Anatomic single bundle anterior cruciate ligament reconstruction by the two anteromedial portal method: the comparison of transportal and transtibial techniques

Arthroscopic Reconstruction of an Anterior Cruciate Ligament Tear Using the Anatomic Single-Bundle Technique: A Clinical and Functional Outcome Evaluation

BACKGROUND

The anterior cruciate ligament (ACL) consists of an anteromedial bundle and a posterolateral bundle giving anteroposterior and rotational stability to the knee. An ACL tear might lead to secondary changes in the knee joint if not operated in time. The aim of the study was to evaluate the clinical and functional results in patients with ACL tears treated by arthroscopic reconstruction using the anatomic single-bundle technique.

METHODS

This was a prospective study conducted between June 2015 and December2017 at a teaching institute in Kolkata, India, on patients who underwent single-bundle arthroscopic reconstruction of an ACL tear. A minimum follow-up of nine months was considered for all patients. The functional outcome was assessed via the Lysholm knee score.

RESULTS

A total of 45 patients were included in this study, of which 34 (75.56%) and eight (17.78%) patients showed excellent and good results, respectively, at the final follow-up. The mean age in this study was 29.88±9.02 years. No complication was seen in 95.6% of patients. The mean Lysholm score by the end of nine months was 95.31±6.55. At the time of the final follow-up, all the patients returned to their same activity status prior to injury.

CONCLUSION

Arthroscopic anatomic single-bundle ACL reconstruction using hamstring autograft is an effective treatment modality for ACL injuries. It restores the stability of the knee and is associated with good recovery of joint function with an early return to active lifestyle and sports activities. This procedure achieves excellent clinical and functional outcomes without any long-term disability.

Dynamics analysis of the anterior cruciate ligament reconstruction surgery based on magnetic resonance imaging

In clinical practice, anterior cruciate ligament (ACL) rupture is always repaired by the single-beam reconstruction method. Before the surgery, the surgeon made the diagnosis based on medical images, such as CT (computerized tomography) and MR (magnetic resonance) images. However, little is known about how biomechanics governs the biological nature for femoral tunnel position. In the present study, three volunteers' motion trails were captured by six cameras when they were doing squat movement. The medical image can reconstruct the structure of the ligaments and bones and a left knee model was reconstructed by MIMICS by MRI data of DICOM format. Finally, the effects of different femoral tunnel positions on ACL biomechanics were characterized by the inverse dynamic analysis method. The results showed that there were significant differences in the direct mechanical effects of the anterior cruciate ligament at different locations of the femoral tunnel (p < 0.05), the peak stress of ACL in the low tension area was 1097.24 ± 25.55 N, and the peak stress of ACL in the distal femur was 356.81 ± 15.39 N, both of which were much higher than that in the direct fiber area (118.78 ± 20.68 N).

Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal

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.

Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction

The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms "anterior cruciate ligament reconstruction," "anatomic or anatomical," and "single bundle." Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow-deep direction (32.3%) and in a high-low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.

Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review

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.

Comparison of hamstring and quadriceps strength after anatomical versus non-anatomical anterior cruciate ligament reconstruction: a retrospective cohort study

Background

Strength recovery of injured knee is an important parameter for patients who want to return to sport after anterior cruciate ligament reconstruction (ACLR). Comparison of muscle strength between anatomical and non-anatomical ACLR has not been reported.

Purpose

To evaluate the difference between anatomical and non-anatomical single-bundle ACLR in hamstring and quadriceps strength and clinical outcomes.

Methods

Patients received unilateral primary single-bundle hamstring ACLR between January 2017 to January 2018 were recruited in this study. Patients were divided into anatomical reconstruction group (AR group) and non-anatomical reconstruction group (NAR group) according to femoral tunnel aperture position. The hamstring and quadriceps isokinetic strength including peak extension torque, peak flexion torque and H/Q ratio were measured at an angular velocity of 180°/s and 60°/s using an isokinetic dynamometer. The isometric extension and flexion torques were also measured. Hamstring and quadriceps strength were measured preoperatively and at 3, 6, and 12 months after surgery. Knee stability including Lachman test, pivot-shift test, and KT-1000 measurement and subjective knee function including International Knee Documentation Committee (IKDC) and Lysholm scores were evaluated during the follow-up.

