The Anterior Medial Portal

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To the Editor:

I read with interest the article by Dr. Lubowitz in the January 2009 issue of Arthroscopy entitled “Anteromedial Portal Technique for the Anterior Cruciate Ligament Femoral Socket: Pitfalls and Solutions.”¹ I have used the anterior medial portal for more than 25 years for anterior cruciate ligament reconstructions. All of the problems Dr. Lubowitz describes occur because he is attempting to use an EndoButton–type technique to allow a graft to be pulled into the femoral tunnel from above. I prepare a freehand femoral tunnel on the posterior lateral notch and use the Transfix Pin for graft fixation in the femur. This allows the graft to remain on the posterior cortex of the femur rather than having to move anterior and lateral. This position does not require driving the pin through the lateral femur as the technique Dr. Lubowitz is using does. Because of the position and technique I use, there is rarely a problem preparing the femoral socket.

I also prepare a freehand tibial tunnel using a needle at the anterior cruciate ligament insertion on the tibia as a guide. Virtually every time, the holes line up perfectly, just as if I drilled one hole from the tibia into the femur. There is no need to drill through the tibia to get the holes lined up, only to pass the Beath pin!

I think Dr. Lubowitz wrongly assumes than everyone pulls a graft into the femoral socket from above. I do not think that is true. If one thinks about the development of the procedure, Tom Rosenberg popularized the EndoButton technique, which involved drilling through the tibia to allow the Beath pin to exit the anterior lateral femur so that a graft could be pulled into the femoral socket. Drilling through the tibia is the best way to get the Beath pin out because the drilling angle is better. However, drilling through the tibia frequently results in poor femoral position because the tibial hole restricts the position of the femoral socket. The end result of this is the double-bundle technique that has become popular.

Now we have a more complicated procedure of dubious value to try to solve a problem that exists only because of the inability to obtain an excellent position for the femoral socket by drilling through the tibia. My advice is to consider a change in technique.

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Reference 

1. Lubowitz JH. Anteromedial portal technique for the anterior cruciate ligament femoral socket: Pitfalls and solutions. Arthroscopy. 2009;25:95–101
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