Tunnel positions in transportal versus transtibial anterior cruciate ligament reconstruction: a case-control magnetic resonance imaging study

Transtibial Femoral Tunnel Technique in ACL Reconstruction and Osteoarthritis Incidence

Objective : Evaluate osteoarthritis incidence in patients that undergone ACL reconstruction using the transtibial technique, with a minimum of 5 years of follow up, with isolated ACL injury. Methods : Patients who underwent ACL reconstruction by the same surgeon using the transtibial technique with hamstrings graft and with a minimum of 5 years of follow-up, without other injuries during the surgical procedure, were selected to undergo imaging exams of the operated knee to assess the incidence of osteoarthritis. The obtained data were evaluated by descriptive statistics. Results : Forty-two patients (44 knees) were evaluated, with a mean age of 31 years old (SD: 8), being 23 right knees and 28 male patients. Mean time from surgery to imaging evaluation was 94.1 months (ranging from 60 to 154 months; SD: 28). Of the evaluated knees, 37 did not have osteoarthritis (83.3%) and 7 had (16.7%). Conclusion : ACL reconstruction with femoral tunnel performed through the transtibial technique in patients without other associated injuries in the operated knee, using hamstrings graft, with a minimum of 5 years of follow up, showed an osteoarthritis incidence of 16.7% in a mean follow-up of 94.1 months. Level Of Evidence V; Case Series.

Freehand vs. Medial Portal Offset Aimer Technique for Accurate Femoral Tunnel Placement in Arthroscopic ACL Reconstruction

Purpose

In this study, our aim was to reveal the effect of the medial femoral offset aimer usage through the femoral tunnel entry and exit points and the tunnel length during femoral tunnel drilling in arthroscopic anterior cruciate ligament (ACL) reconstruction.

Methods

One hundred patients who underwent arthroscopic single-bundle ACL reconstruction were included in the study. Group 1 consisted of 50 patients who underwent femoral tunnel drilling using a medial portal offset aimer device, while Group 2 consisted of 50 patients who were operated on using the freehand technique. Both groups were compared in terms of femoral tunnel and graft tunnel lengths, femoral tunnel angle in the coronal plane, and the location of the femoral tunnel entry and exit points.

Results

The mean femoral tunnel and graft tunnel lengths were significantly longer in Group 2 (p = 0.000). There was no significant difference in terms of localization of the femoral tunnel entry point in both the axial and sagittal planes. The tunnel exit point was located significantly more posterior in Group 1 in the axial plane (p = 0.028). There was no significant difference in terms of the coronal plane femoral tunnel angle between the two groups.

Conclusion

In arthroscopic ACL reconstructions, more successful results may be obtained with the freehand technique compared to drilling with a femoral offset aimer. For an experienced orthopedic surgeon, using a medial portal offset aimer device during femoral tunnel drilling does not seem necessary.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00929-z.

Analysis of Health-Related Quality of Life and Clinical Evaluations in Patients with the Triad of Combined Knee Injuries

Combined knee injuries of the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and medial meniscus were called "the unhappy triad" in the past. With recent advances in diagnostic technology, combined ACL, MCL, and lateral meniscus injuries are now known to be the predominant triad. We examined and verified the treatment outcomes of the triad of combined knee injuries from both patient-based subjective evaluation and objective assessments. We studied 49 knees (49 patients) with combined injuries of the ACL, MCL, and lateral meniscus. These cases were divided into those who underwent simultaneous ACL and MCL reconstruction (group A, 18 cases) and those who underwent ACL reconstruction only because MCL injury could be treated conservatively (group B, 31 cases). Clinical evaluation was conducted preoperative and 24 months or longer after surgery. The methods included patient-reported outcomes using Short Form-36, and conventional assessments using Lysholm's score, visual analogue scale (VAS), and quantitative measurement of knee instability using Telos SE. Compared with presurgical scores, the postsurgical Short Form-36 scores showed improvements in all eight subscales, all reaching the national standard values. Significant improvements were observed in the five subscales in group A and seven subscales in group B. Furthermore, significant improvements in Lysholm's score, VAS pain score, and quantitative knee instability were achieved in both groups. This study demonstrated successful clinical outcomes in patients with a triad of knee injuries who were treated with lateral meniscus repair or partial meniscectomy and either combined MCL/ACL reconstruction or ACL reconstruction alone.

Transtibial versus independent femoral tunnel drilling techniques for anterior cruciate ligament reconstruction: evaluation of femoral aperture positioning

Background

Femoral tunnel can be drilled through tibial tunnel (TT), or independent of it (TI) by out-in (OI) technique or by anteromedial (AM) technique. No consensus has been reached on which technique achieves more proper femoral aperture position because there have been evolving concepts in the ideal place for femoral aperture placement. This meta-analysis was performed to analyze the current literature comparing femoral aperture placement by TI versus TT techniques in ACL reconstruction.

Methods

We performed a comprehensive systematic review and meta-analysis of English-language literature in PubMed, Cochrane, and Web of Science databases for articles comparing femoral aperture placement by TI versus TT techniques with aperture position assessed by direct measurement or by postoperative imaging, PXR and/or CT and/or MRI.

Results

We included 55 articles with study population of 2401 knees of whom 1252 underwent TI and 1149 underwent TT techniques. The relevant baseline characteristics, whenever compared, were comparable between both groups. There was nonsignificant difference between TI and TT techniques in the distance from aperture center to footprint center and both techniques were unable to accurately recreate the anatomic footprint position. TI technique significantly placed aperture at more posterior position than TT technique. TI technique significantly lowered position of placed aperture perpendicular to Blumensaat’s line (BL) than TT technique, and modifications to TT technique had significant effect on this intervention effect. Regarding sagittal plane aperture placement along both AP anatomical axis and BL, there was nonsignificant difference between both techniques.