Results

Seventy-two patients with an average follow-up of 30.4 months (range, 24–35 months) were included in this study. Thirty-three were in AR group and 39 in NAR group. The peak knee flexion torque was significant higher in AR group at 180°/s and 60°/s (P < 0.05 for both velocity) at 6 months postoperatively and showed no difference between the two groups at 12 months postoperatively. The isometric knee extension torque was significant higher in AR group at 6 months postoperatively (P < 0.05) and showed no difference between the two groups at 12 months postoperatively. No significant differences between AR group and NAR group were found regarding knee stability and subjective knee function evaluations at follow-up.

Conclusions

Compared with non-anatomical ACLR, anatomical ACLR showed a better recovery of hamstring and quadriceps strength at 6 months postoperatively. However, the discrepancy on hamstring and quadriceps strength between the two groups vanished at 1 year postoperatively.

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.

A comparative study of a new "off-centre:off-centre" technique of transtibial ACL reconstruction with "centre:centre" transportal ACL reconstruction

BACKGROUND & INTRODUCTION

A Single Bundle ACL Reconstruction aims at placing Tibial and Femoral attachment sites of graft from Centre of Native Tibial Foot-print to Centre of Native Femoral Footprint. In tibial tunnel independent Transportal Reconstruction, where the two points are chosen separately, the objective is easily achievable. In Tibial tunnel dependent Transtibial ACL reconstruction, Capture of Centre of femoral tunnel is dictated by Trajectory of Tibial Tunnel. Heming et al. remarked that a TT technique could produce tunnel centred in the both the tibial and femoral footprint but only if a starting point "prohibitively close" to the joint line with a correspondingly short tibial tunnel were used. A new technique wherein authors aim to place the mouths of Tibial & Femoral tunnel at off-centre location, taking care to contain these tunnels still within native footprints to achieve a tunnel which is of adequate length and does not come too close to the joint and saves MCL from violation.

OBJECTIVE

To study the clinic-radiological outcome of a new "Off-centre to Off-centre" method of Transtibial Reconstruction and compare the results with "centre to centre" method of Transportal reconstruction.

METHODS

A prospective randomised comparative study of consecutive 75 clinico-radiological cases of ACL tear with definitive clinical symptoms of knee instability who underwent arthroscopic ACL reconstruction by Same Arthroscopy Surgeon was conducted between 2016 and 2018. A modification, as described herein below, was used in Transtibial technique with placement of centre of mouth of internal opening of tibial tunnel "off-centre" that allowed a predictable capture of Femoral Footprint in "off-centre" location without tunnel being too close to joint line. Only those cases were included in which the mouths of tunnel were completely contained within footprints. Capture of footprints was verified during arthroscopy. 11 cases were excluded because either the native footprint was not clearly delineated, or surgeon failed to completely contain the mouth of tunnel/socket within the delineated footprint of tibia or femur. Hence 64 patients, 32 each in Transtibial & Transportal group were enrolled into the study. The results were analysed with the objective to arrive at recommendations for improving capture of anatomical footprints at both ends by Transtibial technique.

RESULTS

There were no statistically significant differences in Clinical outcome scores. However there were statistically significant differences in length of Femoral Tunnel, Obliquity of Femoral tunnel as well as Femoral Tunnel Placements. Likewise, Tibial Tunnel Angle in AP & Lateral View as well as Tibial tunnel placement were also significantly different.

CONCLUSION

It is concluded that tunnels follow much different trajectories in the bones in two techniques and trying to apply "Centre of Tibial footprint to Centre of Femoral footprint" philosophy of Transportal technique may be imprudent for Transtibial Technique. An "Off-centre to Off-centre but contained within Footprints" may afford a more predictable and reliable capture of anatomical foot prints without any adverse effect on outcomes.

In vivo gait kinematics of the knee after anatomical and non-anatomical single-bundle anterior cruciate ligament reconstruction-a prospective study

Background

The factors that influence functions of knees after anterior cruciate ligament reconstruction (ACLR) still remains uncertain. The functional restoration of knees after ACLR can be reflected on gait kinematics restoration. The purpose of this study was to evaluate the gait kinematics and clinical outcomes of knees after anatomical and non-anatomical single-bundle ACLR during level walking.

Methods

Thirty-four patients with unilateral primary single-bundle ACLR and 18 healthy people were recruited. Patients were divided into anatomical reconstruction group (AR group; n=13) and non-anatomical reconstruction group (Non-AR group; n=21) according to Bernard Quadrant method. The ACL graft orientations on coronal and sagittal planes were measured on 3D models from medical images. The 6 degrees of freedom (DOF) kinematics of knees and range of motion (ROM) of 6 DOF kinematics were measured with a portable optical tracking system. The comparison of 6 DOF kinematics and ROM of 6 DOF kinematics were performed between the ACLR knees and contralateral knees. The following assessments were also performed including clinical examination, KT-2000 arthrometer measurement, International Knee Documentation Committee (IKDC) and Lysholm scores.

