Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 25, Issue 10 , Pages 1062-1064, October 2009

The Anteromedial Portal for Anterior Cruciate Ligament Reconstruction

Article Outline

 

To the Editor:

We read with great interest the discussion on the use of the anteromedial portal for anterior cruciate ligament (ACL) reconstruction.1 Clearly, Dr. Lanny Johnson and Dr. David Shneider are forefathers of modern-day arthroscopy, and we thank Dr. Shneider for his mentorship and his dedication to advancing the field and improving patient results. With regard to the anteromedial portal approach for ACL reconstruction, we respect Dr. Shneider's experience with the use of this technique and agree with his statement that transtibial drilling could result in poor femoral tunnel positions.2, 3

At our institution, the medial portal approach has been used successfully for a number of years, for both single- and double-bundle reconstructions and with several femoral fixation devices. In addition, an accessory medial portal is used that allows for visualization and instrumentation from the medial side simultaneously (Fig 1).4, 5 The 2 medial portals are created very carefully with guidance from a spinal needle. The anteromedial portal is first established along the inferomedial border of the patellar tendon. It is angled proximally and laterally, along the path of the native ACL, and easily reaches the femoral attachment site. The accessory medial portal is established medially along the joint line as inferiorly as possible without damaging the medial meniscus. Careful visualization from the anterolateral portal ensures that there is enough space to avoid damage to the medial femoral condyle when using cannulated drills (Fig 2).6, 7 By using this approach, we have found that the native femoral ACL insertion site is easily identified and accessed, even in those cases with narrow notch measurements (Fig 3). In our experience this has made the notchplasty largely unnecessary, whereas we performed it routinely in the past. Furthermore, when a notchplasty is performed, the native femoral ACL insertion site is removed along with important bony landmarks such as the lateral intercondylar ridge (resident's ridge).8, 9 This makes finding the correct location for an anatomic femoral tunnel position challenging and removes the ability to individualize each reconstruction to the patient's anatomy. We agree with Dr. Shneider that “exposure is the key to a good result.” This is what view from the anteromedial portal provides, perfect “exposure” of the femoral ACL insertion site and the anatomic roadmap for reconstruction.

  • View full-size image.
  • Figure 1. 

    (A) View of left knee in operating position. The arthroscope is in the anteromedial portal, and the probe is in the accessory medial portal. (B) Arthroscopic image corresponding with previously described situation. Using this approach, with 2 medial portals, allows for visualization of the femoral ACL insertion and simultaneous instrumentation. (C) Arthroscopic view of femoral ACL insertion site through anterolateral portal. (PCL, posterior cruciate ligament.)

  • View full-size image.
  • Figure 2. 

    Arthroscopic anteromedial portal view of left knee in 90° of flexion. The femoral anteromedial (AM) and posterolateral (PL) tunnels have already been drilled. An 8-mm drill is placed through the accessory medial portal near the most posterior border of the ACL insertion site. This image shows that there is still room between the drill and the medial femoral condyle to allow for safe drilling.

  • View full-size image.
  • Figure 3. 

    Arthroscopic view of 2 right knees in 90° of flexion. (A) This patient has a large notch, measuring 19 mm in width. Performing ACL reconstruction in a patient with a large notch is less difficult because the surgeon has good visualization and sufficient room for instrumentation. (B) This patient has a small notch, measuring only 11 mm. Performing ACL reconstruction in a patient with a small notch can present a challenge. Drilling a smaller-diameter tunnel or using a flexible guidewire and cannulated drill might offer a solution.

Our experience with ligament impingement has also changed over the years. We have not found it necessary to perform a notchplasty to avoid any impingement since we have evolved to a more anatomic reconstruction. It is clear that in the native state, the ACL does not impinge, and as such, an anatomically reconstructed ACL should not impinge either.

Finally, Dr. Shneider's advice that failure to perform a notchplasty “is a guarantee for poor results” is misleading and is clearly not supported by the literature. Although his experience with this technique has allowed his patients to have excellent results, he would probably agree that there are many variations in anatomic ACL reconstruction that can be used with equal success, including at our institution where over 1,000 anatomic ACL reconstructions have been performed using the 3-portal technique.

We applaud Dr. Lubowitz and Dr. Shneider for their continued pursuit of a more anatomic reconstruction and willingness to discuss the trials and tribulations that they have experienced with this progression. We can all learn from their experiences and should continue to keep an open mind as we strive to better understand the ACL and its reconstruction.

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References 

  1. Shneider D. The anterior medial portal. Arthroscopy. 2009;25:563;(letter) and responses 563-566
  2. Heming JF, Rand J, Steiner ME. Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med. 2007;35:1708–1715
  3. Pombo MW. The ability of transtibial tunnel drilling in ACL reconstruction to restore the anatomica femoral insertion site: A prospective study (E-poster 564). Presented at the Seventh Biennial International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine Congress, 2009.
  4. Cohen SB, Fu FH. Three-portal technique for anterior cruciate ligament reconstruction: Use of a central medial portal. Arthroscopy. 2007;23:325.e1–325.e5Available online at www.arthroscopyjournal.org
  5. Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy. 2008;24:113–115
  6. Martins CAQ, Kropf EJ, Shen W, van Eck CF, Fu FH. The concept of anatomic anterior cruciate ligament reconstruction. Oper Tech Sports Med. 2008;16:104–115
  7. Shen W, Forsythe B, Ingham SM, Honkamp NJ, Fu FH. Application of the anatomic double-bundle reconstruction concept to revision and augmentation anterior cruciate ligament surgeries. J Bone Joint Surg Am. 2008;90(Suppl 4):20–34
  8. Ferretti M, Ekdahl M, Shen W, Fu FH. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: An anatomic study. Arthroscopy. 2007;23:1218–1225
  9. Fu FH, Jordan SS. The lateral intercondylar ridge—A key to anatomic anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2007;89:2103–2104

PII: S0749-8063(09)00561-1

doi:10.1016/j.arthro.2009.06.016

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    David Shneider
    Arthroscopy: The Journal of Arthroscopic and Related Surgery October 2009 (Vol. 25, Issue 10, Pages 1064-1065)

Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 25, Issue 10 , Pages 1062-1064, October 2009