patients who underwent arthroscopic single-bundle ACLR (486 TT and 503 AM) were included. Patients undergoing AM technique resulted in higher objective-IKDC (p < 0.001) and Lysholm scores (p = 0.002), despite a lower incidence of pathological anterior tibial translation (p < 0.001) and positive pivot-shift test (p < 0.001). No differences were detected in IKDC subjective score (p = 0.26), Tegner activity scale (p = 0.18) and graft failure (p = 0.07). ACL reconstruction through AM portal technique provides better clinical outcomes and lower incidence of residual rotational and anteroposterior laxity in comparison with the TT technique. No statistically significant difference in subjective outcomes and graft failure was reported.
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Affiliation(s)
- M Alessio-Mazzola
- Unità di Ortopedia e Traumatologia, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - D Tradati
- Unità di Ortopedia e Traumatologia, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - M Slongo
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy
| | - A Belluati
- Orthopaedic and Trauma Department, Hospital Santa Maria delle Croci, Viale Vincenzo Randi, 5, 48121, Ravenna, Italy
| | - G Placella
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy
| | - V Salini
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy
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Yañez R, Silvestre R, Roby M, Neira A, Azar C, Madera S, Ortiz-Bernardin A, Carpes FP, De la Fuente C. Finite element graft stress for anteromedial portal, transtibial, and hybrid transtibial femoral drillings under anterior translation and medial rotation: an exploratory study. Sci Rep 2024; 14:11922. [PMID: 38789542 PMCID: PMC11126698 DOI: 10.1038/s41598-024-61061-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
Stress concentration on the Anterior Cruciate Ligament Reconstruction (ACLr) for femoral drillings is crucial to understanding failures. Therefore, we described the graft stress for transtibial (TT), the anteromedial portal (AM), and hybrid transtibial (HTT) techniques during the anterior tibial translation and medial knee rotation in a finite element model. A healthy participant with a non-medical record of Anterior Cruciate Ligament rupture with regular sports practice underwent finite element analysis. We modeled TT, HTT, AM drillings, and the ACLr as hyperelastic isotropic material. The maximum Von Mises principal stresses and distributions were obtained from anterior tibial translation and medial rotation. During the anterior tibia translation, the HTT, TT, and AM drilling were 31.5 MPa, 34.6 Mpa, and 35.0 MPa, respectively. During the medial knee rotation, the AM, TT, and HTT drilling were 17.3 MPa, 20.3 Mpa, and 21.6 MPa, respectively. The stress was concentrated at the lateral aspect of ACLr,near the femoral tunnel for all techniques independent of the knee movement. Meanwhile, the AM tunnel concentrates the stress at the medial aspect of the ACLr body under medial rotation. The HTT better constrains the anterior tibia translation than AM and TT drillings, while AM does for medial knee rotation.
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Affiliation(s)
- Roberto Yañez
- Biomechanics unit, Innovation centre, MEDS clinic, Santiago, Chile
- Orthopaedic knee service, MEDS clinic, Santiago, Chile
| | - Rony Silvestre
- Biomechanics unit, Innovation centre, MEDS clinic, Santiago, Chile
| | - Matias Roby
- Biomechanics unit, Innovation centre, MEDS clinic, Santiago, Chile
- Orthopaedic knee service, MEDS clinic, Santiago, Chile
| | - Alejandro Neira
- Escuela de Kinesiologia, Facultad de Medicina y Ciencias de la Salud, Universidad Mayor, Santiago, Chile
| | - Camilo Azar
- Orthopaedic knee service, MEDS clinic, Santiago, Chile
| | - Samuel Madera
- Ingenieria Civil Mecanica, Facultad de Igenieria, Universidad de Chile, Santiago, Chile
| | | | - Felipe P Carpes
- Laboratory of Neuromechanics, Universidade Federal do Pampa, Uruguaiana, Brazil
| | - Carlos De la Fuente
- Exercise and Rehabilitation Sciences Institute, Postgraduate, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, RM, Chile.