Results

All patients reached a minimum follow-up of 6 months (10±4 months). For AR group and Non-AR group, no statistically significant differences were observed in gait kinematics between the ACLR knees and contralateral knees. No statistically significant differences between the ACLR knees and contralateral knees were observed in terms of ROM of 6 DOF kinematics in AR group. However, in Non-AR group, the ACLR knees exhibited significant ROM of anterior-posterior translation by approximately 0.5 cm than contralateral knees (P=0.0080). No statistically significant differences between the two groups were observed regarding IKDC subjective score, Lysholm score and KT-2000 arthrometer test.

Conclusions

The anatomical ACLR can restore close to normal gait kinematics and ROM of 6 DOF kinematics compared with non-anatomical ACLR. The ACL graft after anatomical ACLR simulated native ACL fibers to function in terms of graft orientation.

The transportal technique shows better clinical results than the transtibial techniques for single-bundle anterior cruciate ligament reconstruction

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.

Tibial tunnel widening associated with anterior cruciate ligament reconstruction using autogenous hamstrings: A comparison between antero-medial portal and transtibial techniques

OBJECTIVE

Evaluate the enlargement effect of the tibial tunnel emergence of 2 different of anterior cruciate ligament reconstruction techniques: antero-medial portal (AMP) vs. transtibial (TT) technique.

METHODS

A prospective, randomized controlled study was performed in 36 consecutive patients who underwent anterior cruciate ligament reconstruction with autologous hamstring tendon grafts employing the AMP and conventional TT techniques. Lateral and antero-posterior radiographs were obtained for each patient at 6 weeks and 12 months postoperatively. The sclerotic margins of the tibial tunnels were measured at the widest dimension of the tunnel as well as the diameter of the tibial emergence and were compared with the initially drilled tunnel size after correction for radiographic magnification. Statistical analysis was performed to compare the 2 groups by use of the independent-samples t test, with significance set at .05.

RESULTS

The mean percentage increase in the diameter of tibial tunnel emergence at 6 weeks after surgery was 8.1%±2.9 for the PAM technique and 21.20%±11.87 for the TT technique on the anteroposterior x-ray view. However, the mean percentage increase in the diameter of the tibial tunnel emergence on the lateral view was 7.1%±4.72 for the medial portal technique and 17.64%±11.48 for the transtibial technique. This difference was statistically significant on both anteroposterior and lateral views.

CONCLUSIONS

The diameter of the tibial tunnel emergence for hamstring autologous anterior cruciate ligament reconstructions was significantly lower for the medial portal technique when compared with the conventional TT technique.

Clinical outcomes of transtibial versus anteromedial drilling techniques to prepare the femoral tunnel during anterior cruciate ligament reconstruction

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.

Comparative evaluation of the results of three techniques in the reconstruction of the anterior cruciate ligament, with a minimum follow-up of two years

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.

Comparison of Anteromedial and Transtibial ACL Reconstruction Using Expandable Fixation

The influence of anatomical or nonanatomical femoral tunnel position on tunnel widening and clinical outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction is not fully understood. This retrospective study examined the influence of tunnel width and placement on anterior knee stability and clinical outcomes after ACL reconstruction using the AperFix System (Cayenne Medical Inc, Scottsdale, Arizona), a direct expandable fixation technique with autologous hamstring grafts. The records of 80 patients (79 men and 1 woman) who underwent ACL reconstruction were evaluated. In 38 patients, anatomical femoral tunnel placement was performed via an accessory medial portal (anteromedial group); in the remaining 42 patients, the femoral tunnel was positioned nonanatomically using a transtibial technique (transtibial group). Mean follow-up was 40.7 months (range, 27-60 months). Postoperative knee kinetics were measured, and clinical outcomes were assessed using International Knee Documentation Committee, Lysholm, and Tegner scores. Femoral tunnel widening was measured by comparing postoperative radiographs with final follow-up radiographs. Femoral tunnel width was significantly greater (P<.001) and anterior knee translation was significantly higher (P=.01) in the transtibial group. Lysholm and Tegner scores were not significantly different (P>.05) between the 2 groups. These findings suggest that femoral tunnel widening is associated with increased anterior joint laxity when a direct fixation technique is used for ACL reconstruction, particularly in nonanatomically positioned femoral tunnels. Anatomical femoral tunnel placement provides better anterior stability and less tunnel widening than transtibial tunnel placement; however, these benefits did not produce a detectable advantage in clinical outcomes measures. [Orthopedics. 2017; 40(3):e532-e537.].

