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DOI: 10.1055/s-0037-1601413
Femoral Tunnel Positioning in Anterior Cruciate Ligament Reconstruction: Anteromedial Portal versus Transtibial Technique—A Randomized Clinical Trial
Publication History
Publication Date:
05 June 2017 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00033766/201701/lookinside/thumbnails/10-1055-s-0037-1601413_1603050-1.jpg)
Abstract
Purpose The purpose of this study was to investigate, through three-dimensional computed tomography (3D-CT), the accuracy of femoral tunnel positioning in patients undergoing anterior cruciate ligament (ACL) reconstruction, comparing transtibial (TT) and anteromedial (AM) techniques.
Methods We evaluated postoperative 3D-CT scans of 26 patients treated with ACL reconstruction with hamstrings autograft using a low accessory AM portal technique and 26 treated with the TT technique. The position of the femoral tunnel center was measured with the quadrant method.
Results Using quadrant method on CT scans, femoral tunnels were measured at a mean of 32.2 and 28.1% from the proximal condylar surface (parallel to Blumensaat line) and at a mean of 31.2 and 15.1% from the notch roof (perpendicular to Blumensaat line) for the AM and TT techniques, respectively.
Conclusion The AM portal technique provides more anatomical graft placement than TT techniques.
Level of Evidence Level I, randomized clinical study.
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References
- 1 Buss DD, Warren RF, Wickiewicz TL, Galinat BJ, Panariello R. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months. J Bone Joint Surg Am 1993; 75 (09) 1346-1355
- 2 Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med 2003; 31 (04) 564-573
- 3 Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990; 18 (03) 292-299
- 4 Bowers AL, Bedi A, Lipman JD. , et al. Comparison of anterior cruciate ligament tunnel position and graft obliquity with transtibial and anteromedial portal femoral tunnel reaming techniques using high-resolution magnetic resonance imaging. Arthroscopy 2011; 27 (11) 1511-1522
- 5 Lee MC, Seong SC, Lee S. , et al. Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 2007; 23 (07) 771-778
- 6 Woo SL, Wu C, Dede O, Vercillo F, Noorani S. Biomechanics and anterior cruciate ligament reconstruction. J Orthop Surg 2006; 1: 2 . Doi: 10.1186/1749-799X-1-2
- 7 Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 2002 Richard O'Connor Award paper. Arthroscopy 2003; 19 (03) 297-304
- 8 Musahl V, Plakseychuk A, VanScyoc A. , et al. Varying femoral tunnels between the anatomical footprint and isometric positions: effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med 2005; 33 (05) 712-718
- 9 Padua R, Alviti F, Venosa M, Mazzola C, Padua L. The influence of graft placement on clinical outcome in anterior cruciate ligament reconstruction. Joints 2016; 4 (01) 12-16
- 10 Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 2008; 24 (01) 113-115
- 11 van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy 2010; 26 (02) 258-268
- 12 Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 2002; 30 (05) 660-666
- 13 Gavriilidis I, Motsis EK, Pakos EE, Georgoulis AD, Mitsionis G, Xenakis TA. Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study. Knee 2008; 15 (05) 364-367
- 14 Bernard M, Hertel P, Hornung H, Cierpinski T. Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 1997; 10 (01) 14-21 , discussion 21–22
- 15 Kopf S, Forsythe B, Wong AK, Tashman S, Irrgang JJ, Fu FH. Transtibial ACL reconstruction technique fails to position drill tunnels anatomically in vivo 3D CT study. Knee Surg Sports Traumatol Arthrosc 2012; 20 (11) 2200-2207
- 16 Lee KW, Hwang YS, Chi YJ, Yang DS, Kim HY, Choy WS. Anatomic single bundle anterior cruciate ligament reconstruction by low accessory anteromedial portal technique: an in vivo 3D CT study. Knee Surg Relat Res 2014; 26 (02) 97-105
- 17 Yamamoto Y, Hsu WH, Woo SL, Van Scyoc AH, Takakura Y, Debski RE. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med 2004; 32 (08) 1825-1832
- 18 Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett Jr WE. Reconstruction technique affects femoral tunnel placement in ACL reconstruction. Clin Orthop Relat Res 2008; 466 (06) 1467-1474
