Skip to main content
Top
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 4/2013

01-04-2013 | Knee

Transtibial versus low anteromedial portal drilling for anterior cruciate ligament reconstruction: a radiographic study of femoral tunnel position

Authors: Cecilia Pascual-Garrido, Britta L. Swanson, Kyle E. Swanson

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 4/2013

Login to get access

Abstract

Purpose

The purpose of this study is to compare femoral tunnel positions after ACL reconstruction by the transtibial (TT) approach versus the low anteromedial approach using radiographs from a single surgeon.

Methods

The standard postoperative knee radiographs of 50 patients with an ACL reconstruction were studied. Two groups were determined according to the technique used. The low anteromedial portal group and the transtibial portal group. The femoral bone tunnel was identified radiographically, and its position determined in the lateral and A–P view. Coronal and sagittal obliquity of the tunnel was measured and compared among both groups.

Results

In the sagittal plane, femoral bone tunnels averaged 54° ± 6° for the TT technique and 59° ± 12° (p = 0.07) for the low anteromedial portal technique. In the coronal plane, the bone tunnels drilled through the low anteromedial portal showed a significantly more oblique femoral tunnel position (50° ± 6°) compared to TT drilling (58° ± 9°), p ≤ 0.05.

Conclusion

Drilling the femoral tunnel through the low anteromedial portal resulted in a more oblique femoral tunnel position compared to the TT technique. Clinically, the low anteromedial portal may allow to better restore the anatomic orientation of the ACL.

