Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction

Abstract

The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms “anterior cruciate ligament reconstruction,” “anatomic or anatomical,” and “single bundle.” Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow–deep direction (32.3%) and in a high–low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.

Compressed Lateral and anteroposterior Anatomical Systematic Sequences «CLASS»: compressed MRI sequences with assessed anatomical femoral and tibial ACL's footprints, a feasibility study

“…The 5th and 95th percentiles were 28% and 43%, respectively, for HL, and 24% and 37%, respectively, for DS. Iriuchishima et al[ 13 ] did a systematic study on the performed methods and tunnel placement strategies in anatomical single-bundle ACL reconstruction. Evaluation of 19 studies showed a targeted femoral footprint center at 32.3 ± 7% HL and at 30.6 ± 4.3% DS.…”

Transportal versus all-inside techniques of anterior cruciate ligament reconstruction: a systematic review

“…TP technique is a popular and widely practiced technique of ACLR, as it allows independent femoral tunnel drilling [ 9 , 10 ]. Among the advantages of this technique is it does not require special equipment, performance ease, and its ability to reach the center of the native ACL footprint [ 11 ]. However, a caveat to this technique is that it may result in disproportionate stress on the graft which increases the possibility of graft failure, rupture of the femoral posterior wall, and short femoral tunnel length [ 10 , 12 – 17 ].…”

Biomechanical Effects of Aspect Ratio of the Knee during Outside-In Anterior Cruciate Ligament Reconstruction Surgery

“…The surgeon creates a tunnel by drilling in the direction guided by the instrument, and the operator can adjust the tunnel entry position at the lateral epicondyle. Therefore, many studies have been conducted on the effect of tunnel position on surgical outcome, and the femoral tunnel position is an important parameter when planning ACLR to restore knee stability [ 8 ]. Also, the femoral tunnel position has been reported to influence biomechanical characteristics of an implanted graft, and it affects knee function during postoperative rehabilitation [ 9 ].…”