Conclusion

Modifications to TT technique could overcome limitations in aperture placement perpendicular to BL. The more anterior placement of femoral aperture by TT technique might be considered, to some extent, a proper position according to recent concept of functional anatomical ACL reconstruction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03040-5.

Effect of Tunnel Drilling Portal on Femoral Tunnel Entry Aperture’s Location in Arthroscopic Anterior Cruciate Ligament Reconstruction

Introduction

Transportal techniques for femoral tunnel drilling have the advantage of anatomical anterior cruciate ligament reconstruction, which was earlier difficult to achieve through transtibial femoral tunnels. However, the medial arthroscopic portal used for femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction (ACLR) has not been uniformly placed in different studies. Therefore, we performed a computed tomography-based analysis to compare the femoral tunnel entry aperture of the ACLR cases that used the standard AM portal and those using a far medial portal for femoral tunnel drilling.

Methods

We retrospectively reviewed computed tomography images of patients who underwent isolated single-bundle ACLR in our institute with either standard anteromedial portal or the far medial portal used for the femoral tunnel drilling. The femoral tunnel aperture's depth and height, measured using the quadrant method, were compared between the two portal methods.

Results

A total of forty-two case records were reviewed, sixteen belonging to standard anteromedial portal technique and twenty-six belonging to far medial portal technique. The tunnels created through the far AM portal were significantly shallower (more anterior) and inferior than the standard AM portal-created femoral tunnels.

Conclusion

The choice of drilling portals can influence transportal femoral tunnel drilling. A tendency towards anterior and inferior positioning of the femoral tunnel entry aperture has been observed when a far medial arthroscopic portal is used for femoral tunnel drilling. Therefore, care must be taken to ensure that the drilling guide pin position does not change when the reamer is passed over it.

Higher Incidence of Radiographic Posttraumatic Osteoarthritis With Transtibial Femoral Tunnel Positioning Compared With Anteromedial Femoral Tunnel Positioning During Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Anteromedial (AM) femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) has been reported by some authors to yield superior clinical and functional outcomes compared with the transtibial (TT) approach; however, differences in the subsequent rates of posttraumatic osteoarthritis (PTOA) are not clear.

PURPOSE

To perform a systematic review and meta-analysis of the literature to evaluate the influence of femoral tunnel positioning during primary ACLR on the development of radiographic PTOA.

STUDY DESIGN

Systematic review and Meta-analysis.

METHODS

The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019) were queried for all studies describing the development of PTOA after TT or AM ACLR. Data pertaining to patient demographics, ACLR technique, and radiographic PTOA were extracted. A meta-analysis utilizing the DerSimonian-Laird method for random effects was used to compare the weighted proportion of PTOA after ACLR between the TT and AM approaches.

RESULTS

There were 16 studies identified for inclusion with a total of 1546 patients. The mean follow-up across all studies was 10.9 years (range, 5.4-17.8 years). The mean follow-up in the AM and TT groups was 10.8 years (range, 5.4-17 years) and 11.4 years (range, 6-17.8 years), respectively. A total of 783 (50.6%) patients underwent TT ACLR. Of these patients, 401 (weighted mean, 49.3%) developed radiographic PTOA. A total of 763 (49.4%) patients underwent AM ACLR. Of these patients, 166 (mean, 21.8%) went on to develop radiographic PTOA. The meta-analysis demonstrated a significantly greater rate of PTOA after ACLR using a TT technique compared with an AM technique overall (49.3% vs 25.4%, respectively; P < .001) and when studies were stratified by 5- to 10-year (53.7% vs 14.2%, respectively; P < .001) and greater than 10-year (45.6% vs 31.2%, respectively; P < .0001) follow-up.

CONCLUSION

TT ACLR was associated with higher overall rates of radiographic PTOA compared with the AM ACLR approach. The rates of radiographic PTOA after ACLR with a TT approach were also significantly higher than using an AM approach when stratified by length of follow-up (5- to 10-year and >10-year follow-up).

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.

Does radiological evaluation of endobutton positioning in the sagittal plane affect clinical functional results in single-bundle anterior cruciate ligament reconstruction?

INTRODUCTION

Sports injuries are increasing today due to the increased interest in sports. The most common injured knee ligament is the anterior cruciate ligament (ACL) in sport injuries. Accordingly, surgical treatment of the ACL is performed frequently. In this study, it was aimed to retrospectively evaluate whether the location of an endobutton on lateral knee radiography was effective on knee functional scores in patients who underwent ACL reconstruction.

MATERIALS AND METHODS

One hundred thirty patients who underwent ACL reconstruction between January 2015 and February 2019 were identified. The patients were divided into three groups according to the location of the endobutton on lateral radiographs taken in the postoperative period. Group 1 patients were classified as anterior, group 2 as middle, and group 3 as posterior according to the location of the endobutton. Functional scoring, physical examination tests, comparative thigh diameter measurements, and single-leg hop tests were compared between the groups. It was evaluated as to whether there was a statistically significant difference between the groups.

RESULTS

There were 38 patients in group 1, 63 patients in group 2, and 29 patients in group 3. The mean age was 29.1 in group 1, 29.1 in group 2, and 29.7 in group 3. The mean follow-up period of the patients was 18.4 months in group 1, 19.1 months in group 2, and 21.4 months in group 3. The average Lysholm score was 92.9 in group 1, 93.3 in group 2, and 91.7 in group 3. The mean modified Cincinnati scores were 27.0, 27.1, and 26.6, respectively, in the groups. The mean IKDC score of the subjective knee assessments was 92.5, 92.8, and 91, respectively, according to the groups. The average thigh atrophy value was 1 cm, 1 cm, and 1.2 cm, respectively, in the groups. In the single-leg hop test, 34 patients in group 1 jump to over 85% of the distance compared with the intact side, while 58 patients in group 2, and 23 patients in group 3 were successfully able to jump this distance. The effect of the placement of the endobutton in the anterior, middle or posterior was not statistically significant on functional scores and physical examination results. In patients with endobuttons in the middle, functional scores were found better than in those with anterior or posterior placement.