Level of evidence

Case series, Level IV.
Literature
1.
go back to reference Alentorn-Geli E, Lajara F, Samitier G, Cugat R (2010) The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18(8):1013–1037PubMedCrossRef Alentorn-Geli E, Lajara F, Samitier G, Cugat R (2010) The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18(8):1013–1037PubMedCrossRef
2.
go back to reference Araujo PH, van Eck CF, Macalena JA, Fu FH (2011) Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(8):1239–1242PubMedCrossRef Araujo PH, van Eck CF, Macalena JA, Fu FH (2011) Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(8):1239–1242PubMedCrossRef
3.
go back to reference Bedi A, Musahl V, Steuber V, Kendoff D, Choi D, Allen AA, Pearle AD, Altchek DW (2011) Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy 27(3):380–390PubMedCrossRef Bedi A, Musahl V, Steuber V, Kendoff D, Choi D, Allen AA, Pearle AD, Altchek DW (2011) Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy 27(3):380–390PubMedCrossRef
4.
go back to reference Bedi A, Raphael B, Maderazo A, Pavlov H, Williams RJ III (2010) Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy 26(3):342–350PubMedCrossRef Bedi A, Raphael B, Maderazo A, Pavlov H, Williams RJ III (2010) Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy 26(3):342–350PubMedCrossRef
5.
go back to reference Behrend H, Stutz G, Kessler MA, Rukavina A, Giesinger K, Kuster MS (2006) Tunnel placement in anterior cruciate ligament (ACL) reconstruction: quality control in a teaching hospital. Knee Surg Sports Traumatol Arthrosc 14(11):1159–1165PubMedCrossRef Behrend H, Stutz G, Kessler MA, Rukavina A, Giesinger K, Kuster MS (2006) Tunnel placement in anterior cruciate ligament (ACL) reconstruction: quality control in a teaching hospital. Knee Surg Sports Traumatol Arthrosc 14(11):1159–1165PubMedCrossRef
6.
go back to reference Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10(1):14–22 Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10(1):14–22
7.
go back to reference Bowers AL, Bedi A, Lipman JD, Potter HG, Rodeo SA, Pearle AD, Warren RF, Altchek DW (2011) Comparison of anterior cruciate ligament tunnel positon and graft obliquity with transtibial and anteromedial portal femoral tunnel reaming techniques using high resolution magnetic resonance imaging. Arthroscopy 27(11):1511–1522PubMedCrossRef Bowers AL, Bedi A, Lipman JD, Potter HG, Rodeo SA, Pearle AD, Warren RF, Altchek DW (2011) Comparison of anterior cruciate ligament tunnel positon and graft obliquity with transtibial and anteromedial portal femoral tunnel reaming techniques using high resolution magnetic resonance imaging. Arthroscopy 27(11):1511–1522PubMedCrossRef
8.
go back to reference Chang CB, Choi JY, Koh IJ, Lee KH, Kim TH (2011) Comparison of femoral tunnel position and length in anterior cruciate ligament reconstruction: modified transtibial versus anteromedial portal techniques. Arthroscopy 27(10):1389–1394PubMedCrossRef Chang CB, Choi JY, Koh IJ, Lee KH, Kim TH (2011) Comparison of femoral tunnel position and length in anterior cruciate ligament reconstruction: modified transtibial versus anteromedial portal techniques. Arthroscopy 27(10):1389–1394PubMedCrossRef
9.
go back to reference Chang CB, Yoo JH, Chung BJ, Seong SC, Kim TK (2010) Oblique femoral tunnel placement can increase risk of short femoral tunnel and cross-pin protrusion in anterior cruciate ligament reconstruction. Am J Sports Med 38(6):1237–1245PubMedCrossRef Chang CB, Yoo JH, Chung BJ, Seong SC, Kim TK (2010) Oblique femoral tunnel placement can increase risk of short femoral tunnel and cross-pin protrusion in anterior cruciate ligament reconstruction. Am J Sports Med 38(6):1237–1245PubMedCrossRef
10.
go back to reference Cole J, Brand JC Jr, Caborn DN, Johnson DL (2000) Radiographic analysis of femoral tunnel position in anterior cruciate ligament reconstruction. Am J Knee Surg 13(4):218–222PubMed Cole J, Brand JC Jr, Caborn DN, Johnson DL (2000) Radiographic analysis of femoral tunnel position in anterior cruciate ligament reconstruction. Am J Knee Surg 13(4):218–222PubMed
11.
go back to reference Colvin AC, Shen W, Musahl V, Fu FH (2009) Avoiding pitfalls in anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 17(8):956–963PubMedCrossRef Colvin AC, Shen W, Musahl V, Fu FH (2009) Avoiding pitfalls in anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 17(8):956–963PubMedCrossRef
12.
go back to reference Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T (2009) Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 17(3):220–227PubMedCrossRef Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T (2009) Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 17(3):220–227PubMedCrossRef
13.
go back to reference Fu FH, Karlsson J (2010) A long journey to be anatomic. Knee Surg Sports Traumatol Arthrosc 18(9):1151–1153PubMedCrossRef Fu FH, Karlsson J (2010) A long journey to be anatomic. Knee Surg Sports Traumatol Arthrosc 18(9):1151–1153PubMedCrossRef
14.
go back to reference Garofalo R, Moretti B, Kombot C, Moretti L, Mouhsine E (2007) Femoral tunnel placement in anterior cruciate ligament reconstruction: rationale of the two incision technique. J Orthop Surg Res 2(10):1–6 Garofalo R, Moretti B, Kombot C, Moretti L, Mouhsine E (2007) Femoral tunnel placement in anterior cruciate ligament reconstruction: rationale of the two incision technique. J Orthop Surg Res 2(10):1–6
15.
go back to reference Hantes ME, Zachos VC, Liantsis A, Venouziou A, Karantanas AH, Malizos KN (2009) Differences in graft orientation using the transtibial and anteromedial portal technique in anterior cruciate ligament reconstruction: a magnetic resonance imaging study. Knee Surg Sports Traumatol Arthrosc 17(8):880–886PubMedCrossRef Hantes ME, Zachos VC, Liantsis A, Venouziou A, Karantanas AH, Malizos KN (2009) Differences in graft orientation using the transtibial and anteromedial portal technique in anterior cruciate ligament reconstruction: a magnetic resonance imaging study. Knee Surg Sports Traumatol Arthrosc 17(8):880–886PubMedCrossRef
16.
go back to reference Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ (2001) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 50:463–474PubMed Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ (2001) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 50:463–474PubMed