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Zhang L, Lin J, Zhao X, Liu M, Hou Y, Zhang Y, Zhao J, Wang S. Robotic-assisted anatomic anterior cruciate ligament reconstruction: a comparative analysis of modified transtibial and anteromedial portal techniques in cadaveric knees. Front Bioeng Biotechnol 2024; 12:1360560. [PMID: 38511128 PMCID: PMC10953503 DOI: 10.3389/fbioe.2024.1360560] [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: 12/23/2023] [Accepted: 02/07/2024] [Indexed: 03/22/2024] Open
Abstract
Introduction: This study employed surgical robot to perform anatomic single-bundle reconstruction using the modified transtibial (TT) technique and anteromedial (AM) portal technique. The purpose was to directly compare tunnel and graft characteristics of the two techniques. Methods: Eight cadaveric knees without ligament injury were used in the study. The modified TT and AM portal technique were both conducted under surgical robotic system. Postoperative data acquisition of the tunnel and graft characteristics included tibial tunnel position, tunnel angle, tunnel length and femoral tunnel-graft angle. Results: The mean tibial tunnel length of the modified TT technique was significantly shorter than in the AM portal technique (p < 0.001). The mean length of the femoral tunnel was significantly longer for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the tibial tunnel was significantly lower for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the femoral tunnel was significantly lower for the AM portal technique than for the modified TT technique (p < 0.001). The AM portal technique resulted in a graft bending angle that was significantly more angulated in the coronal (p < 0.001) and the sagittal planes (p < 0.001) compared with the modified TT technique. Discussion: Comparison of the preoperative planning and postoperative femoral tunnel positions showed that the mean difference of the tunnel position was 1.8 ± 0.4 mm. It suggested that the surgical navigation robot could make predictable tunnel position with high accuracy. The findings may support that the modified TT technique has benefits on femoral tunnel length and obliquity compared with AM portal technique. The modified TT technique showed a larger femoral tunnel angle in the coronal plane than the AM portal technique. Compared with the modified TT technique, the more horizontal trajectory of the femoral tunnel in the AM portal technique creates a shorter femoral tunnel length and a more acute graft bending angle.
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Affiliation(s)
- Ling Zhang
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Jinpeng Lin
- Department of Orthopaedics, Guangdong Provincial Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuan Zhao
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Mingwei Liu
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Yao Hou
- Shanghai Droidsurg Medical Technology Co., Ltd., Shanghai, China
| | - Yu Zhang
- Department of Orthopaedics, Guangdong Provincial Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shaobai Wang
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
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Yang Q, Lu W, Luo Y, Li J, Huang X, You T. A Novel Predictor of the Length and Size of ACL Grafts in Chinese Han Adults for ACL Reconstruction: An MRI Study. Orthop Surg 2024; 16:481-489. [PMID: 38174408 PMCID: PMC10834193 DOI: 10.1111/os.13976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/25/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Currently, there is no simple and valid method to predict the length and size of the native anterior cruciate ligament (ACL) in each adult patient who will undergo ACL reconstruction. This study aimed to develop an imaging prediction method that can predict the length and size of ACL grafts using the intact posterior cruciate ligament (PCL), in order to enhance the graft preparation individualized sizing. METHODS Three hundred and nineteen patients aged 18 years or older who underwent magnetic resonance imaging (MRI) of the knee at an orthopaedic clinic between September 9, 2021, and February 5, 2023, were included. The length, sagittal diameter, and coronal diameter of the ACL and PCL were measured in all patients, and F-test were performed to explore linear relationship between ligament measurements. RESULTS Equations were established to predict a variable of the native ACL for the corresponding variable of the intact PCL (i.e., sagittal diameter of the ACL = 4.32 + 1.08 × sagittal diameter of the PCL, and coronal diameter of the ACL = 2.45 + 0.59 × coronal diameter of the PCL, length of the male ACL = 10.92 + 0.64 × length of the male PCL, length of the female ACL = 11.76 + 0.58 × length of the female PCL) (R2 = 0.532; R2 = 0.417; R2 = 0.488; R2 = 0.509; respectively). CONCLUSIONS The length and size of the intact PCL in cases without PCL buckling are predictors of the length and size of the native ACL in adults, respectively. The use of this information to optimize graft diameter may lower the rates of ACL graft failure in the future.
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Affiliation(s)
- Qingjun Yang
- Peking University Shenzhen HospitalShenzhenChina
| | - Wenqian Lu
- Clinical Medical CollegeShenzhen UniversityShenzhenChina
| | - Yong Luo
- Clinical Medical CollegeShantou UniversityShantouChina
| | - Jiatong Li
- Clinical Medical CollegeShenzhen UniversityShenzhenChina
| | - Xiancheng Huang
- Clinical Medical College, Weifang Medical UniversityWeifangChina
| | - Tian You
- Peking University Shenzhen HospitalShenzhenChina
