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.

Anatomic femoral tunnel placement is difficult by the transtibial technique: comparison of three different femoral tunnel drilling techniques in double-bundle anterior cruciate ligament reconstructions

PURPOSE

To compare the position and direction of femoral and tibial tunnels for both the anteromedial bundle (AMB) and posterolateral bundle (PLB) among three different femoral tunnel drilling techniques, transtibial (TT), transportal (TP), and outside-in (OI) techniques, in anatomic double-bundle ACL reconstruction to clarify advantages and disadvantages of each technique.

METHODS

One-hundred and thirty-nine patients underwent primary ACL reconstruction with an autologous semitendinosus tendon in our institution between 2014 and 2016. Thirteen patients were excluded according to the exclusion criteria. Of the 126 patients, 98 patients agreed to be included in this study. Patients were then randomized into three groups according to the femoral tunnel drilling technique; the TT, TP, and OI groups. Femoral and tibial tunnel angles and positions were measured using three-dimensional computed tomography.

RESULTS

Of patients who agreed to be included in this study, eight patients (seven in TT and one in OI) were excluded since the femoral tunnel could not be created at the intended position. Eighty-six patients (29 in TT, 29 in TP, and 28 in OI) were included for the analyses. Tunnel angles, as well as tunnel lengths, had significant differences among different techniques depending on each technique's characteristics. In terms of tunnel position, femoral tunnel positions of both the AMB and PLB in the TT group were significantly higher than those in the TP group (AMB: p = 0.003, PLB: p = 0.001), and the PLB tunnel position in the TP group had significantly smaller vaciance than that in the TT group (p = 0.004) and OI group (0.002).

CONCLUSIONS

The femoral tunnel positions created by the TT technique were significantly higher, with larger variance, than the TP technique in double-bundle ACL reconstruction, although the positions seemed to be within anatomical footprint. In addition, there were several cases in which femoral tunnels could not be created at the intended position by the TT technique.

LEVEL OF EVIDENCE

I.

Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique

PURPOSE

To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel.

METHODS

Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups.

RESULTS

There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004).

CONCLUSION

There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.

Femoral tunnel position in chronic anterior cruciate ligament rupture reconstruction: randomized controlled trial comparing anatomic, biomechanical and clinical outcomes

PURPOSE

The aim of this study was to compare the outcomes between anteromedial (AM) and transtibial (TT) femoral tunnel positioning techniques for the reconstruction of chronic anterior cruciate ligament (ACL) rupture.

MATERIALS AND METHODS

It is a randomized prospective study of 106 patients who underwent ACL reconstruction because of a chronic ACL rupture (55 AMT, 51 TT). Minimum follow-up was 2 years. Demographic, clinical and radiological data, including MRI grafts' anatomy and biomechanics intraoperative navigation system evaluation, were analyzed. Also, International Knee Documentation Committee score, Tegner Knee score, Lysholm Knee Score, Short-Form Health Survey and 4-point Likert Scale were evaluated.

RESULTS

The AM technique achieves a more anatomic graft than TT technique in both sagittal and coronal plane (6° approximately). Immediate postoperative biomechanical evaluation of the graft showed both techniques significantly improved translational and rotational laxity (p = 0.000). AMT showed superiority only in controlling internal rotation (p = 0.016). Both techniques reported significant improvement in all evaluated score scales, without differences between techniques. Independently of the femoral tunnel positioning technique, patients with cartilage lesion had worse clinical outcomes.

CONCLUSIONS

Our findings suggest that AMT achieves a more anatomical and biomechanically accurate graft allowing better control over internal rotation laxity; however, this does not lead to better clinical outcomes if we compare with TT in the reconstruction of chronic ACL rupture. Patients with chronic ACL rupture and cartilage lesion had worse clinical outcomes, independently the femoral tunnel positioning technique.

Tibiofemoral joint contact area and stress after single-bundle anterior cruciate ligament reconstruction with transtibial versus anteromedial portal drilling techniques

Background

During single-bundle ACLR, femoral tunnel location plays an important role in restoring the intact knee mechanisms, whereas malplacement of the tunnel was cited as the most common cause of knee instability. The objective of this study is to evaluate, objectively, the tibiofemoral contact area and stress after single-bundle (SB) anterior cruciate ligament reconstruction (ACLR) with femoral tunnel positions drilled by transtibial (TT) or anteromedial (AM) portal techniques.

Methods

Seven fresh human cadaveric knees underwent ACLR by the use of TT or AM portal techniques in a randomized order. These specimens were reused for ACL-R (TT and AM). The tibiofemoral contact area and stresses were gauged by an electronic stress-sensitive film inserted into the joint space. The knee was under the femoral axial compressive load of 1000 N using a biomechanics testing machine at 0°, 10°, 20°, and 30° of flexion. Three conditions were compared: (1) intact ACL, (2) ACLR by the use of the TT method, and (3) ACLR by the use of the AM portal method.