Mid-Term Outcomes of Anterior Cruciate Ligament Reconstruction with Far Anteromedial Portal Technique

Purpose

The purpose of this study was to evaluate the mid-term outcomes of anatomic anterior cruciate ligament (ACL) reconstruction using two anteromedial (AM) portals by comparing with short-term follow-up results.

Materials and Methods

Fifty patients who were treated by ACL reconstruction using a two AM portal technique were evaluated retrospectively. The follow-up period was at least 5 years. The mean follow-up period was 68.5±13.9 months. The mid-term clinical outcomes were compared with short-term (≥12 months) results. For the assessment of knee stability, anterior tibial translation was evaluated using the Lachman test and the KT-2000. Rotational stability was evaluated using pivot shift test. For clinical assessment, the Lysholm and International Knee Documentation Committee scores were used.

Results

The average anterior translation was 2.1±1.4 mm at the short-term follow-up and 2.8±1.8 mm at the mid-term follow-up. Stability and midterm clinical outcomes were not significantly improved compared to the short-term follow-up results. At the mid-term follow-up, anteroposterior (AP) instability assessed by the KT-2000 was slightly increased, but still acceptable. On the other clinical physical evaluation, there was no statistically significant difference.

Conclusions

The short-term and mid-term outcomes of ACL reconstruction using the two AM portal technique were not significantly different except for AP stability although the value was less than 3 mm at both follow-ups. Therefore, this operative technique could be considered a satisfactory alternative for ACL reconstruction.

Association of fibrosis in the infrapatellar fat pad and degenerative cartilage change of patellofemoral joint after anterior cruciate ligament reconstruction

BACKGROUND

The purpose of this study was to evaluate the prevalence and risk factor of cartilage degeneration of the patellofemoral joint (PFJ) that was diagnosed by second-look arthroscopy.

METHODS

One-hundred and seven patients who underwent ACL reconstruction were evaluated by preoperative MRI, postoperative MRI and second-look arthroscopy. Severity of infrapatellar fat pad (IPFP) fibrosis was evaluated by MRI at an average of 26months after ACL reconstruction. Cartilage degeneration was assessed by second-look arthroscopy at 29months.

RESULTS

Twenty-five patients (24.0%) showed cartilage degeneration of the PFJ in second-look arthroscopy. Patients were divided into three groups according to severity of IPFP fibrosis of postoperative MRI (i.e. Group A, focal and incomplete band fibrosis, n=69; Group B, complete band fibrosis, n=31; and Group C, diffuse and infiltrated fibrosis, n=7). Cartilage degeneration of the PFJ was significantly worsened with more fibrosis formation of the IPFP (P<0.001). Other factors for instabilities (BMI, age, concomitant meniscal procedure, time from injury to reconstruction, severity of IPFP fibrosis at preoperative MRI and clinical scores) were not correlated with cartilage degeneration of the PFJ. The multivariate logistic regression analysis of degeneration of the PFJ after ACL reconstruction identified more severe fibrosis tissue formation of the IPFP and initial cartilage defect as significant predictors.

CONCLUSIONS

More extensive fibrosis of the IPFP and initial cartilage defect may be related to further degenerative changes of the PFJ. Other factors did not affect cartilage degeneration of the PFJ, although the muscle strength, the individual activity level or the rehabilitation protocol was not evaluated in the short-term follow-up period.

TRANSTIBIAL VERSUS ANTEROMEDIAL PORTAL TECHNIQUES IN ACL RECONSTRUCTION

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.

Transtibial technique versus two incisions in anterior cruciate ligament reconstruction: tunnel positioning, isometricity and functional evaluation

OBJECTIVE

To compare the transtibial and two-incision techniques for anterior cruciate ligament (ACL) reconstruction using a single band.

METHODS

A prospective and randomized study was conducted in blocks. Patients underwent ACL reconstruction by means of two techniques: transtibial (group 1: 20 patients) or two incisions (group 2: 20 patients). The radiographic positioning of the tunnel, inclination of the graft, graft isometricity and functional results (IKDC and Lysholm) were evaluated.

RESULTS

The positioning of the femoral tunnel on the anteroposterior radiograph, expressed as a mean percentage relative to the medial border of the tibial plateau, was 54.6% in group 1 and 60.8% in group 2 (p < 0.05). The positioning of the femoral tunnel on the lateral radiograph, expressed as a mean percentage relative to the anterior border of Blumensaat's line, was 68.4% in group 1 and 58% in group 2 (p < 0.05). The mean inclination of the graft was 19° in group 1 and 27.2° in group 2 (p < 0.05). The mean graft isometricity was 0.96 mm in group 1 and 1.33 mm in group 2 (p > 0.05). Group 2 had better results from the pivot-shift maneuver (p < 0.05).