- 19 Zantop T, Diermann N, Schumacher T, Schanz S, Fu FH, Petersen W. Anatomical and nonanatomical double-bundle anterior cruciate ligament reconstruction: importance of femoral tunnel location on knee kinematics. Am J Sports Med 2008; 36 (04) 678-685
- 20 van Eck CF, Kropf EJ, Romanowski JR. , et al. Factors that influence the intra-articular rupture pattern of the ACL graft following single-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19 (08) 1243-1248
- 21 Kato Y, Maeyama A, Lertwanich P. , et al. Biomechanical comparison of different graft positions for single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2013; 21 (04) 816-823
- 22 Hosseini A, Lodhia P, Van de Velde SK. , et al. Tunnel position and graft orientation in failed anterior cruciate ligament reconstruction: a clinical and imaging analysis. Int Orthop 2012; 36 (04) 845-852
- 23 Chambat P, Guier C, Sonnery-Cottet B, Fayard JM, Thaunat M. The evolution of ACL reconstruction over the last fifty years. Int Orthop 2013; 37 (02) 181-186
- 24 Zantop T, Wellmann M, Fu FH, Petersen W. Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 2008; 36 (01) 65-72
- 25 Abebe ES, Moorman III CT, Dziedzic TS. , et al. Femoral tunnel placement during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques. Am J Sports Med 2009; 37 (10) 1904-1911
- 26 Arnold MP, Duthon V, Neyret P, Hirschmann MT. Double incision iso-anatomical ACL reconstruction: the freedom to place the femoral tunnel within the anatomical attachment site without exception. Int Orthop 2013; 37 (02) 247-251
- 27 Brown Jr CH, Spalding T, Robb C. Medial portal technique for single-bundle anatomical anterior cruciate ligament (ACL) reconstruction. Int Orthop 2013; 37 (02) 253-269
- 28 Marcacci M, Zaffagnini S, Marcheggiani Muccioli GM. , et al. Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review. Curr Rev Musculoskelet Med 2011; 4 (02) 73-77
- 29 Pastrone A, Ferro A, Bruzzone M. , et al. Anterior cruciate ligament reconstruction creating the femoral tunnel through the anteromedial portal. Surgical technique. Curr Rev Musculoskelet Med 2011; 4 (02) 52-56
- 30 Lee SR, Jang HW, Lee DW, Nam SW, Ha JK, Kim JG. Evaluation of femoral tunnel positioning using 3-dimensional computed tomography and radiographs after single bundle anterior cruciate ligament reconstruction with modified transtibial technique. Clin Orthop Surg 2013; 5 (03) 188-194
- 31 Heming JF, Rand J, Steiner ME. Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 2007; 35 (10) 1708-1715
- 32 Meuffels DE, Potters JW, Koning AH, Brown Jr CH, Verhaar JA, Reijman M. Visualization of postoperative anterior cruciate ligament reconstruction bone tunnels: reliability of standard radiographs, CT scans, and 3D virtual reality images. Acta Orthop 2011; 82 (06) 699-703
- 33 Kopf S, Forsythe B, Wong AK. , et al. Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. J Bone Joint Surg Am 2010; 92 (06) 1427-1431
- 34 Lertwanich P, Martins CA, Asai S, Ingham SJ, Smolinski P, Fu FH. Anterior cruciate ligament tunnel position measurement reliability on 3-dimensional reconstructed computed tomography. Arthroscopy 2011; 27 (03) 391-398
- 35 Forsythe B, Kopf S, Wong AK. , et al. The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models. J Bone Joint Surg Am 2010; 92 (06) 1418-1426
- 36 Tsukada H, Ishibashi Y, Tsuda E, Fukuda A, Toh S. Anatomical analysis of the anterior cruciate ligament femoral and tibial footprints. J Orthop Sci 2008; 13 (02) 122-129
- 37 Steckel H, Musahl V, Fu FH. The femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 2010; 18 (01) 52-55
- 38 Yang JH, Chang M, Kwak DS, Jang KM, Wang JH. In vivo three-dimensional imaging analysis of femoral and tibial tunnel locations in single and double bundle anterior cruciate ligament reconstructions. Clin Orthop Surg 2014; 6 (01) 32-42
- 39 Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T. Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 2009; 17 (03) 220-227
- 40 Giron F, Cuomo P, Edwards A, Bull AM, Amis AA, Aglietti P. Double-bundle “anatomic” anterior cruciate ligament reconstruction: a cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy 2007; 23 (01) 7-13