CONCLUSIONS

No statistically significant differences were found in clinical functional results when comparing patients' endobutton location on femur. For this reason, surgical time should not be extended using unnecessary extra effort to change the orientation of the exit hole during surgery.

Clinical outcomes of primary anatomic all-inside Anterior Cruciate Ligament reconstruction using the TransLateral technique: A minimum one-year follow-up study

BACKGROUND

Anatomic all-inside Anterior Cruciate Ligament (ACL) reconstruction using the TransLateral technique is relatively new. This technique utilises single tendon autograft and instruments permitting inside-to-out drilling to create retrograde sockets. Few studies have investigated clinical outcomes following this technique. We investigate clinical outcomes in patients who underwent primary anatomic all-inside ACL reconstruction using the TransLateral technique with a minimum one-year follow-up.

METHODS

Interrogation of our prospectively maintained database identified patients who underwent surgery from June 2013 to December 2017. Patients were followed up clinically and using patient-reported outcome measures (PROMS) including EQ-5D, KOOS, IKDC and Tegner scores from the National Ligament Registry. Paired two-tailed Student t-test was used to assess for clinical significance.

RESULTS

One hundred forty-one cases with a mean age of 30 years (range 16.0-60.2) and mean follow-up of 17.4 months (12.1-75.2) were included. Grafts included isolated quadrupled semitendinosus (n = 115) and both quadrupled semitendinosus and gracilis (n = 26). One hundred and two patients (72.3%) had complete peri-operative PROMS. Mean increases in EQ-5D VAS and IKDC scores were 18.9 and 29.2 points (p < 0.001). Significant peri-operative improvements were observed for all KOOS domains (p < 0.001). Median Tegner activity score increased by two levels (p < 0.001). Incidence of graft re-rupture was 5.7% (n = 8), all were following significant knee trauma and seven cases were mid-bundle femoral tunnel placements.

CONCLUSIONS

All-inside ACL reconstruction using the TransLateral technique demonstrates good clinical and functional outcomes with low complication and failure rate. Mid-bundle femoral tunnel placements have been abandoned in favour of placement deep within the anteromedial bundle footprint.

Clinico-radiological outcomes following anatomical anterior cruciate ligament reconstruction using the TransLateral, all-inside technique

We present early clinical outcomes of patients following anatomical anterior cruciate ligament reconstruction using a TransLateral, single bundle, all-inside technique with a one-year follow-up and radiological evaluation of socket position. Eligible Patients who underwent a primary ACL reconstruction, using the TransLateral, all-inside technique alone, between Jan 2013 and Feb 2016 were included in this study. Of this group, all patients underwent isolated semitendinosus graft harvest. The Lysholm knee scores were measured preoperatively and at one-year follow-up in 40 patients who underwent ACL reconstruction. Postoperatively, antero-posterior and lateral radiographs were obtained to evaluate the position of the femoral socket (using the Bernard and Hertel Grid) and tibial socket (using the Amis-Jakob line). There were 36 males and 4 females with a mean age of 27.1 years (range 16-49). There was a single non-surgical related mortality prior to the one year follow up. We report no postoperative infections or graft failure at one year. The mean preoperative Lysholm score was 68.7 (Range: 29-95). The mean Lysholm score increased to 92.5% (Range: 59-100, p < 0.05). Evaluation of femoral sockets revealed accurate positioning on the Bernard and Hertel Grid with a mean ACL center of 27% along Blumensaat's line and 34% of the height of the intercondylar notch. The mean tibial socket position was 41.8% (Range: 32%-47%) along the Amis-Jakob Line. Our single surgeon case series utilizing the all-inside, TransLateral ACLR technique highlights good early outcomes with no postoperative complications or graft failure at one year.

Graft Inclination Angles in Anterior Cruciate Ligament Reconstruction Vary Depending on Femoral Tunnel Reaming Method: Comparison Among Transtibial, Anteromedial Portal, and Outside-In Retrograde Drilling Techniques

PURPOSE

To compare graft coronal and sagittal inclination angles in anterior cruciate ligament (ACL) reconstruction performed by different femoral tunnel drilling techniques with respect to intact native ACL.

METHODS

In total, 72 patients were prospectively enrolled in the study. The inclusion criteria were complete ACL rupture and patient age between 18 and 55 years. Reconstructions were performed using 4 different femoral tunnel drilling technique: transtibial (TT), anteromedial portal with rigid (AMP-RR) or flexible (AMP-FR) reamer, and outside-in retrograde drilling (OI) techniques. Eighteen patients with intact native ACL were included as controls. Sagittal and coronal graft inclination angles were measured by magnetic resonance imaging 6 months after the procedure by 1 radiologist blinded in regards to the used technique.

RESULTS

OI and AMP-FR techniques allowed for the maintenance of native-like ACL inclination in both the sagittal and coronal planes, whereas TT and AMP-RR increased the sagittal angle by a mean of 9.5° (P < .001) and 6.7° (P = .003), respectively, compared with native ACLs. AMP-RR and TT also showed increased sagittal graft inclination compared with AMP-FR (+6.1°, P = .009 and +9.0°, P < .001, respectively) and OI-drilling techniques (+5.5°, P = .024 and +8.4°, P < .001, respectively). No differences were observed among study groups in terms of coronal graft inclination.

CONCLUSIONS

The study hypothesis was partially confirmed, since OI and AMP-FR techniques, but not AMP-RR, using an independent portal for femoral drilling produce a more anatomic graft inclination on the sagittal plane with respect to TT.