CONCLUSION

The technique of two incisions allowed positioning of the femoral tunnel that was more lateralized and anteriorized, such that the graft was more inclined and there was a clinically better result from the pivot-shift maneuver. There was no difference in isometricity and no final functional result over the short follow-up time evaluated.

Outcome of arthroscopic single-bundle anterior cruciate ligament reconstruction: anteromedial portal technique versus transtibial drilling technique

PURPOSE

Controversies exist about the femoral tunnel preparation technique in anterior cruciate ligament (ACL) reconstruction surgeries. The aim of this study was to evaluate mid-term outcomes of transtibial (TT) technique in comparison with anteromedial portal (AMP) one.

METHODS

Demographic data, height, weight, period of time from injury to surgery, and follow-up duration of patients underwent ACL reconstruction using single-bundle hamstring graft by the senior author between 2007 and 2011 were evaluated, retrospectively. Mid-quadriceps circumference difference, passive range of motion of the joint, anterior drawer test, Lachman test, and pivot shift test were assessed for each case. Function of the knee joint was calculated using International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores.

RESULTS

Of 50 cases in the AMP group (age 30.6 ± 6.5), 45 were male and of the 44 patients in the TT group (age 30.0 ± 6.5), forty were male. Mean follow-up times in the AMP and TT group were 18.2 months (range 12-84 months) and 25.7 months (range 16-48 months), respectively. No statistically significant difference was found in mid-quadriceps circumference difference (P = 0.861). Also, functional knee scores (P values of IKDC = 0.329, Lysholm score = 0.08, Tegner = 0.504) and stability tests (P values of anterior drawer test = 0.07, Lachman test = 0.486, pivot shift test = 0.348) did not differ statistically between groups.

CONCLUSION

There is no superiority of AMP technique on TT technique in ACL reconstructive surgeries. It could be suggested that performing a well-done technique, either TT or AMP, may be more important than only choosing a technique.

Outcome of Single-Bundle Hamstring Anterior Cruciate Ligament Reconstruction Using the Anteromedial Versus the Transtibial Technique: A Systematic Review and Meta-analysis

PURPOSE

To compare the clinical outcomes of single-bundle hamstring anterior cruciate ligament (ACL) reconstruction between the anteromedial (AM) and transtibial (TT) techniques.

METHODS

We performed a comprehensive systematic review and meta-analysis of the English-language literature in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases for articles that compared clinical outcomes of AM versus TT ACL reconstruction. The outcome measures analyzed included postoperative Lachman test, pivot-shift test, International Knee Documentation Committee (IKDC), and Lysholm scores.

RESULTS

We included 10 articles from an initial 308 abstracts for the systematic review and included 6 studies for the meta-analysis. The study population consisted of a total of 733 patients, of whom 366 (49.9%) underwent the AM technique and 367 (50.1%) underwent the TT technique for ACL reconstruction. For postoperative knee stability, the AM technique yielded superior results in terms of the proportion of negative Lachman test results (n = 243; odds ratio [OR], 2.98 [95% confidence interval (CI), 1.29 to 6.88]) and proportion of negative pivot-shift test results (n = 238; OR, 3.67 [95% CI, 1.80 to 7.52]). For postoperative functional status, the AM technique yielded superior results in terms of objective IKDC grading (proportion with IKDC grade A) (n = 269; OR, 2.19 [95% CI, 1.23 to 3.88]) but had comparable Lysholm scores (n = 478; mean difference, 1.43 [95% CI, 0.01 to 2.84]).

CONCLUSIONS

Single-bundle hamstring ACL reconstruction using the AM technique showed superior surgeon-recorded stability according to the IKDC knee score, Lachman test, and pivot-shift test. However, there was no difference in patient-reported functional outcome (Lysholm score).

LEVEL OF EVIDENCE

Level III, systematic review and meta-analysis of Level I, II, and III studies.

A comparison of distal femoral physeal defect and fixation position between two different drilling techniques for transphyseal anterior cruciate ligament reconstruction

The defect of the femoral tunnel at the level of the physeal scar during transtibial and anteromedial portal (AMP) drilling for transphyseal anterior cruciate ligament reconstruction was compared. Five matched pairs of knees (n=10) were drilled, and computed tomography was used to evaluate tunnel position and size at the level of the physeal scar. Significant radiographic changes were observed, including tunnel defect area at the physeal scar: 0.44 cm (1.2%) in the transtibial group versus 0.99 cm (2.7%) in the AMP group (P=0.008). AMP drilling creates a larger and more lateral tunnel defect at the level of the physeal scar.