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Mao Y, Zhang K, Li J, Fu W. Transtibial Versus Anteromedial Portal Technique for Femoral Tunnel Drilling in Primary Single-Bundle Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Level 1 and 2 Evidence of Clinical, Revision, and Radiological Outcomes. Am J Sports Med 2023; 51:250-262. [PMID: 34652233 DOI: 10.1177/03635465211044476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although numerous clinical studies have compared transtibial (TT) and anteromedial portal (AMP) drilling of femoral tunnels during anterior cruciate ligament reconstruction (ACLR), there is no high-quality, evidence-based consensus regarding which technique affords the best outcome. HYPOTHESIS There would be no difference between the TT and AMP techniques in terms of knee stability, patient-reported outcomes, incidence of revision, and radiological results. STUDY DESIGN Meta-analysis; Level of evidence, 2. METHODS The PubMed and EMBASE databases were searched from inception to February 1, 2021. Level 1 and 2 clinical trials that compared TT and AM techniques were included. Data were meta-analyzed for the outcome measures of knee stability, patient-reported functional outcomes, incidence of revision, and radiological results. Dichotomous variables were presented as odds ratios (ORs), and continuous variables were presented as mean differences (MDs) and standard mean differences (SMDs). RESULTS The meta-analysis included 18 clinical studies, level of evidence 1 or 2, that involved 53,888 patients. Pooled data showed that the AMP group had a lower side-to-side difference (SMD, 0.22; 95% CI, 0.06 to 0.39; P = .009), a lower incidence of pivot-shift phenomenon (OR, 3.69; 95% CI, 1.26 to 10.79; P = .02), and a higher postoperative Lysholm score (SMD, -0.26; 95% CI, -0.44 to -0.08; P = .005) than the TT group. However, no statistically significant differences were seen in other outcomes, including subjective International Knee Documentation Committee scores (SMD, -0.11; 95% CI, -0.30 to 0.09; P = .30) or grades (OR, 0.93; 95% CI, 0.35 to 2.49; P = .89), postoperative activity level (MD, -0.14; 95% CI, -0.42 to 0.15; P = .35), and incidence of revision ACLR (OR, 1.04; 95% CI, 0.93 to 1.16; P = .45). The TT technique was more likely to create longer (SMD, 1.05; 95% CI, 0.05 to 2.06; P = .04) and more oblique (SMD, 0.81; 95% CI, 0.51 to 1.11; P < .001) femoral tunnels than the AMP technique, and a higher height ratio of the aperture position was detected with the TT technique (SMD, -3.51; 95% CI, -5.54 to -1.49; P < .001). CONCLUSION The AMP technique for ACLR may be more likely to produce better knee stability and improved clinical outcomes than the TT technique, but no difference was found in the incidence of revision between the 2 groups.
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Affiliation(s)
- Yunhe Mao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Kaibo Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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The Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Finite Element Analysis Model of Graft Bending Angles and Peak Graft Stresses in Comparison With Transtibial and Anteromedial Portal Techniques. J Am Acad Orthop Surg 2022; 30:e1195-e1206. [PMID: 36001883 DOI: 10.5435/jaaos-d-21-00883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/05/2022] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The purpose of this finite element analysis was to compare femoral tunnel length; anterior cruciate ligament reconstruction graft bending angle; and peak graft stress, contact force, and contact area created by the transtibial, anteromedial portal (AMP), and hybrid transtibial techniques. METHODS Finite element analysis modeling was used to examine anterior cruciate ligament reconstruction models based on transtibial, AMP, and hybrid transtibial femoral tunnel drilling techniques. An evaluation of femoral tunnel length, graft bending angle, peak graft stress, contact force, and contact area was done in comparison of these techniques. RESULTS The femoral tunnel created with the hybrid transtibial technique was 45.3 mm, which was 13.3% longer than that achieved with the AMP technique but 15.2% shorter than that with the transtibial technique. The femoral graft bending angle with the hybrid transtibial technique (105°) was less acute than that with the AMP technique (102°), but more acute than that with the transtibial technique (109°). At 11° knee flexion, the hybrid transtibial technique had 22% less femoral contact force, 21% less tibial contact force, 21% less graft tension than the AMP technique. Yet, the hybrid transtibial technique had 41% greater femoral contact force, 39% greater tibial contact force, 33% greater graft tension, and 6% greater graft von Mises stress than the transtibial technique. A similar trend was found for the anterior knee drawer test. At both 6-mm anterior tibial displacement and 11° knee flexion, the hybrid transtibial and AMP techniques had at least 51% more femoral contact area than the transtibial technique. CONCLUSION This finite element analysis highlights that the hybrid transtibial technique is a true hybrid between the AMP and transtibial techniques for femoral tunnel drilling regarding femoral tunnel length, graft bending angle, and peak graft stress.
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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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Achilles Tendon Allograft Preparation Technique for Anterior Cruciate Ligament Reconstruction: A Technical Note. Arthrosc Tech 2021; 10:e2143-e2150. [PMID: 34504754 PMCID: PMC8417340 DOI: 10.1016/j.eats.2021.05.016] [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: 03/19/2021] [Accepted: 05/18/2021] [Indexed: 02/03/2023] Open
Abstract
Several factors associated with graft preparation for the surgery of the anterior cruciate ligament (ACL) like the wrong thawed, prophylaxis, bone cuts, excessive bone removal as well as positioning problems like a tunnels-graft mismatch, insufficient harvesting of the donor's tendon, size graft limitations (length and diameter), uncontrolled rotation of graft in their longitudinal axis, over or under tensioned graft, fixation mistakes, bone defects, secondary arthrofibrosis or morbidity of the donor site, and others factors importantly affect the outcomes of the ACL surgery. In this sense, the Achilles tendon Allograft is an advantageous technique where many of the previous limitation factors described can be controlled during an appropriate preparation. However, to obtain the maximum potentialities of the graft a detailed knowledge of the preparation is required. Hence, we aimed to describe how to prepare the Achilles tendon Allograft to control the graft's length and diameter, bone removal, and fixation requirements.
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