Creation of an Anatomic Femoral Tunnel With Minimal Damage to the Remnant Bundle in Remnant-Preserving Anterior Cruciate Ligament Reconstruction Using an Outside-In Technique

Abstract

We established a method for creation of an anatomic femoral tunnel with minimal damage to the remnant bundle in remnant-preserving anterior cruciate ligament (ACL) reconstruction. The goals of this surgical technique were to preserve the remnant bundle as much as possible, especially at the femoral insertion, and to make the tunnel at the anatomic position. The critical points are that the posterior side of the femoral footprint of the ACL is observed through the posterolateral portal using a 70 arthroscope and a femoral tunnel is made by use of an outside-in technique with remnant preservation. This technique allows for easy viewing of the posterior side of the ACL and enables performance of an anatomic ACL reconstruction.

Accuracy and Reproducibility of the Femoral Tunnel With Different Viewing Techniques in the ACL Reconstruction

“…Under visualization through the PL portal using a 70° arthroscope and through the TS portal, the anatomic femoral tunnel could be made with minimal damage to the remnant bundle and without interfering with the vision of the femoral footprint. 4 The current study confirmed the validity of the methods of creating the femoral tunnel viewed through the PL and TS portals. Many authors believe that improper femoral tunnel placement is a common reason for ACL reconstruction failure.…”

“…Between June 2011 and August 2014, 106 patients undergoing single-bundle, outside-in, remnant-preserving ACL reconstruction were recruited. 4 Patients were divided into 3 groups according to viewing technique (A group=36 patients; PL group=35 patients; TS group=35 patients). All patients agreed to be evaluated using 3-D CT within 1 week postoperatively.…”

“…Drilling of the AM tunnel was performed with a FlipCutter, and the aperture of the tunnel was aligned with the inner margin of the cartilage (Figure 2B). 4 Trans-septal Portal Using a 30° Arthroscope. A posterior TS portal was established.…”

“…cause the wall of the ACL insertion should be seen from an posterior to anterior direction. 4 The posterior trans-septal (TS) portal has greatly improved visualization of the posterior compartment, thus facilitating many troublesome arthroscopic surgeries. 4,[15][16][17] This portal can allow direct visual access to the posterior part of the ACL femoral footprint through the posteromedial (PM) portal.…”

Re-Tensioning Technique to Cover the Graft With Remnant in Anterior Cruciate Ligament Reconstruction

“…On the basis of the fact that most mechanoreceptors exist in the subsynovial layer near the tibial attachment, many authors have introduced surgical techniques to save the remnant of the ruptured ACL. [1][2][3][4][5][6][7] However, most of these techniques are about preserving remnant, not covering the graft more with remnant.…”