LEVEL OF EVIDENCE

II, prospective comparative study.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication

BACKGROUND

This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).

METHODS

The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.

CONCLUSIONS

This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

[A comparative study of arthroscopic anterior cruciate ligament reconstruction via transtibial and transportal techniques]

OBJECTIVE

To investigate the effectiveness of arthroscopic anterior cruciate ligament (ACL) reconstruction via transtibial (TT) and transportal (TP) techniques after 10 years follow-up.

METHODS

A clinical data of 103 patients who underwent arthroscopic ACL reconstruction with a single bundle of autologous hamstring tendon between March 2006 and March 2009 was retrospectively analyzed, among which 57 patients were reconstructed with TT technique (TT group) and 46 patients were reconstructed with TP technique (TP group). There was no significant difference in gender, age, cause of injury, interval between injury and operation, preoperative pivot shift test, preoperative International Knee Documentation Committee (IKDC) score, Lysholm score, and KT-2000 side-to-side difference (SSD) between the two groups ( P>0.05). At 10 years after operation, Lachman test was used to evaluate the forward joint stability and pivot shift test to evaluate the rotational stability of the knee; KT-2000 SSD was used to measure tibial anterior displacement; IKDC score and Lysholm score were used to evaluate knee function; MRI examination was performed to observe graft healing and measure coronal inclination angles of the tibia and femoral tunnels. The rate of return to sports was also calculated.

RESULTS

The incisions healed by first intention in the two groups, and no early complication occurred after operation. All patients were followed up 10-13 years, with an average of 11.5 years. During the follow-up period, there was no limitation of knee extension and flexion, no discomfort of donor site or graft failure in either group. MRI examination showed that the graft healed well. The IKDC score, Lysholm score, and KT-2000 SSD in the two groups were significantly improved after 10 years ( P<0.05), and there was no significant difference between the two groups at 10 years after operation ( P>0.05). There were significant differences in coronal inclination angles of femoral tunnel and tibial tunnel between the two groups ( P<0.05). There was no significant difference in Lachman test and pivot shift test between the two groups ( P>0.05). The rate of return to sports of patients was 61.40% (35/57) in TT group and 63.04% (29/46) in TP group, showing no significant difference between the two groups ( χ 2=0.29, P=0.87).

CONCLUSION

TT and TP techniques can both achieve good effectiveness in ACL reconstruction.

Comparison of 2 femoral tunnel drilling techniques in anterior cruciate ligament reconstruction. A prospective randomized comparative study

BACKGROUND

To evaluate the length and position of femoral tunnel,and exam whether knee stability and clinical functional outcomes are superior in AMP method.

METHODS

From August 2014 to February 2015, we prospectively recruited 104 patients undergoing anterior cruciate ligament reconstruction. They were randomized to anteromedial portal or transtibial method. All patients underwent Lysholm score, International Knee Documentation Committee score,Tegner score at pre-operative and last follow-up point as subjective assessment of clinical function. The Lachman test, the Pivot-shift test and KT-1000 were performed at the last follow-up as a evaluation of knee joint stability. We measured the length of femoral tunnel intraoperatively and at 1 week post-operatively, CT-based three-dimensional reconstruction was used to assess femoral tunnel location.

RESULTS

The average follow-up time of anteromedial portal group was 25.7 ± 6.8 months (range:12-36.5 months), and the average follow-up time of the transtibial group was 24.9 ± 6.0 months (range:12-37 months). There was no significant difference between the groups pre-operative Lysholm score, IKDC score and Tegner scores. Both groups showed significantly improvement in these clinical function scores at follow up for their ACL reconstruction. However, there was no significant difference in the function scores between the two groups at last follow up. However, the mean femoral tunnel length in the anteromedial portal group was significantly shorter than that in the transtibial group. And tunnel location was significantly lower and deeper with the anteromedial portal technique than with the transtibial technique.

CONCLUSION

The use of anteromedial portal method resulted in a significantly lower and deeper placement of the femoral tunnel, and a shorter tunnel length compared to the transtibial method. However, there was no statistical difference in terms of clinical function and knee joint stability between the anteromedial portal method and the transtibial method.

TRIAL REGISTRATION

Name of the registry: Chinese Clinical Trial Registry. The registration number: ChiCTR1800014874 . The date of registration: 12 February, 2018. The study is retrospectively registered.

No difference in graft healing or clinical outcome between trans-portal and outside-in techniques after anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to compare femoral tunnel geometry including tunnel position, length, and graft bending angle between trans-portal and outside-in techniques in anterior cruciate ligament (ACL) reconstruction and discover whether such differences in tunnel geometry could influence graft healing or clinical outcome.

METHODS

Sixty-four patients with anatomical single-bundle ACL reconstruction performed with either trans-portal technique (32 patients, one centre) or outside-in technique (32 patients, the other centre) were included in this retrospective study. Femoral tunnel location and length, and graft bending angle at the femoral tunnel were analysed on 3D CT knee model. The location and length of the femoral tunnel and graft bending angle were compared between the two techniques. All patients underwent MRI scans at around 1 year following ACL reconstruction. It was found that all patients had intact ACL graft on MRI images. On oblique axial image taken after ACL reconstruction to determine graft healing at femoral and tibial tunnels and the intra-articular portion, graft signal intensity ratio was calculated by dividing signal intensity (SI) of the reconstructed ACL by that of posterior cruciate ligament (PCL) in the region of interest selected with Marosis software. Clinical outcomes regarding Tegner activity scores, the International Knee Documentation Committee (IKDC) evaluation scores, Lachman test, and pivot shift test results were also compared between the two groups.

