A Hybrid Transtibial Technique Combines the Advantages of Anteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial

Abstract

Background: The anteromedial (AM) portal and transtibial (TT) approaches are 2 common anterior cruciate ligament (ACL) femoral tunnel drilling techniques, each with unique benefits and disadvantages. A hybrid TT (HTT) technique using medial portal guidance of a flexible TT guide wire has recently been described that may combine the strengths of both the AM portal and the TT approaches. Hypothesis: The HTT technique will achieve anatomic femoral tunnel apertures similar to the AM portal technique, with improved femoral tunnel length and orientation. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 30 consecutive patients with primary ACL tears were randomized to undergo the TT, AM portal, or HTT technique for femoral tunnel positioning at the time of reconstruction. All patients underwent 3-dimensional computed tomography of the operative knee at 6 weeks postoperatively. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as graft bending angles in the sagittal and coronal planes, were measured. Results: Tibial tunnel lengths and aperture positions were identical between the 3 groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regard to both height ( P = .629) and depth ( P = .582). By contrast, compared with the AM portal and HTT techniques, femoral apertures created with the TT technique were significantly higher ( P < .001 and P < .001, respectively) and shallower ( P = .014 and P = .022, respectively) in the notch. The mean femoral tunnel length varied significantly between the groups, measuring 35.2, 41.6, and 54.1 mm for the AM portal, HTT, and TT groups, respectively ( P < .001). Last, there was no difference between the mean coronal ( P = .190) and sagittal ( P = .358) graft bending angles between the TT and HTT groups. By contrast, compared with the TT and HTT techniques, femoral tunnels created with the AM portal technique were significantly more angulated in the coronal plane (17.7° [ P < .001] and 12.5° [ P = .006], respectively) and sagittal plane (13.5° [ P < .001] and 10.5° [ P = .013], respectively). Conclusion: This prospective randomized controlled trial found that the HTT technique achieved femoral aperture positions equally as anatomic as the AM portal technique but produced longer, less angulated femoral tunnels, which may help reduce graft strain and mismatch. As such, this hybrid approach may represent a beneficial combination of both the TT and the AM portal techniques. Registration: NCT02795247 (ClinicalTrials.gov identifier)

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

“…Our review included 39 clinical studies [ 12 – 50 ] and 16 basic science studies [ 51 – 66 ]. The clinical studies included 21 retrospective cohort studies, 11 prospective cohort studies, and 7 randomized controlled trials (RCTs) [ 14 , 24 , 28 , 36 , 44 , 48 , 50 ].…”

“…Our review included 39 clinical studies [ 12 – 50 ] and 16 basic science studies [ 51 – 66 ]. The clinical studies included 21 retrospective cohort studies, 11 prospective cohort studies, and 7 randomized controlled trials (RCTs) [ 14 , 24 , 28 , 36 , 44 , 48 , 50 ]. (Three of them were registered, two [ 36 , 50 ] prospectively in ClinicalTrials.gov and the third [ 24 ] retrospectively in Chinese Clinical Trial Registry.)…”

“…The clinical studies included 21 retrospective cohort studies, 11 prospective cohort studies, and 7 randomized controlled trials (RCTs) [ 14 , 24 , 28 , 36 , 44 , 48 , 50 ]. (Three of them were registered, two [ 36 , 50 ] prospectively in ClinicalTrials.gov and the third [ 24 ] retrospectively in Chinese Clinical Trial Registry.) From the 16 cadaveric studies, 6 were RCTs [ 53 , 60 – 64 ] (2 of them quasi-randomized [ 53 , 62 ]).…”

“…As the first modification of altering tibial tunnel starting point is an old modification and was performed in nearly two-third (24/36) of studies reporting tibial tunnel starting point, in our review, modified technique (mTT) would denote only the other 4 modifications. So, there were 11 studies utilized mTT technique [ 14 , 28 , 32 , 33 , 47 , 48 , 50 , 52 , 57 , 63 , 64 ]. (Details of modifications in these studies are presented in table in Additional file 3 ).…”

Achilles Tendon Allograft Preparation Technique for Anterior Cruciate Ligament Reconstruction: A Technical Note

“…Thereafter, not exclusively limited to a unique technique, we use the Achilles allograft under a hybrid transtibial technique. 10 , 11 We drill the tibial tunnel 1-2 mm lower than the Achilles bone diameter, followed by enlargement to 1-2 mm using a dilator tunnel instrument (Arthrex, Inc., Naples, FL) to obtain a compacted tibial tunnel wall. 12 Then, a femoral tunnel is drilled near the footprint using a guide typically 1-2 mm longer than the bone end length.…”