Results

Compared with AM portal ACL-reconstructed knees, a significantly decreased tibiofemoral contact area on the medial compartment was detected in the TT ACL-reconstructed knees at 20°of knee flexion (P = .047). Compared with the intact group, the TT ACLR group showed a higher mean stress at 20° and 30° of flexion on the medial compartments (P = .001, P = .003, respectively), while the AM portal ACLR group showed no significant differences at 30° of flexion (P = .073). The TT ACLR group also showed a higher mean maximum stress at 20° of flexion on the medial compartments (P = .047), while the AM portal ACLR group showed no significant differences at this angle(P = .319).

Discussion

The alternation of the tibiofemoral joint contact area and stress in reconstructed knees may be caused by the mismatch of the tibiofemoral joint during knee movement procedures compared with intact knees.

Conclusions

SB ACLR by the use of the AM portal method and TT method both alter the tibiofemoral contact area and stress when compared with the intact knee. When compared with the TT technique, ACLR by the AM portal technique more closely restores the intact tibiofemoral contact area and stress at low flexion angles.

Tomographic Study of Femoral Positioning in Anterior Cruciate Ligament Reconstruction Using the Transtibial Technique

Purpose

To analyze the location of the femoral tunnel by three-dimensional computed tomography (3D CT) of the lateral condyle in patients who underwent arthroscopic single-bundle anterior cruciate ligament (ACL) reconstruction, performed using a modified transtibial technique, and to compare the results with data from the literature.

Materials and Methods

Seventeen patients with ACL lesions underwent modified transtibial ACL reconstruction. Postoperatively, 3D CT examinations were performed and the images were analyzed by the quadrant system described by Bernard and Hertel to define the femoral tunnel coordinates.

Results

The mean value of femoral tunnel location coordinates was 37.1±5.9 in the horizontal plane and 23.9±7.5 in the vertical plane. Compared with other studies using the transtibial or transportal technique, femoral positioning was improved in the vertical plane. The outside-in technique provided the best results both in the vertical and horizontal planes.

Conclusions

The modified transtibial technique was not effective for systematically anatomic femoral tunnel positioning; however, it was relatively better than the conventional transtibial technique.

Comparing Transtibial and Anteromedial Drilling Techniques for Single-bundle Anterior Cruciate Ligament Reconstruction

Background:

Among the many factors that determine the outcome following anterior cruciate ligament (ACL) reconstruction, the position of the femoral tunnel is known to be critically important and is still the subject of extensive research.

Objective:

We aimed to retrospectively compare the outcomes of arthroscopic ACL reconstruction using transtibial (TT) or anteromedial (AMP) drilling techniques for femoral tunnel placement.

Methods:

ACL reconstruction was performed using the TT technique in 49 patients and the AMP technique in 56 patients. Lachman and pivot-shift tests, the Lysholm Knee Scale, International Knee Documentation Committee (IKDC) score, Tegner activity scale and visual analog scale (VAS) were used for the clinical and functional evaluation of patients. Time to return to normal life and time to jogging were assessed in addition to the radiological evaluation of femoral tunnel placement.

Results:

In terms of the Lysholm, IKDC, Tegner score, and stability tests, no significant differences were found between the two groups (p > 0.05). Statistical analysis revealed reduced time to return to normal life and jogging in the AMP group (p < 0.05). The VAS score was also significantly reduced in the AMP group (p < 0.05). The position of the femoral tunnel was anatomically appropriate in 51 patients in the AMP group and 5 patients in the TT group.

Conclusion:

The AMP technique is superior to the TT technique in creating anatomical femoral tunnel placement during single-bundle ACL reconstruction and provides faster recovery in terms of return to normal life and jogging at short-term follow-up.

Transtibial vs anatomical single bundle technique for anterior cruciate ligament reconstruction: A Retrospective Cohort Study

INTRODUCTION

Most of the ACL reconstruction is done with isometric single-bundle technique. Traditionally, surgeons were trained to use the transtibial technique (TT) for drilling the femoral tunnel. Our study compared the early postoperative period functional and clinical outcomes of patients who had ACL reconstruction with TT and patients who had ACL reconstruction with anatomical single-bundle technique (AT).