RESULTS

While the location of femoral tunnel was similar to each other in both groups, the femoral tunnel length was longer in the outside-in technique (37.0 vs. 32.4 mm, p = .02). Meanwhile, the outside-in technique showed significantly more acute graft tunnel angle than the trans-portal technique (106.7° vs. 113.8°, p = .01). However, signal intensity ratios of grafts (compared with SI of PCL) were similar in femoral and tibial tunnels and intra-articular portions. Moreover, there were no statistically significant differences in terms of IKDC scores (89.4 vs. 90.5, n.s.) or Tegner activity scores (6.2 vs. 6.4, n.s.) between the two groups. There was no significant difference in measurement of Lachman or Pivot shift test either between the two groups.

CONCLUSION

Even though the outside-in technique in ACL reconstruction created a more acute femoral graft bending angle and a longer femoral tunnel length than the trans-portal technique, these had no negative effect on graft healing. In addition, trans-portal and outside-in techniques in ACL reconstruction showed similar femoral tunnel positions and clinical outcomes. Acceptable graft healing and clinical outcomes can be obtained for both trans-portal and outside-in techniques in ACL reconstruction.

LEVEL OF EVIDENCE

III.

Anatomic All-Inside Anterior Cruciate Ligament Reconstruction Using the TransLateral Technique

Background: Anterior cruciate ligament (ACL) reconstruction is a commonly performed procedure and considered to be the gold standard in restoring knee function and stability in ACL-deficient knees. The TransLateral all-inside technique implies the use of only two portals – anterolateral and anteromedial, without the use of an accessory portal. The work is done using the lateral portal, while the medial portal serves as a viewing site. Only a few studies have been published regarding the assessment of the functional and clinical outcomes of this novel technique.

Aim of the study: To determine the clinical effectiveness of the TransLateral procedure used for ACL reconstruction and its ability to re-establish joint functionality and stability in ACL-deficient knees.

Material and methods: A prospective study was conducted at the Orthopedics and Traumatology Clinic no. 2 in Tîrgu Mureș. Thirty-two patients matched our inclusion criteria and were operated using the TransLateral technique for ACL reconstruction. Outcome assessment was performed using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm score and the Tegner Activity Scale. The questionnaires include items referring to pain, physical functioning, sports activities, and quality of life. Operative time and ACL graft size were also documented.

Results: All patients underwent single-bundle ACL restoration using a quadrupled semitendinosus tendon. Out of 32 patients, 21 had associated meniscus lesions and 8 collateral ligament injuries. Mean graft diameter was 8.7 mm and mean length 63.2 mm. Significantly improved KOOS values were found at 12 months post-surgery regarding the mean baseline score: 59.3 ± 5.3 vs. 95.3 ± 4.9, p <0.0001. The Lysholm score improved from a mean of 56.3 ± 4.9 to 93.9 ± 5.6, p <0.0001 at the end-point. The Tegner activity scale ranged from 3.8 ± 1.9 to 5.9 ± 2.4, p <0.0001 at the final follow-up.

Conclusions: The TransLateral technique proved its clinical effectiveness and its ability to restore knee stability after ACL reconstruction surgery.

Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials

Background

The aim of this study was to compare the clinical outcome and postoperative complication between single-bundle anterior cruciate ligament (ACL) reconstruction with an anteromedial (AM) technique and a transtibial (TT) technique.

Methods

The study includes clinical randomized controlled trials comparing the clinical outcomes of ACL reconstruction using the autologous hamstring tendon with an AM method and a TT method published up to September 2017 were retrieved from PubMed, Cochrane Library, and Embase databases. Relevant data were extracted and the Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality. Stata/SE 12.0 was used to perform a meta-analysis of the clinical outcome.

Results

Five RCTs were included, with a total of 479 patients: 239 patients and 240 patients in the AM group and the TT group, respectively. Assessing postoperative stability, better results were found in the AM group for the negative rate of the Lachman test (P < 0.05), the negative rate of the pivot-shift test (P < 0.05) and the side-to-side difference (P < 0.05). Assessing postoperative functional outcome, the AM group yielded superior results in proportion with International Knee Documentation Committee (IKDC) grade A (P < 0.05) and the Lysholm scores (P < 0.05) but had a comparable IKDC score (P > 0.05). In terms of postoperative complication, no significant difference was found between the AM group and the TT group (P > 0.05).

Conclusions

The outcome of single-bundle ACL reconstruction with the AM technique is better than that with the TT technique in terms of postoperative stability and functional recovery of the knee.

Three dimensionalCT analysis of femoral tunnel position after ACL reconstruction. A prospective study of one hundred and thirty five cases

BACKGROUND

One of the principal causes for failure of anterior cruciate ligament reconstruction (ACL) is femoral tunnel mal-position. Several studies compare the position of femoral tunnels achieved with various techniques, with small series and using a quadrant assessment method.

QUESTIONS

(1) What is the incidence of anatomical positioning of the intra-articular femoral tunnel aperture in primary ACL reconstruction in a university knee surgery? (2) What are the main errors in positioning?

METHODS

3D-CT scans were performed after primary ACL reconstruction in 135 consecutive cases. The intra-articular position of the femoral tunnel aperture was analyzed using the Magnussen classification.

RESULTS

The intra-articular tunnel position was deemed anatomical in 77%, intermediate in 20.8%, and non-anatomical in 2.2%. Among the mal-positioned tunnels, 54.8% were vertical, 29% were anteriorly positioned, and 16.1% were both.

CONCLUSIONS

The intra articular femoral tunnel aperture was well positioned using an outside-in technique. The main error of tunnel positioning was a tunnel too vertical.

LEVEL OF EVIDENCE

Level III, prospective study (case series).

Comparison of tunnel variability between trans-portal and outside-in techniques in ACL reconstruction

PURPOSE

Although trans-portal and outside-in techniques are commonly used for anatomical ACL reconstruction, there is very little information on variability in tunnel placement between two techniques.

