Transtibial Versus Anteromedial Portal Reaming in Anterior Cruciate Ligament Reconstruction: An Anatomic and Biomechanical Evaluation of Surgical Technique

Bedi, Asheesh; Musahl, Volker; Steuber, Volker; Kendoff, Daniel; Choi, Daniel; Allen, Answorth A.; Pearle, Andrew D.; Altchek, David W.

doi:10.1016/j.arthro.2010.07.018

Cited by 266 publications

(264 citation statements)

References 41 publications

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“…These results are consistent with Schairer et al [38] and Sim et al [40] who found no difference in AP translation compared with the intact knee with either the TT or AM technique. This is in contrast to Bedi et al [9,10] who found the AM technique to result in more accurate positioning of the ACL footprint compared with the TT technique, which corresponded with less tibial translation according to the Lachman and pivot shift test as tested on five matched cadaveric knee pairs. In regard to rotational stability, Schairer et al noted more total tibial rotation in the TT group compared with the AM group [38].…”

Section: Discussioncontrasting

confidence: 86%

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Arno

Bell

Alaia

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Considerable debate remains over which anterior cruciate ligament (ACL) reconstruction technique can best restore knee stability. Traditionally, femoral tunnel drilling has been done through a previously drilled tibial tunnel; however, potential nonanatomic tunnel placement can produce a vertical graft, which although it would restore sagittal stability, it would not control rotational stability. To address this, some suggest that the femoral tunnel be created independently of the tibial tunnel through the use of an anteromedial (AM) portal, but whether this results in a more anatomic footprint or in stability comparable to that of the intact contralateral knee still remains controversial. Questions/purposes (1) Does the AM technique achieve footprints closer to anatomic than the transtibial (TT) technique? (2) Does the AM technique result in stability equivalent to that of the intact contralateral knee? (3) Are there differences in patient-reported outcomes between the two techniques? Methods Twenty male patients who underwent a bonepatellar tendon-bone autograft were recruited for this study, 10 in the TT group and 10 in the AM group. Patients in each group were randomly selected from four surgeons at our institution with both groups demonstrating similar demographics. The type of procedure chosen for each patient was based on the preferred technique of the surgeon. Some surgeons exclusively used the TT technique, whereas other surgeons specifically used the AM technique. Surgeons had no input on which patients were chosen to participate in this study. Mean postoperative time was 13 ± 2.8 and 15 ± 3.2 months for the TT and AM groups, respectively. Patients were identified retrospectively as having either the TT or AM Technique from our institutional database. At followup, clinical outcome scores were gathered as well as the footprint placement and knee stability assessed. To assess the footprint placement and knee stability, three-dimensional surface models of the femur, tibia, and ACL were created from MRI scans. The femoral and tibial footprints of the ACL reconstruction as compared with the intact contralateral ACL were determined. In addition, the AP displacement and rotational displacement of the femur were determined. Lastly, as a secondary measurement of stability, KT-1000 measurements were obtained at the followup visit. An a priori sample size calculation indicated that with 2n = 20 patients, we could detect a difference of 1 mm with 80% power at p \ 0.05. A Welch two-sample t-test (p \ 0.05) was performed to determine differences in the footprint measurements, AP displacement, rotational displacement, and KT-1000 measurements between the TT and AM groups. We further used the confidence interval approach with 90% confidence intervals on the pairwise mean group differences using a Games-Howell post hoc test to assess equivalence between the TT and AM groups for the previously mentioned measures. Results The AM and TT techniques were the same in terms of footprint except in the distal...

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Section: Discussioncontrasting

confidence: 86%

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Arno

Bell

Alaia

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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“…The tibial tunnel can be modified (modified transtibial technique) and moved medially to avoid vertical femoral tunnels [23]; but even then, when the femoral tunnel is accurately placed, the tibial tunnel may be compromised and placed too posteriorly, resulting in a vertical graft on the sagittal plane [6]. The use of an arthroscopic AMP for femoral drilling, with the knee in hyperflexion, allows a more accurate posterior and horizontal placement of the femoral tunnel by keeping any bony structures from limiting the drills and allowing the two tunnels (tibial and femoral) to be placed independently [1,4,19]. The use of AMP has been demonstrated to accurately restore the native ACL position [6] and achieve better stability in cadaveric knees [4].…”

