Comparison of clinical results of anteromedial and transtibial femoral tunnel drilling in ACL reconstruction

[Comparative study of I.D.E.A.L. technique and transtibial technique in anterior cruciate ligament reconstruction]

Objective

To compare the effectiveness of I.D.E.A.L technique and transtibial (TT) technique in anterior cruciate ligament (ACL) reconstruction.

Methods

A clinical data of 60 patients with ACL injury, who were admitted and met the selection criteria between January 2020 and September 2022, was retrospectively analyzed. All patients underwent arthroscopic ACL reconstruction with autologous tendon. During operation, the femoral tunnel was prepared by using I.D.E.A.L technique in 30 cases (I.D.E.A.L group) and using TT technique in 30 cases (TT group). There was no significant difference in baseline data such as age, gender, body mass index, cause of injury, injured side, interval from injury to operation, constituent ratio of combined cartilage and meniscus injury, and preoperative Lysholm score, International Knee Documentation Committee (IKDC) score, visual analogue scale (VAS) score, anterior tibial translation difference, and Blumensaat angle between the two groups ( P>0.05). The length of hospital stay and the occurrence of early and late complications were recorded. During follow-up, the Lysholm score, IKDC score, and VAS score were used to evaluate knee joint function and pain degree, and the anterior tibial translation difference was measured. MRI reexamination was performed to observe the healing of the graft, and the signal to noise quotient (SNQ) values of the femoral end, middle section, and tibial end of the graft, as well as the Blumensaat angle of the knee joint were measured. The differences in tibial anterior translation difference and Blumensaat angle before and after operation (change values) were calculated and compared between the two groups.

Results

The incisions in both groups healed by first intention after operation, and there was no significant difference in the length of hospital stay between the two groups ( P>0.05). All patients were followed up 12-18 months, with an average of 14.9 months. The Lysholm score and IKDC score of the knee joint in both groups after operation increased when compared with those before operation, and the VAS score decreased. Compared to preoperative scores, except for the VAS score of the TT group at 1 week after operation ( P>0.05), there were significant differences in all scores at different time points postoperatively in the two groups ( P<0.05). The above scores in both groups showed a further improvement trend with the prolongation of time after operation. There were significant differences in Lysholm score and VAS score among 1 week, 1 month, 3 months, 6 months, and 12 months after operation in the two groups ( P<0.05). The IKDC score of both groups at 1 month after operation was significantly different from that at 1 week after operation ( P<0.05). At 1 week after operation, the Lysholm score and IKDC score in the I.D.E.A.L group were significantly higher than those in the TT group ( P<0.05), and the VAS score was significantly lower ( P<0.05); there was no significant difference between the two groups at 1, 3, 6, and 12 months after operation ( P>0.05). At 12 months after operation, the anterior tibial translation differences in both groups were significantly lower than those before operation ( P<0.05); and the change value in the I.D.E.A.L group was significantly higher than that in the TT group ( P<0.05). The incidences of early and late complications in the I.D.E.A.L group were significantly lower than those in the TT group ( P<0.05). At 12 months after operation, MRI examination showed that the grafts of the knee joint in both groups survived well, and the Blumensaat angles of both groups were significantly smaller than those before operation ( P<0.05). The change value of the Blumensaat angle in the I.D.E.A.L group was significantly higher than that in the TT group ( P<0.05). The SNQ values of the femoral end, middle section, and tibial end of the graft in the I.D.E.A.L group were significantly higher than those in the TT group ( P<0.05).

Conclusion

The early effectiveness of ACL reconstruction by using the I.D.E.A.L technique is better, the knee joint is more stable, and the incidence of postoperative complication is lower. However, the maturity of the graft after reconstruction using the TT technique is higher.