Comparison of the Modified Transtibial Technique, Anteromedial Portal Technique and Outside-in Technique in ACL Reconstruction

Purpose

To compare clinical and radiographic results of anterior cruciate ligament (ACL) reconstruction using modified transtibial technique (mTT), anteromedial (AM) portal technique and outside-in (OI) technique.

Materials and Methods

From March 2007 to December 2012, ACL reconstruction was performed using the mTT, AM portal technique and OI technique in 20 patients each. Anteroposterior and rotational stability were assessed using the GNRB arthrometer and pivot-shift test. Femoral tunnel obliquity was measured on the anteroposterior and lateral radiographs.

Results

Tegner score, Lysholm score, International Knee Documentation Committee score, pivot-shift test were improved at final follow-up in all three groups. However, statistical difference was not shown. Side-to-side difference in GNRB arthrometer was average of 1.4 mm, 1.0 mm and 0.9 mm in mTT, AM and OI group, showing the signicant difference between mTT and AM/OI groups (p<0.001). The mean femoral tunnel obliquity was 56.4° in the mTT group, 39.4° in the AM group and 33.6° in the OI group, showing significant intergroup difference (p<0.001). It showed the significant difference among three groups (p<0.001).

Conclusions

Clinical results were improved in all three groups. Femoral tunnel obliquity in AM and OI were more horizontal on the coronal plane. They are thought to have more benefits in oblique positioning of the grafted ACL in rotational stability; however, there was no significant difference among three techniques in pivot-shift test to assess the rotational stability in this study.

Clinical and three-dimensional computed tomographic comparison between ACL transportal versus ACL transtibial single-bundle reconstructions with hamstrings

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction using a single-bundle transtibial technique can achieve good or excellent results in more than 90% of patients, but anatomical and biomechanical studies have questioned its ability to restore knee function. The purpose of this study was to evaluate clinical and tomographic results (patient satisfaction, knee function, and tunnel location) of patients who underwent transportal or transtibial single-bundle ACL reconstruction.

METHODS

Seventy-one patients with ACL tears were included. Forty-one patients were treated by the single-bundle transportal technique and 30 patients were treated by the single-bundle transtibial technique. Clinical and tomographic data were analyzed in both groups.

RESULTS

After a minimum of 2-year period, the transportal group showed more patients with normal clinical tests than the transtibial group (Lachman [p=0.037], pivot shift [0.00], anterior drawer [0.002]; and arthrometer [0.002] tests). Regarding CT evaluation, transportal and transtibial groups obtained the following femoral central tunnel location (mean [SD]), as percentage: 30 (6.5) and 4.2 (6.4) in high-low axis; and 30.9 (5.9) and 33.2 (4.6) in the deep-shallow axis. Values in the tibial side were, respectively: 38 (6.5) and 46.0 (6.8) in the anterior-posterior axis; and 47.2 (2.5) and 46.9 (2.1) in the medial-lateral axis.

CONCLUSION

CT findings showed that the transportal single-bundle technique positions the ACL tunnel closer to the native ACL footprint in both femur and tibia compared with the transtibial single-bundle technique. Moreover, mild asymptomatic instability and extension deficit were observed more often in the transtibial group.

Transtibial versus anteromedial portal anterior cruciate ligament reconstruction using soft-tissue graft and expandable fixation

PURPOSE

To compare clinical outcomes between transtibial drilling and anteromedial portal techniques for anterior cruciate ligament (ACL) reconstruction using soft-tissue grafts secured with expandable fixation.

METHODS

Patients undergoing soft-tissue ACL reconstruction using expandable fixation between 2007 and 2011 were reviewed for inclusion in this study. Revision ACL cases were excluded. All surgeries were performed by 1 of 2 sports medicine fellowship-trained surgeons (T.S.D., K.D.M.). A total of 128 patients (67 comprising transtibial cohort and 61 comprising anteromedial portal cohort) had a minimum of 24 months' follow-up (mean, 27 months) and met the inclusion criteria. The patients were divided into 2 groups based on the method used for creation of the femoral tunnel. At final follow-up, outcomes were assessed with KT-1000 (MEDmetric, San Diego, CA) measurements, as well as International Knee Documentation Committee, Lysholm, and Tegner scores. Data were screened for normality and skew before use of parametric statistics and were transformed if necessary. Data were analyzed by 1-way analysis of variance with post hoc paired comparisons using the Bonferroni approximation.