MATERIAL METHOD

Fifty-five patients who had ACL reconstruction and adequate follow-up between January 2010-December 2013 were included the study. Patients were grouped by their surgery technique. 28 patients included into anatomical single-bundle ACL reconstruction surgery group (group 1) and 27 patients were included into transtibial AC reconstruction group (group 2). Average age of patients in group 1 and group 2 was 28.3 ± 6, and 27.9 ± 6.4, respectively. Lachman and Pivot-shift tests were performed to patients. Laxity was measured by KT-1000 arthrometer test with 15, 20 and 30 pound power. All patients' muscle strength between both extremities were evaluated with Cybex II (Humac) at 60°/sec, 240°/sec frequencies with flexion and extension peak torque. The maximum force values of non-operated knee and the operated knee were compared to each other. Groups were evaluated by using International Knee Documentation Committee (IKDC) knee ligament healing Standard form, IKDC activity scale, modified Lysholm and Cincinnati evaluation forms. Return to work and exercise time of patients were compared. Functional and clinical outcomes of two groups were compared. NCSS 2007 and PASS 2008 Statistical Software programs were used for statistical analysis.

RESULT

There was no statistically significant difference between Lachman and Pivot-shift results (p > 0.01). Positive value of Pivot-shift test and incidence of anterior translation in Lachman test were higher in the patients who had TT. Lysholm activity level of patients who had TT, 33.3% (n = 9) were excellent, 51.9% (n = 14) were good and 14.8% (n = 4) were moderate; patients who had AT, 57.1% (n = 16) were excellent, 39.3% (n = 11) were good and 3.6% (n = 1) was good level. There was no statistically significant difference between Lysholm Activity level of the patients (p < 0.01). Lysholm Activity level of patients who had AT significantly higher than TT. There was no statistically significant difference between Modified Cincinnati activity level of the patients (p < 0.05). Modified Cincinnati activity level of patients who had AT were significantly higher than those had TT. There was no statistically significant difference between two groups with post treatment IKDC activity level (p < 0.01). Intense activity after treatment rate of patient who had AT was significantly higher than those had TT. There was statistically significant difference between Cybex extension-flexion 60 measurement and extension 240 measurement of the patients (p < 0.01). KT-1000 arthrometer test results with AT was better than the TT in antero-posterior translation of the knee kinematics at 20 and 30 pound of forces. Return to exercise time of patients who had TT was significantly higher than those had AT (p < 0.01). There was no statistically significant difference between return to work time of patients (p > 0.05).

CONCLUSION

Single-bundle anatomic ACL reconstruction was better than the TT in term of clinical, functional, and laboratory results. We believe that AT ACL reconstruction will increase in use and traditional method which is TT ACL reconstruction surgery will decrease in the long term. Theoretically, anatomic relocation of the ACL can provide better knee kinematics.

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.

Anatomical Single-bundle Anterior Cruciate Ligament Reconstruction Using a Freehand Transtibial Technique

Purpose

In anatomical single-bundle (SB) anterior cruciate ligament (ACL) reconstruction, the traditional transtibial approach can limit anatomical placement of the femoral tunnel.

Surgical Technique

We present a novel three-point freehand technique that allows for anatomic SB ACL reconstruction with the transtibial technique.

Materials and Methods

Between January 2012 and December 2012, 55 ACL reconstructions were performed using the three-point freehand technique. All the patients were followed for a minimum of 12 months post-operatively. Clinical evaluation was done using the Lysholm score and International Knee Documentation Committee (IKDC) grade. All patients were analyzed by 3-dimensional computed tomography (3D CT) at 1 week after surgery.

Results

The mean Lysholm score improved from 68.2±12.7 points preoperatively to 89.2±8.2 points at final follow-up. At final follow-up, the IKDC grade was normal in 42 patients and nearly normal in 13 patients. None of the patients had a positive pivot shift test, anterior drawer test and Lachman test at final follow-up. The anatomical position of the femoral tunnel was confirmed on 3D CT scans.

Conclusions

The three-point freehand technique for SB transtibial ACL reconstruction is a simple, anatomic technique showing good clinical results.

Clinical results comparing transtibial technique and outside in technique in single bundle anterior cruciate ligament reconstruction

Purpose

To compare the clinical results of single-bundle anterior cruciate ligament (ACL) reconstruction using the conventional transtibial technique and the anatomical outside-in technique for femoral tunneling.

Materials and Methods

From 2007 to 2011, 89 patients who received ACL reconstruction were followed for ≥1 year were enrolled in the study. The conventional transtibial technique was used in 41 patients and the outside-in technique, in 48 patients. Femoral tunnel angle measurement and three-dimensional computed tomography (3D CT) were used for radiologic assessment of the location of femoral tunnel and Lysholm score and other tests were used for clinical assessment.