METHODS

A total of 103 patients who received ACL reconstruction using trans-portal (50 patients) and outside-in techniques (53 patients) were included in the study. The ACL tunnel location, length and graft-femoral tunnel angle were analyzed using the 3D CT knee models, and we compared the location and length of the femoral and tibial tunnels, and graft bending angle between the two techniques. The variability in each technique regarding the tunnel location, length and graft tunnel angle using the range values was also compared.

RESULTS

There were no differences in the average of femoral tunnel depth and height between the two groups. The ranges of femoral tunnel depth and height showed no difference between two groups (36 and 41 % in trans-portal technique vs. 32 and 41 % in outside-in technique). The average value and ranges of tibial tunnel location also showed similar results in two groups. The outside-in technique showed longer femoral tunnel than the trans-portal technique (34.0 vs. 36.8 mm, p = 0.001). The range of femoral tunnel was also wider in trans-portal technique than in outside-in technique. Although the outside-in technique showed significant acute graft bending angle than trans-portal technique in average values, the trans-portal technique showed wider ranges in graft bending angle than outside-in technique [ranges 73° (SD 13.6) vs. 53° (SD 10.7), respectively].

CONCLUSIONS

Although both trans-portal and outside-in techniques in ACL reconstruction can provide relatively consistent in femoral and tibial tunnel locations, trans-portal technique showed high variability in femoral tunnel length and graft bending angles than outside-in technique. Therefore, the outside-in technique in ACL reconstruction is considered as the effective method for surgeons to make more consistent femoral tunnel.

LEVEL OF EVIDENCE

III.

Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction

BACKGROUND

This paper reports the outcomes of patients undergoing ACL reconstruction using a TransLateral single bundle, all-inside hamstring technique at a minimum of two year follow-up.

METHODS

The semitendinosus alone is harvested, quadrupled and attached in series to two adjustable suspensory fixation devices. Femoral and tibial sockets are produced using a retrograde drill. The graft is deployed, fixed and tensioned on both tibia and femur. Patients were evaluated preoperatively using the KOOS, Lysholm and Tegner scores and at six, 12 and 24months postoperatively. Objective assessment of knee laxity was performed using the KT-1000 along with goniometric measurement of range or motion.

RESULTS

One hundred and eight patients, mean age 30.9years (range 15 to 61) were included. Mean follow-up 49.8months (range 30-66). The mean increase in KOOS at two years was 30.3 points; Lysholm, 33.1 points; Tegner Activity scale, 2.0 levels. These were all statistically significant (p<0.001). Range of motion in the reconstructed knee approximated the uninjured knee by 12months and was restored by two years. KT-1000 showed significant reduction in side-side difference to no more than 2.4mm at all postoperative time points (p<0.001). Re-rupture rate in this series was 6.5%, all following episodes of significant additional postoperative trauma to the knee.

CONCLUSIONS

TransLateral all-inside ACL reconstruction demonstrates good medium term subjective and objective outcomes with a low complication and failure rate.

Graft position in arthroscopic anterior cruciate ligament reconstruction: anteromedial versus transtibial technique

INTRODUCTION

When treating anterior cruciate ligament (ACL) injuries, the position of the ACL graft plays a key role in regaining postoperative knee function and physiologic kinematics. In this study, we aimed to compare graft angle, graft position in tibial tunnel, and tibial and femoral tunnel positions in patients operated with anteromedial (AM) and transtibial (TT) methods to those of contralateral healthy knees.

MATERIALS AND METHODS

Forty-eight patients who underwent arthroscopic ACL reconstruction with ipsilateral hamstring tendon autograft were included. Of these, 23 and 25 were treated by AM and TT techniques, respectively. MRI was performed at 18.4 and 19.7 months postoperatively in AM and TT groups. Graft angles, graft positions in the tibial tunnel and alignment of tibial and femoral tunnels were noted and compared in these two groups. The sagittal graft insertion tibia midpoint distance (SGON) has been used for evaluation of graft position in tunnel.

RESULTS

Sagittal ACL graft angles in operated and healthy knees of AM patients were 57.78° and 46.80° (p < 0.01). With respect to TT patients, ACL graft angle was 58.87° and 70.04° on sagittal and frontal planes in operated knees versus 47.38° and 61.82° in healthy knees (p < 0.001). ACL graft angle was significantly different between the groups on both sagittal and frontal planes (p < 0.001). Sagittal graft insertion tibia midpoint distance ratio was 0.51 and 0.48 % in the operated and healthy knees of AM group (p < 0.001) and 0.51 and 0.48 % in TT group (p < 0.001). Sagittal tibial tunnel midpoint distance ratio did not differ from sagittal graft insertion tibia midpoint distance of healthy knees in either group. Femoral tunnel clock position was better in AM [right knee 10:19 o'clock-face position (310° ± 4°); left knee 1:40 (50° ± 3°)] compared with TT group [right knee 10:48 (324° ± 5°); left knee 1:04 (32° ± 4°)]. With respect to the sagittal plane, the anterior-posterior position of femoral tunnel was better in AM patients. Lysholm scores and range of motion of operated knees in the AM and TT groups showed no significant difference (p > 0.05).

CONCLUSIONS

Precise reconstruction on sagittal plane cannot be obtained with either AM or TT technique. However, AM technique is superior to TT technique in terms of anatomical graft positioning. Posterior-placed grafts in tibial tunnel prevent ACL reconstruction, although tibial tunnel is drilled on sagittal plane.

