Autologous Hamstring Anterior Cruciate Ligament Graft Failure Using the Anteromedial Portal Technique With Suspensory Femoral Fixation

Abstract

Background:The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint. Furthermore, suspensory fixation of soft tissue grafts has become popularized because of complications associated with cross-pin fixation. Concerns regarding the use of both have recently arisen.Purpose:To raise awareness of the increased risk of graft failure when using the anteromedial portal technique with suspensory femoral fixation during ACL reconstruction.Study Design:Cohort study; Level of evidence, 3.Methods:From November 1998 to August 2012, a total of 465 primary ACL reconstructions were performed using quadrupled hamstring autograft tendons, with drilling of the femoral tunnel performed via the transtibial portal. Graft fixation on the femur was achieved with cross-pin fixation, while interference screw fixation was used on the tibia. From September 2012 to October 2013, there were 69 reconstructions performed through an anteromedial portal. While there was no change in graft choice, a change was made to using suspensory femoral fixation. No other surgical or postoperative rehabilitation changes were made.Results:During the 14-year period in which ACL reconstructions were performed via the transtibial portal and with cross-pin fixation, 2 graft failures (0.4% failure rate) were reported. After switching to the anteromedial portal with suspensory fixation, 7 graft failures (10.1% failure rate) were reported over a 13-month period. These were 5 male and 2 female patients, with a mean age of 18.8 years—all elite athletes. The same surgical technique was used in all patients, and all patients had at least an 8 mm–diameter graft. Patients were cleared to return to sport at an average of 8.4 months postoperatively, after completing functional performance tests. Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition. The final patient sustained a rerupture 10 months after being cleared to play.Conclusion:Compared with the transtibial technique with cross-pin graft fixation, there is an increased risk of graft failure when performing autologous hamstring ACL reconstructions using the anteromedial portal technique with cortical suspensory fixation.

Femoral-tibial fixation affects risk of revision and reoperation after anterior cruciate ligament reconstruction using hamstring autograft

“…These authors and others hypothesized drilling through the AM portal places the graft in a more anatomic position, therefore, seeing more load and ultimately putting the graft at higher risk for failure [4, 9, 37, 42]. Similarly, Galdi et al [15] suggested the lower and more anatomic position of an AM placed graft is more susceptible to lateral wall impingement, leading to another potential cause for failure. Over the study period, suspensory femoral fixation was more likely to be placed using the AM portal technique.…”

Suspensory Versus Aperture Fixation of a Quadrupled Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Meta-analysis

“…Corticocancellous cross-pin fixation was designed to avoid soft tissue graft damage experienced during interference screw fixation. 20,87 Numerous studies have compared cross-pin fixation to both cortical button and interference screw fixation methods. 7,33,64,67 A biomechanical study by Rodriguez et al 64 compared cortical button and cross-pin fixation and found that both methods of fixation provide adequate strength to support early mobilization.…”

“…Transfemoral corticocancellous cross-pin fixation was subsequently developed and has been found to provide adequate fixation strength while avoiding complications associated with interference screws. 14,20 Bioabsorbable cross-pin fixation, however, has been associated with a complication profile that includes breakage, 3,13,24,28 prominence, 56 stress fractures, 5 and migration. 54 Although corticocancellous cross-pin fixation is still used, the development of cortical button fixation has resulted in secure fixation while avoiding second incisions and weakened graft integrity from damage by screw threads.…”

“…74 Osteolysis of the bone adjacent to tunnels has been observed in both biocomposite interference screw and cortical button suspensory fixation methods, although there has been no definite associated clinical consequence. 11,19,29,69 Galdi et al 20 reported on suspensory ACL construct failures and theorized that lateral wall impingement accentuated by tunnel widening may lead to increased graft failures.…”

The reasons for revision surgery after reconstruction of the anterior cruciate ligament: a systematic review

“…Достигнутая полная амплитуда движений в суставе в данном случае может привести к потере необходимого тонуса трансплантата. При чрезмерном заднем позиционировании большеберцового канала уменьшается внутрисуставная длина трансплантата, что приводит к снижению ограничивающей функции от переднего смещения голени относительно бедра [19]. Медиальное или латеральное смещение большеберцового канала может привести к конфликту трансплантата с соответствующим мыщелком бедренной кости, а также возможному повреждению хряща плато большеберцовой кости [17,18].…”