Results

Both techniques did not reveal statistical differences in the clinical assessment. However, in International Knee Documentation Committee subjective knee evaluation, the sum of two questionnaire items regarding instability showed a statistically significant difference (p=0.01). In the pivot shift test, the anatomical outside-in technique showed outstanding rotational stability over the transtibial technique (p=0.04). The mean femoral tunnel inclination in coronal plane were 69.2° and 30.3°, respectively, for both techniques, and 21.6° and 50.8°, respectively in sagittal plane, showing statistically significant differences on simple radiography (p=0.04, 0.05). A 3D CT was performed in 17 patients with the conventional transtibial technique and 25 patients with the outside-in technique. Coefficients of variation were 0.33 and 0.13, respectively, from dorsal border of the condyle and 0.67 and 0.24, respectively, from the roof of intercondylar notch.

Conclusions

Femoral tunnels created with the outside-in technique have superior knee joint rotational stability compare to the transtibial technique. Therefore, the outside-in technique could be considered as a valuable technique in single-bundle ACL reconstruction.

Evaluation of femoral tunnel positioning using 3-dimensional computed tomography and radiographs after single bundle anterior cruciate ligament reconstruction with modified transtibial technique

BACKGROUND

The purpose of this study is to report a modified transtibial technique to approach the center of anatomical femoral footprint in anterior cruciate ligament (ACL) reconstruction and to investigate the accurate femoral tunnel position with 3-dimensional computed tomography (3D-CT) and radiography after reconstruction.

METHODS

From December 2010 to October 2011, we evaluated 98 patients who underwent primary ACL reconstruction using a modified transtibial technique to approach the center of anatomical femoral footprint in single bundle ACL reconstruction with hamstring autograft. Their femoral tunnel positions were investigated with 3D-CT and radiography postoperatively. Femoral tunnel angle was measured on the postoperative anteroposterior (AP) radiograph and the center of the femoral tunnel aperture on the lateral femoral condyle was assessed with 3D-CT according to the quadrant method by two orthopedic surgeons.

RESULTS

According to the quadrant method with 3D-CT, the femoral tunnel was measured at a mean of 32.94% ± 5.16% from the proximal condylar surface (parallel to the Blumensaat line) and 41.89% ± 5.58% from the notch roof (perpendicular to the Blumensaat line) with good interobserver (intraclass correlation coefficients [ICC], 0.766 and 0.793, respectively) and intraobserver reliability (ICC, 0.875 and 0.893, respectively). According to the radiographic measurement on the AP view, the femoral tunnel angles averaged 50.43° ± 7.04° (ICC, 0.783 and 0.911, respectively).

CONCLUSIONS

Our modified transtibial technique is anticipated to provide more anatomical placement of the femoral tunnel during ACL reconstruction than the former traditional transtibial techniques.

Three-dimensional reconstruction computed tomography evaluation of tunnel location during single-bundle anterior cruciate ligament reconstruction: a comparison of transtibial and 2-incision tibial tunnel-independent techniques

Background

Anatomic tunnel positioning is important in anterior cruciate ligament (ACL) reconstructive surgery. Recent studies have suggested the limitations of a traditional transtibial technique to place the ACL graft within the anatomic tunnel position of the ACL on the femur. The purpose of this study is to determine if the 2-incision tibial tunnel-independent technique can place femoral tunnel to native ACL center when compared with the transtibial technique, as the placement with the tibial tunnel-independent technique is unconstrained by tibial tunnel.

Methods

In sixty-nine patients, single-bundle ACL reconstruction with preservation of remnant bundle using hamstring tendon autograft was performed. Femoral tunnel locations were measured with quadrant methods on the medial to lateral view of the lateral femoral condyle. Tibial tunnel locations were measured in the anatomical coordinates axis on the top view of the proximal tibia. These measurements were compared with reference data on anatomical tunnel position.

Results

With the quadrant method, the femoral tunnel centers of the transtibial technique and tibial tunnel-independent technique were located. The mean (± standard deviation) was 36.49% ± 7.65% and 24.71% ± 4.90%, respectively, from the over-the-top, along the notch roof (parallel to the Blumensaat line); and at 7.71% ± 7.25% and 27.08% ± 7.05%, from the notch roof (perpendicular to the Blumensaat line). The tibial tunnel centers of the transtibial technique and tibial tunnel-independent technique were located at 39.83% ± 8.20% and 36.32% ± 8.10%, respectively, of the anterior to posterior tibial plateau depth; and at 49.13% ± 4.02% and 47.75% ± 4.04%, of the medial to lateral tibial plateau width. There was no statistical difference between the two techniques in tibial tunnel position. The tibial tunnel-independent technique used in this study placed femoral tunnel closer to the anatomical ACL anteromedial bundle center. In contrast, the transtibial technique placed the femoral tunnel more shallow and higher from the anatomical position, resulting in more vertical grafts.

Conclusions

After single-bundle ACL reconstruction, three-dimensional computed tomography showed that the tibial tunnel-independent technique allows for the placement of the graft closer to the anatomical femoral tunnel position when compared with the traditional transtibial technique.