Functional knee assessment with advanced imaging

The purpose of anterior cruciate ligament (ACL) reconstruction is to restore the native stability of the knee joint and to prevent further injury to meniscus and cartilage, yet studies have suggested that joint laxity remains prevalent in varying degrees after ACL reconstruction. Imaging can provide measurements of translational and rotational motions of the tibiofemoral joint that may be too small to detect in routine physical examinations. Various imaging modalities, including fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI), have emerged as powerful methods in measuring the minute details involved in joint biomechanics. While each technique has its own strengths and limitations, they have all enhanced our understanding of the knee joint under various stresses and movements. Acquiring the knowledge of the complex and dynamic motions of the knee after surgery would help lead to improved surgical techniques and better patient outcomes.

Transportal femoral drilling creates more horizontal ACL graft orientation compared to transtibial drilling: A 3D CT imaging study

BACKGROUND

The principle of anatomic anterior cruciate ligament (ACL) reconstruction is to create a femoral and tibial tunnel that resembles the insertion of the native ACL. Anatomic reconstruction leads to a more horizontal graft orientation that provides more rotational stability. The aim of this study is to investigate the best method to achieve anatomical reconstruction of femoral insertion of the ACL and thus, a more horizontal orientation of the ACL. We compared tunnel position and orientation between transportal femoral drilling technique and transtibial technique.

METHODS

Thirty-two patients were included. Post-operative CT scans were obtained and femur, tibia and ACL tunnels were reconstructed. The position and orientation of tibial and femoral tunnels were quantified using the quadrant method, and femoral tunnel length, ellipticity and posterior wall breakage were assessed. We also investigated clinical outcome.

RESULTS

Analyses show that transportal drilled femoral tunnels were situated significantly lower than transtibial drilled tunnels (p<0.0001), resulting in a significantly more horizontal oriented ACL in the transportal group in coronal (p<0.0001) and sagittal plane (p=0.01). No differences were observed in depth of femoral tunnel position (p=0.44). Femoral tunnel length was shorter in the transportal group (p=0.01) with a more ellipsoidal femoral aperture (p=0.01). There were no differences between both groups in tibial position. There were no differences in clinical outcome measure between the transportal and transtibial groups.

CONCLUSION

This study indicates that transportal drilling of the femoral tunnel leads to a more horizontal graft orientation of the ACL, without differences in clinical outcome.

Current practice variations in the management of anterior cruciate ligament injuries in Delhi

BACKGROUND

The aim of this study was to determine the current practices and preferences of the arthroscopic surgeons of Delhi in the diagnosis, treatment and rehabilitation of patients with anterior cruciate ligament (ACL) injury.

METHODS

It was a cross-sectional descriptive study conducted among arthroscopic surgeons of Delhi. A survey was conducted using a questionnaire that was sent either by e-mail or by direct contact to all sixty arthroscopic surgeons of Delhi.

RESULTS

Forty-eight (80%) surgeons responded to our questionnaire. Maximum participants (83.3%) used semitendinosus/gracilis tendon autograft for ACL reconstruction (ACLR) and only 2.1% were using bone-patellar-tendon-bone (BPTB) autograft. Most preferred method of graft fixation was an 'interference screw' on the tibial side and an 'endobutton' on the femoral side, which was preferred by 95.83% and 93.75% surgeons, respectively. Almost all respondents (97%) used a bio-absorbable interference screw for tibial side graft fixation. Postoperative bracing was advised for <3 weeks by 47.9% surgeons and for 3-6 weeks by 31.3%. The results were analysed using statistical analysis.

CONCLUSION

Surgeon preferences in ACLR differ considerably among the arthroscopic surgeons of Delhi. There is majority consensus for using Hamstring autograft (single bundle) with a suspensory fixation on the femoral side and an aperture fixation on the tibial side. Transportal technique of making the femoral tunnel and preservation of amputation stump were the preferred methods. However, differences exist over the timing of surgery, rehab after surgery, pain management, etc.

Current Trends in Anterior Cruciate Ligament Reconstruction: A Review

Anterior cruciate ligament reconstruction (ACLR) is an accepted and established surgical technique for anterior cruciate ligament (ACL) injuries and is now being practiced across the globe in increasing numbers. Although most patients get good to excellent results in the short-term after ACLR, its consequences in the long-term in prevention or acceleration of knee osteoarthritis (OA) are not yet well-defined. Still, there are many debatable issues related to ACLR, such as the appropriate timing of surgery, graft selection, fixation methods of the graft, operative techniques, rehabilitation after surgery, and healing augmentation techniques. Most surgeons prefer not to wait long after an ACL injury to do an ACLR, as delayed reconstruction is associated with secondary damages to the intra- and periarticular structures of the knee. Autografts are the preferred choice of graft in primary ACLR, and hamstring tendons are the most popular amongst surgeons. Single bundle ACLR is being practiced by the majority, but double bundle ACLR is getting popular due to its theoretical advantage of providing more anatomical reconstruction. A preferred construct is the interference fixation (Bio-screw) at the tibial site and the suspensory method of fixation at the femoral site. In a single bundle hamstring graft, a transportal approach for creating a femoral tunnel has recently become more popular than the trans-tibial technique. Various healing augmentation techniques, including the platelet rich plasma (PRP), have been tried after ACLR, but there is still no conclusive proof of their efficacy. Accelerated rehabilitation is seemingly more accepted immediately after ACLR.

Finite element study on the anatomic transtibial technique for single-bundle anterior cruciate ligament reconstruction

The anatomic transtibial (TT) technique is proposed as a new approach for single-bundle anterior cruciate ligament (ACL) reconstruction. Geometric models of the anatomic TT and anteromedial (AM) portal techniques were fabricated with a reconstructed knee joint model and virtual surgical operations. Grafts of 7 mm diameter were modeled and inserted into tunnels drilled in each model. In the models, the shape of the graft between the femur and the tibia, the lengths of the bone tunnels, and the femoral graft bending angles were evaluated. To evaluate the biomechanical effects of both techniques on the grafts, the contact pressures and maximum principal stresses in the grafts were calculated using the finite element method. The anatomic TT technique placed the femoral tunnel to the anatomic position of the native ACL femoral attachment site. In addition, it decreased the peak contact pressure and the maximum principal stress at the full extension position of the graft compared with the AM portal technique. The anatomic TT technique may be regarded as a superior surgical technique compared with the conventional TT and AM portal techniques. Because of the easy surgical operation involved, the technique decreases the operation time for ACL reconstruction and it provides a deformation behavior of grafts similar to that in the native ACL in a knee joint. With its few side effects, the anatomic TT technique may considerably help patients.