RESULTS

No differences in demographic characteristics were observed between the 2 groups. There was no significant difference in postoperative KT-1000 measurements between the 2 cohorts (1.571 ± 0.2275 mm in transtibial cohort [n = 35] and 1.246 ± 0.09249 mm in anteromedial cohort [n = 61], P = .1259). A significant improvement in International Knee Documentation Committee scores was observed in the anteromedial cohort, increasing from 41 ± 16 to 89 ± 7.4 (mean ± SD) (P < .0001). Similar changes were observed for the Lysholm score. There was no significant difference between cohorts for any postoperative scores measured (P > .2).

CONCLUSIONS

Our data show comparable KT-1000 measurements for both anteromedial and transtibial femoral drilling techniques when using a soft-tissue graft with expandable fixation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A comparison of the anteromedial and transtibial drilling technique in ACL reconstruction after a short-term follow-up

INTRODUCTION

The purpose of this study was to compare clinical and radiological outcomes of patients who underwent single-bundle anterior cruciate ligament (ACL) reconstruction with anteromedial portal (AMP) and transtibial (TT) techniques.

MATERIALS AND METHODS

Arthroscopic single-bundle ACL reconstruction was performed using AMP technique in 34 patients and TT technique in 30 patients. The patients were evaluated retrospectively. Aperture fixation was used for femoral fixation, and absorbable screws and U staples were used for tibial fixation of the graft. Pivot shift test, Lachman test, Lysholm, Tegner, and International Knee Documentation Committee (IKDC-2000) scoring systems were used in the clinical and functional evaluation of patients before and after the surgery. Time to return sports and activity level were assessed. In the radiological evaluation of non-anatomic bone tunnel placement, the criteria developed by lllingworth et al. were used. The mean duration of follow-up was 20.4 and 24.6 months in the AMP and TT groups, respectively.

RESULTS

There was a significant difference between the AMP group (86.7 %) and the TT (14.7 %) group in terms of anatomical placement of the femoral tunnels and grafts (p < 0.001). No significant difference was observed between the two groups in terms of the Pivot shift test, Lachman test, Lysholm, Tegner, and IKDC scores, and activity level (p > 0.05). The patients in the AMP group returned to sports 1.5 months earlier on average (p < 0.001).

CONCLUSIONS

It was shown that AMP technique was superior to the TT technique in providing anatomical placement of the graft and in recovery time to return sports; however, there was no difference between groups in early periods in terms of the clinical and functional outcomes.

Current trends in anterior cruciate ligament reconstruction

The advances in the knowledge of anatomy, surgical techniques, and fixation devices have led to the improvement of anterior cruciate ligament (ACL) reconstruction over the past 10 years. Nowadays, double bundle and anatomical single bundle ACL reconstruction that more closely restores the normal anatomy of the ACL are becoming popular. Although there is still no definite conclusion whether double bundle ACL reconstruction provides better clinical results than single bundle reconstruction, the trend has shifted to anatomic reconstruction regardless of single bundle or double bundle techniques. We could not find any significant differences in the clinical outcomes and stability after ACL reconstruction according to the type of graft or fixation device. Therefore, surgeons should select an ideal ACL reconstruction according to the patient's condition and surgeon's experience.

Determinants of Femoral Tunnel Length in Anterior Cruciate Ligament Reconstruction: CT Analysis of the Influence of Tunnel Orientation on the Length

Purpose

The purpose of the study was to identify the femoral tunnel orientation that consistently results in a tunnel length of more than 35 mm in anterior cruciate ligament reconstruction.

Materials and Methods

Computed tomography (CT) scans were obtained from 30 patients who did not have any pathology in the distal femur. Virtual tunnels were marked on 3D (3-dimensional) reconstructed CT images after determining the orientation defined by sagittal inclination and axial angle. The length of a femoral tunnel in 64 different combinations of orientations (between 30° and 65° in 5° increments in two planes) was measured on 3D reconstructed images in both knees in 30 patients. Reliability of measurement was assessed with correlation coefficient for intra-observer and inter-observer measurements. A one-way analysis of variance (ANOVA) was used for statistical analysis.

Results

The mean femoral tunnel length varied significantly with each 10° change in orientation in both planes (p<0.05, ANOVA). A femoral tunnel of more than 35 mm in length could be obtained only with a sagittal inclination of more than 50° and axial angle of 30°-45°. When the axial angle was kept constant, the tunnel length increased with the increase in sagittal inclination. Higher sagittal inclinations consistently resulted in longer tunnels (r>0.9) and reduced the incidence of posterior cortical breakage.