Section: Surgical Approach For Drilling the Femoral Tunnelmentioning

confidence: 99%

“…An ideal portal should allow anatomic placement of both tibial and femoral tunnels, while minimizing complications. The use of a transtibial portal for femoral tunnel drilling may limit the surgeon's ability to achieve anatomic position and result in an anterior/superior femoral tunnel starting point [1,4]. The tibial tunnel can be modified (modified transtibial technique) and moved medially to avoid vertical femoral tunnels [23]; but even then, when the femoral tunnel is accurately placed, the tibial tunnel may be compromised and placed too posteriorly, resulting in a vertical graft on the sagittal plane [6].…”

Section: Surgical Approach For Drilling the Femoral Tunnelmentioning

confidence: 99%

“…The use of an arthroscopic AMP for femoral drilling, with the knee in hyperflexion, allows a more accurate posterior and horizontal placement of the femoral tunnel by keeping any bony structures from limiting the drills and allowing the two tunnels (tibial and femoral) to be placed independently [1,4,19]. The use of AMP has been demonstrated to accurately restore the native ACL position [6] and achieve better stability in cadaveric knees [4]. Its potential disadvantages, on the other hand, include the creating of short sockets, posterior wall blowout, distal/inferior exit in the lateral thigh endangering the peroneal nerve, possible impingement of the aimer at the inter-condylar notch throughout the entire range of motion, possible damage to the medial femoral condyle cartilage and other technical difficulties [19].…”

Section: Surgical Approach For Drilling the Femoral Tunnelmentioning

confidence: 99%

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An international survey on anterior cruciate ligament reconstruction practices

Chechik

Amar

Khashan

et al. 2012

International Orthopaedics (SICOT)

168

134

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Purpose Bone-patellar-tendon-bone (BPTB) autografting fixed with metal interference screws (IS) is the gold standard for anterior cruciate ligament (ACL) reconstruction. Advances in surgical technology provide a wide choice of grafts, fixation devices and surgical approaches. Methods Two-hundred and sixty-one orthopedic surgeons of ten subspecialties from 57 countries were surveyed on their choice of graft and fixation device, the number of reconstructed bundles, and arthroscopic portal. Their preferences were analyzed according to country of origin, field of expertise and seniority, and compared to current publications. Results Hamstring autografting was the most popular choice (63 %), then BPTB (26 %) and allograft (11 %). The anteromedial portal was preferred over the traditional transtibial portal (68 % versus 31 %). Two-thirds reported routinely performing a single-bundle graft reconstruction, compared to one-third who used the double-bundle technique. The Endo-button was the most common graft fixation method (40 %), followed by the bioabsorbable IS (34 %), metallic IS (12 %), rigidfix (10 %) and others (4 %). The preferences of hamstring tendon grafting and the anteromedial portal are not supported in the literature. Responses from North American and European surgeons were different from all the others.Conclusions Surgeon preferences in ACL reconstruction differ considerably worldwide. Common practice is not always supported by evidence-based publications.

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“…1 Although there is clearly variability in the agreement among surgeons regarding ideal tunnel location, 2 some recent literature indicates that anatomic ACL reconstruction may be more easily performed by drilling the femoral tunnel through an accessory anteromedial portal. 3,4 This has led some surgeons to drill the femoral tunnel either through an accessory anteromedial portal or through a 2-incision, outside-in approach. Drilling the femoral tunnel through an accessory anteromedial portal allows for the placement of the femoral tunnel or tunnels independently of the tibial tunnel and in the location of the anatomic attachment of the ACL.…”

mentioning

confidence: 99%

“Retrograde Technique” for Drilling the Femoral Tunnel in an Anterior Cruciate Ligament Reconstruction

Branam

Hasselfeld

2013

Arthroscopy Techniques

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Recent literature has led some surgeons to drill the femoral tunnel in an anterior cruciate ligament reconstruction through an accessory anteromedial portal. Several techniques have been reported for the safe, effective drilling of the femoral tunnel by this approach. This technical note presents a new "retrograde technique" in which all instruments are passed independently into the notch and across the medial compartment. This technique is safe and reproducible and allows for meticulous evaluation and creation of the femoral tunnel(s) while minimizing steps.

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Transtibial Versus Anteromedial Portal Reaming in Anterior Cruciate Ligament Reconstruction: An Anatomic and Biomechanical Evaluation of Surgical Technique

Cited by 266 publications

References 41 publications

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

An international survey on anterior cruciate ligament reconstruction practices

“Retrograde Technique” for Drilling the Femoral Tunnel in an Anterior Cruciate Ligament Reconstruction

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