Functional and Symptomatic Improvements Based on the Femoral Tunnel Drilling Technique in Anterior Cruciate Ligament (ACL) Reconstruction

BACKGROUND

The current literature comparing femoral tunnel techniques often reports on short-term outcomes after anterior cruciate ligament reconstruction (ACLR), but only a few studies have analyzed long-term outcomes. In addition, many studies have compared transtibial to anteromedial portal techniques without differentiating whether rigid or flexible reaming is used, making it difficult to infer how the techniques truly compare to one another.

PURPOSE

This study aimed to detect differences in patient-reported outcome scores in those treated with three different femoral tunnel drilling techniques.

STUDY DESIGN

This study is a prospective cohort study.

METHODS

Of 650 patients treated for anterior cruciate ligament (ACL) injuries with ACLR, 350 were 5+ years out from surgery. Of these patients, 111 completed patient-reported outcome surveys (PROs). The Kruskal-Wallis H test was used to detect differences between patients treated with either of the three femoral tunnel drilling techniques: transtibial (TT), anteromedial portal with rigid reaming (AMP-RR), or anteromedial portal with flexible reaming (AMP-FR). Bonferroni correction was applied to the p-values to reduce the risk of making a type 1 error.

RESULTS

No differences were found between the three groups in demographics or postoperative PROs. However, there was a significant change between pre-surgery and post-surgery PROs. TT, when compared to AMP-RR, had a greater increase in satisfaction and greater improvement in a patient's ability to go up and down the stairs from pre-surgery to post-surgery. AMP-FR, when compared to TT, had greater improvement of the patient's knee stiffness/swelling. AMP-FR, when compared to AMP-RR, had greater improvement in knee pain during stairs and the ability to go down the stairs. No differences in return to sport, additional procedures on the affected knee (meniscal surgeries or cyclops lesion excisions), or revision surgery rates were found.

CONCLUSION

Overall, postoperative PROs did not show statistically significant differences between the three femoral tunnel drilling techniques. Differences, however, were identified in the responses to specific questions on PRO surveys, which may have otherwise been overlooked. It is important to recognize the differences between TT, AMP-RR, and AMP-FR in the improvement of stair climbing and swelling/stiffness as these likely directly affect a patient's satisfaction from pre-ACLR to post-ACLR.

Deficits in muscle strength are not seen following recovery from augmented primary repair of anterior cruciate ligament tears

OBJECTIVES

Anterior cruciate ligament (ACL) repair for proximal tears, where the ligament is re-attached and augmented with suture tape, can negate the need for graft harvest, thereby maintaining native anatomy. Autograft harvest has been associated with persistent deficits in lower limb muscle strength after recovery from ACL reconstruction. The aim of this study is to compare lower limb muscle strength following ACL repair and reconstruction.

METHODS

Nineteen ACL repair patients augmented with suture tape and nineteen ipsilateral semitendinosus-gracilis autograft ACL reconstruction patients (both mean 4 years postoperatively) were recruited, along with twenty healthy volunteers. Patient-reported outcome measures (PROMs) were obtained using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner scores. Maximal isometric quadriceps and hamstring strength at 90° knee flexion were measured using a fixed Myometer after a warm-up and three maximal-effort contractions.

RESULTS

Mean hamstring strength of the reconstructed legs was lower than that of healthy volunteers by 0.29 Nm/kg. The hamstring strength ratio of the operated side to the uninjured side was greater in the repair (95% ​± ​13) than in the reconstruction (81% ​± ​18) group. There were no statistically significant differences between sides for quadriceps peak torque or for hamstrings in the volunteer or repair group. PROMs scores for the reconstruction group were significantly lower than volunteers across all domains and lower than repair for KOOS activities of daily living and Lysholm scores.

CONCLUSION

Hamstring weakness seen following ACL reconstruction is not evident following ACL repair with suture tape augmentation. Strength asymmetry could contribute to re-injury risk and influence functional performance, while altered loads affect knee biomechanics and may lead to osteoarthritis progression. The absence of these deficits in the repair group demonstrates a potential benefit of this technique when used in appropriate patients.

LEVEL OF EVIDENCE

II.