Conclusions

A tunnel orientation with an axial angle between 30°-45° and a sagittal inclination of more than 50° can result in a tunnel length of more than 35 mm.

Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: a systematic review

PURPOSE

Failure to anatomically reconstruct the femoral footprint can lead to rotational instability and clinical failure. Thus we sought to compare femoral tunnel drilling techniques, specifically anteromedial (AM) and transtibial (TT) methods, with respect to rotational stability.

METHODS

In this study we evaluated available scientific support for the ability of both techniques to achieve rotational stability of the knee through a systematic review of the literature for directly comparative biomechanical and clinical studies.

RESULTS

We identified 9 studies (5 clinical Level II or III studies and 4 cadaveric studies) that directly compared AM and TT techniques. Three cadaveric and 2 clinical studies showed superior rotational stability with the AM technique as compared with the TT technique, whereas 2 cadaveric studies and 1 clinical study were unable to show any similar differences. Two studies showed superior clinical outcomes with the AM technique, whereas 3 studies were unable to show any difference.

CONCLUSIONS

In this systematic review of clinical and biomechanical studies directly comparing AM and TT techniques for anterior cruciate ligament reconstruction (ACLR) in the literature, there are mixed results, with some studies finding superior rotational stability and clinical outcomes with the AM technique and some finding no difference. No studies showed significantly better results with the TT technique. This study shows that the AM portal technique for ACLR may be more likely to produce improved clinical and biomechanical outcomes but that the TT technique is capable of producing similar outcomes.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies plus cadaver studies.

Dynamic evaluation of pivot-shift kinematics in physeal-sparing pediatric anterior cruciate ligament reconstruction techniques

BACKGROUND

Conventional transphyseal anterior cruciate ligament (ACL) reconstruction techniques in skeletally immature patients have been questioned because of potential physeal injuries. Consequently, multiple alternative reconstruction options have been described to restore stability while sparing the physes in the skeletally immature patient.

HYPOTHESIS

All pediatric reconstruction techniques will restore knee stability to intact levels, and the knee stability index (KSI) will discriminate stability patterns between reconstruction techniques.

STUDY DESIGN

Controlled laboratory study.

METHODS

A novel mechanical pivot-shift device (MPSD) that consistently applies dynamic loads to cadaveric knees was used to study the effect of different physeal-sparing ACL reconstruction techniques on knee stability. Six adult cadaveric fresh-frozen knees were used. All knees were tested with 3 physeal-sparing reconstruction techniques: all epiphyseal (AE), transtibial over the top (TT), and iliotibial band (ITB). The MPSD was used to consistently perform a simulated pivot-shift maneuver. Tibial anterior displacement (AD), internal rotation (IR), posterior translational velocity (PTV), and external rotational velocity (ERV) were recorded using an Optotrak navigation system. The KSI (score range, 0-100; 0 = intact knee) was quantified using a regression analysis of AD, IR, PTV, and ERV. Repeated-measures analysis of variance and logistic regression were used for comparison of kinematics and derivation of KSI coefficients, respectively.

RESULTS

ACL deficiency resulted in an increase of 20% to 115% in all primary stability measures tested compared with the ACL-intact state. All reconstructions resulted in a decrease in ADmax and IRmax as well as PTVmax and ERVmax to within intact ranges, indicating that all reconstructions do improve stability compared with the ACL-deficient state. The ITB reconstruction overconstrained AD and IR by 38% and 52%, respectively. The mean (±SD) KSI for the ACL-deficient state was 61.7 ± 22.2 (range, 47-100), while the ITB reconstruction had a mean KSI of 0.82 ± 24.0 (range, -24 to 35), the TT reconstruction had a mean KSI of 13.3 ± 8.9 (range, 0.3-23), and the AE reconstruction had a mean KSI of -4.0 ± 15.2 (range, -24 to 14). The KSI was not significantly different between reconstructions, and all were significantly lower than the ACL-deficient state (P < .0001).

CONCLUSION

Although all reconstruction techniques tested were able to partially stabilize an ACL-deficient knee, the AE reconstruction was most effective in restoring native knee kinematics under dynamic loading conditions that mimic the pivot-shift test.

CLINICAL RELEVANCE

This study provides orthopaedic surgeons with objective dynamic rotational data on the ability of physeal-sparing ACL reconstructions to better determine the ideal technique for ACL construction in skeletally immature patients.