Direct Visualization of Existing Footprint and Outside-In Drilling of the Femoral Tunnel in Anterior Cruciate Ligament Reconstruction in the Knee

Improper femoral tunnel placement in anterior cruciate ligament (ACL) reconstruction is a significant problem and may be a cause of ACL graft failure and abnormal kinematics, which may lead to late degenerative changes after reconstruction. Recently, there has been concern that the transtibial approach may contribute to nonanatomic placement of the femoral tunnel, resulting in abnormal knee kinematics. Tibial-independent techniques can provide more anatomic placement of the ACL graft, but these can be technically demanding. This technical note describes the senior author's technique to directly identify the femoral ACL remnant and use the center of the femoral ACL footprint and retrograde drilling to create an anatomic femoral socket for single-bundle reconstruction. This technique provides femoral tunnel placement based on identification of a patient-specific ACL footprint instead of averaged anatomic measurements from large groups. This technique has been shown to produce anatomic ACL graft position and orientation and restore more normal knee kinematics.

Reliability and reproducibility of several methods of arthroscopic assessment of femoral tunnel position during anterior cruciate ligament reconstruction

PURPOSE

To assess interobserver and intraobserver agreement of estimating anterior cruciate ligament (ACL) femoral tunnel positioning arthroscopically using circular and linear (noncircular) estimation methods and to determine whether overlay template visual aids improve agreement.

METHODS

Standardized intraoperative pictures of femoral tunnel pilot holes (taken with a 30° arthroscope through an anterolateral portal at 90° of knee flexion with horizontal being parallel to the tibial surface) in 27 patients undergoing single-bundle ACL reconstruction were presented to 3 fellowship-trained arthroscopists on 2 separate occasions. On both viewings, each surgeon estimated the femoral tunnel pilot hole location to the nearest half-hour mark using a whole clock face and half clock face, to the nearest 15° using a whole compass and half compass, in the top or bottom half of a linear quadrant, and in the top or bottom half of a linear trisector. Evaluations were performed first without and then with an overlay template of each estimation method.

RESULTS

The average difference among reviewers was quite similar for all 4 circular methods with the use of visual aids. Without overlay template visual aids, pair-wise κ statistic values for interobserver agreement ranged from -0.14 to 0.56 for the whole clock face and from 0.16 to 0.42 for the half clock face. With overlay visual guides, interobserver agreement ranged from 0.29 to 0.63 for the whole clock face and from 0.17 to 0.66 for the half clock face. The quadrant method's interobserver agreement ranged from 0.22 to 0.60, and that of the trisection method ranged from 0.17 to 0.57. Neither linear estimation method's reliability uniformly improved with the use of overlay templates. Intraobserver agreement without overlay templates ranged from 0.17 to 0.49 for the whole clock face, 0.11 to 0.47 for the half clock face, 0.01 to 0.66 for the quadrant method, and 0.20 to 0.57 for the trisection method. Use of overlay templates did not uniformly improve intraobserver agreement for any estimation method.

CONCLUSIONS

There does not appear to be any advantage of using a half clock face or compass for estimating femoral tunnel position compared with a whole clock-face analogy. Visual reference aids appear to improve interobserver agreement (reliability) of circular analogies. The linear quadrant appears to be the most reliable method (fair to moderate agreement) for estimating femoral tunnel position without a visual aid for reference, but even better reliability, ranging from fair to good agreement, may be obtained by using the whole clock-face analogy with a visual aid.

CLINICAL RELEVANCE

Increasing femoral tunnel position reliability may improve outcomes of ACL reconstruction surgery.

Low inter- and intraobserver variability allows for reliable tunnel measurement in ACL reconstruction using the quadrant method

INTRODUCTION

Correct anatomic tunnel positions are essential in anterior cruciate ligament (ACL) reconstruction. To establish recommendations for tunnel positioning based on anatomical findings and to compare tunnel positions with clinical results, different radiological measurement methods as the quadrant method exist. Comparing the data of different observers requires the validation of the reliability of measurement methods. The purpose of this study therefore was to determine the reliability of the quadrant method to measure tunnel positions in ACL reconstruction. The hypothesis was, that the quadrant method shows a low inter- and intraobserver variability.

MATERIALS AND METHODS

In a test/retest scenario 20 knee surgeons were asked to determine defined tunnel positions in five lateral radiographs applying the quadrant method. Rotation, angle deviation, height and depth of the quadrant as well as absolute and relative tunnel positions of each observation were measured along referenced scales. Mean sizes and angle deviations of the quadrants, tunnel positions and deviations between the test/retest positions were calculated as well as standard deviations and range.

RESULTS

Interobserver variability analyses, to plan as well as to determine tunnel positions in ACL reconstruction, showed a mean variability (SD) of <1 mm, with ranges of 2.5 mm for planning and 3.7 mm for determination of tunnel positions using the quadrant method. Intraobserver analysis showed mean variability with deviations of <1 mm and maximum standard deviations of 0.7 mm and ranges of up to 2.3 mm.

CONCLUSIONS

We confirmed the hypothesis that the quadrant method has a low inter- and intraobserver variability. Based on the presented validation data, the quadrant method can be recommended as reliable method to radiographically describe insertion areas of the ACL as well as to determine tunnel positions in ACL reconstruction intra and postoperatively.