Accuracy of Femoral Tunnel Placement between Anteromedial and Anterolateral Visualisation Portals in Anterior Cruciate Ligament Reconstruction - Outcomes of a CT based Cross-Sectional Study

Introduction

Anatomical femoral tunnel placement is critical for anterior cruciate ligament reconstruction (ACLR). Tunnel placement may vary with different surgical techniques. The aim of this study was to compare the accuracy of femoral tunnel placement between the Anteromedial (AM) and Anterolateral (AL) visualisation portals on post-operative CT scans among a cohort of ACLR patients.

Materials and methods

This cross-sectional study was conducted from January 2018 to March 2020 after obtaining ethics clearance. Patients who went for arthroscopic ACLR in our institute were divided into an AM (group 1) and an AL (group 2) based on the visualisation portal for creating the femoral tunnel and a 3D CT scan was done. The femoral tunnel position was calculated in deep to shallow and high to low direction using the Bernard Hertel grid. Femoral tunnel angle was measured in the 2D coronal image. Statistical analysis was done with the data collected.

Results

Fifty patients with an average age of 26.36 (18-55) years ±7.216 SD were enrolled in the study. In this study, the AM technique was significantly more accurate (p<0.01) than the AL technique in terms of femoral tunnel angle. Furthermore, the deep to the shallow position was significantly (p= 0.018) closer to normative values, as determined by the chi-square test. The chances of error in tunnel angle in femoral condyle are 2.6 times greater in the AL technique (minimal clinical difference).

Conclusion

To conclude, in ACLR the anteromedial visualisation portal can facilitate accurate femoral tunnel placement compared to the anterolateral visualisation portal.

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

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.

Association Between Anteromedial Portal Versus Tibial Tunnel Drilling and Meniscal Reoperation Risk Following Anterior Cruciate Ligament Reconstruction: A Cohort Study

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) provides functional stability to an injured knee. While multiple techniques can be used to drill the femoral tunnel during ACLR, a single technique has yet to be proven as clinically superior. One marker of postoperative functional stability is subsequent meniscal tears; a lower risk of subsequent meniscal surgery could be expected with improved knee stability.

PURPOSE

To determine if there is a meniscal protective effect when using an anteromedial portal (AMP) femoral tunnel drilling technique versus transtibial (TT) drilling.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Data from Kaiser Permanente's ACLR registry were used to identify patients who had a primary isolated ACLR between 2009 and 2018; those with previous surgery in the index knee and meniscal pathology at the time of ACLR were excluded. The exposure of interest was TT (n = 2711) versus AMP (n = 5172) drilling. Multivariable Cox proportional hazard regression was used to evaluate the risk of a subsequent ipsilateral meniscal reoperation with adjustment for age, sex, femoral fixation, and graft choice. We observed a shift in surgeon practice from the TT to AMP over the study time frame; therefore, the relationship between technique and surgeon experience on meniscal reoperation was evaluated using an interaction term in the model.

RESULTS

At the 9-year follow-up, the crude cumulative meniscal reoperation probability for AMP procedures was 7.76%, while for TT it was 5.88%. After adjustment for covariates, we observed a higher risk for meniscal reoperation with AMP compared with TT (hazard ratio [HR], 1.53; 95% CI, 1.05-2.23). When stratifying by surgeon experience, this adverse association was observed for patients who had their procedure performed by surgeons with less AMP experience (no previous AMP ACLR: HR, 1.26; 95% CI, 0.84-1.91) while a protective association was observed for patients who had their procedure with more experienced surgeons (40 previous AMP ACLRs: HR, 0.34; 95% CI, 0.13-0.92).

CONCLUSION

Drilling the femoral tunnel via the AMP was associated with a higher risk of subsequent meniscal surgery compared with TT drilling. However, when AMP drilling was used by surgeons experienced with the technique, a meniscal protective effect was observed.

Comparison of Clinical Outcomes between Anteromedial and Transtibial Techniques of Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

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.