17.
go back to reference Hefzy MS, Grood ES, Noyes FR (1989) Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med 17(2):208–216PubMedCrossRef Hefzy MS, Grood ES, Noyes FR (1989) Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med 17(2):208–216PubMedCrossRef
18.
go back to reference Hoser C, Tecklenburg K, Kuenzel KH, Fink C (2005) Postoperative evaluation of femoral tunnel position in ACL reconstruction: plain radiography versus computed tomography. Knee Surg Sports Traumatol Arthrosc 13(4):256–262PubMedCrossRef Hoser C, Tecklenburg K, Kuenzel KH, Fink C (2005) Postoperative evaluation of femoral tunnel position in ACL reconstruction: plain radiography versus computed tomography. Knee Surg Sports Traumatol Arthrosc 13(4):256–262PubMedCrossRef
19.
go back to reference Illingworth KD, Hensler D, Working ZM, Macalena JA, Tashman S, Fu FH (2011) A simple evaluation of anterior cruciate ligament femoral tunnel position: the inclination angle and femoral tunnel angle. Am J Sports Med 39(12):2611–2618PubMedCrossRef Illingworth KD, Hensler D, Working ZM, Macalena JA, Tashman S, Fu FH (2011) A simple evaluation of anterior cruciate ligament femoral tunnel position: the inclination angle and femoral tunnel angle. Am J Sports Med 39(12):2611–2618PubMedCrossRef
20.
go back to reference Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD (1996) Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res 325:100–109PubMedCrossRef Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD (1996) Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res 325:100–109PubMedCrossRef
21.
go back to reference Karlsson J, Irrgang JJ, van Eck CF, Samuelsson K, Mejia HA, Fu FH (2011) Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique. Am J Sports Med 39(9):2016–2026PubMedCrossRef Karlsson J, Irrgang JJ, van Eck CF, Samuelsson K, Mejia HA, Fu FH (2011) Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique. Am J Sports Med 39(9):2016–2026PubMedCrossRef
22.
go back to reference Lee MC, Seong SC, Lee S, Chang CB, Park YK, Jo H, Kim CH (2007) Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 23(7):771–778PubMedCrossRef Lee MC, Seong SC, Lee S, Chang CB, Park YK, Jo H, Kim CH (2007) Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 23(7):771–778PubMedCrossRef
23.
go back to reference Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Richard O’Connor Award paper. Arthroscopy 19(3):297–304 Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Richard O’Connor Award paper. Arthroscopy 19(3):297–304
24.
go back to reference Group MARS, Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, Allen CR, Cooper DE, DeBerardino TM, Lantz BB, Mann BJ, Stuart MJ (2010) Descriptive epidemiology of the multicenter ACL revision study (MARS) cohort. Am J Sports Med 38(10):1979–1986CrossRef Group MARS, Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, Allen CR, Cooper DE, DeBerardino TM, Lantz BB, Mann BJ, Stuart MJ (2010) Descriptive epidemiology of the multicenter ACL revision study (MARS) cohort. Am J Sports Med 38(10):1979–1986CrossRef
25.
go back to reference Noyes FR, Barber-Westin SD (2011) Anterior cruciate ligament graft placement recommendations and bone-patellar tendon-bone graft indications to restore knee stability. Instr Course Lect 60:499–521PubMed Noyes FR, Barber-Westin SD (2011) Anterior cruciate ligament graft placement recommendations and bone-patellar tendon-bone graft indications to restore knee stability. Instr Course Lect 60:499–521PubMed
26.
go back to reference Scopp JM, Jasper LE, Belkoff SM, Moorman CT III (2004) The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20(3):294–299PubMedCrossRef Scopp JM, Jasper LE, Belkoff SM, Moorman CT III (2004) The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20(3):294–299PubMedCrossRef
27.
go back to reference Silva A, Sampaio R, Pinto E (2010) Placement of femoral tunnel between the AM and PL bundles using a transtibial technique in single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 18(9):1245–1251PubMedCrossRef Silva A, Sampaio R, Pinto E (2010) Placement of femoral tunnel between the AM and PL bundles using a transtibial technique in single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 18(9):1245–1251PubMedCrossRef
28.
go back to reference Sommer C, Friederich NF, Müller W (2000) Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 8(4):207–213PubMedCrossRef Sommer C, Friederich NF, Müller W (2000) Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 8(4):207–213PubMedCrossRef
29.
go back to reference van Eck CF, Martins CA, Vyas SM, Celentano U, van Dijk CN, Fu FH (2010) Femoral intercondylar notch shape and dimensions in ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 8(9):1257–1262CrossRef van Eck CF, Martins CA, Vyas SM, Celentano U, van Dijk CN, Fu FH (2010) Femoral intercondylar notch shape and dimensions in ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 8(9):1257–1262CrossRef
30.
go back to reference van Eck CF, Morse KR, Lesniak BP, Kropf EJ, Tranovich MJ, van Dijk CN, Fu FH (2010) Does the lateral intercondylar ridge disappear in ACL deficient patients? Knee Surg Sports Traumatol Arthrosc 18(9):1184–1188PubMedCrossRef van Eck CF, Morse KR, Lesniak BP, Kropf EJ, Tranovich MJ, van Dijk CN, Fu FH (2010) Does the lateral intercondylar ridge disappear in ACL deficient patients? Knee Surg Sports Traumatol Arthrosc 18(9):1184–1188PubMedCrossRef
31.
go back to reference Xu Y, Ao Y, Wang J, Yu J, Cui G (2011) Relation of tunnel enlargement and tunnel placement after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 27(7):923–932PubMedCrossRef Xu Y, Ao Y, Wang J, Yu J, Cui G (2011) Relation of tunnel enlargement and tunnel placement after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 27(7):923–932PubMedCrossRef
Metadata
Title
Transtibial versus low anteromedial portal drilling for anterior cruciate ligament reconstruction: a radiographic study of femoral tunnel position
Authors
Cecilia Pascual-Garrido
Britta L. Swanson
Kyle E. Swanson
Publication date
01-04-2013
Publisher
Springer-Verlag
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 4/2013
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-012-1988-4

Other articles of this Issue 4/2013

Knee Surgery, Sports Traumatology, Arthroscopy 4/2013 Go to the issue