Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 26, Issue 9 , Pages 1147-1148, September 2010

Anteromedial Portal Drilling for Anatomic Anterior Cruciate Ligament Reconstruction

Article Outline

 

To the Editor:

We read with interest the article by Bedi et al.1 The study clearly shows better obliquity of the tunnel as well as the risk of a short tunnel and posterior wall damage when the anteromedial (AM) portal is used for creating femoral tunnels.

However, the results of this study might suggest that there are better alternatives for making femoral tunnels than the standard AM portal. The 3-portal technique has been advocated especially for double-bundle anterior cruciate ligament reconstruction where the accessory medial portal is placed at approximately 2 cm medial to the standard medial portal.2, 3, 4, 5 This medially positioned portal can result in lateralizing the tunnel outlet on the lateral epicondyle. Although the posterolateral tunnel in double-bundle reconstruction is generally more oblique than that in single-bundle reconstruction, Neven et al.6 showed that at least 32 mm of posterolateral tunnel length was made through a low AM portal.

It is important to note that tunnel obliquity is not necessarily reflected by the graft angle within the knee joint because of bending at the tunnel aperture, especially by use of the transportal technique,7 whereas previous reports showed the relation between the intra-articular graft angle and stability.8, 9, 10, 11

In addition, anatomically correct positioning of the tunnel needs to be considered, because Basdekis et al.12 used a 5-mm offset drill guide through the AM portal to create the AM tunnel in anatomic position and did not create a short tunnel or posterior wall blowout. This means that a 6-mm offset guide could lead to an anatomic AM position with appropriate rotation, resulting in fewer complications but not with high obliquity. Putting these data together with our clinical experience,13 anatomic placement with appropriate technique could avoid unnecessary complications (Fig 1).

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  • Figure 1. 

    Typical case of femoral tunnel drilling through accessory medial portal for single-bundle anterior cruciate ligament reconstruction: (A) arthroscopic view and (B) postoperative computed tomography image. In this case the entrance of the femoral hole was slightly carved into an oval shape to fit the original footprint as much as possible. The resultant tunnel length in this case was 35 mm.

To summarize, we thank Dr. Bedi and his coauthors for this excellent article, which raises awareness of the pitfalls during anterior cruciate ligament reconstruction procedures. However, we believe that questions concerning the merits of alternative operative techniques and anatomic placement should be considered before abandoning the transportal technique based solely on the results of this study.

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References 

  1. Bedi A, Raphael B, Maderazo A, Pavlov H, Williams R. Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: A cadaveric study of femoral tunnel length and obliquity. Arthroscopy. 2010;26:342–350
  2. Cha PS, Brucker PU, West RV, et al. Arthroscopic double-bundle anterior cruciate ligament reconstruction: An anatomic approach. Arthroscopy. 2005;21:1275
  3. Cohen SB, Fu FH. Three-portal technique for anterior cruciate ligament reconstruction: Use of a central medial portal. Arthroscopy. 2007;23:325.e1–325.e5
  4. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M. Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res. 2007;454:100–107
  5. Toritsuka Y, Amano H, Kuwano M, et al. Outcome of double-bundle ACL reconstruction using hamstring tendons. Knee Surg Sports Traumatol Arthrosc. 2009;17:456–463
  6. Neven E, D'Hooghe P, Bellemans J. Double-bundle anterior cruciate ligament reconstruction: A cadaveric study on the posterolateral tunnel position and safety of the lateral structures. Arthroscopy. 2008;24:436–440
  7. Nishimoto K, Kuroda R, Mizuno K, et al. Analysis of the graft bending angle at the femoral tunnel aperture in anatomic double bundle anterior cruciate ligament reconstruction: A comparison of the transtibial and the far anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc. 2009;17:270–276
  8. Yamamoto Y, Hsu WH, Woo SL, Van Scyoc AH, Takakura Y, Debski RE. Knee stability and graft function after anterior cruciate ligament reconstruction: A comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med. 2004;32:1825–1832
  9. Scopp JM, Jasper LE, Belkoff SM, Moorman CT. The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy. 2004;20:294–299
  10. Musahl V, Plakseychuk A, VanScyoc A, et al. Varying femoral tunnels between the anatomical footprint and isometric positions: Effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med. 2005;33:712–718
  11. Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 2002 Richard O'Connor Award paper. Arthroscopy. 2003;19:297–304
  12. Basdekis G, Abisafi C, Christel P. Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy. 2008;24:459–464
  13. Fu FH, Shen W, Starman JS, Okeke N, Irrgang JJ. Primary anatomic double-bundle anterior cruciate ligament reconstruction: A preliminary 2-year prospective study. Am J Sports Med. 2008;36:1263–1274

PII: S0749-8063(10)00727-9

doi:10.1016/j.arthro.2010.07.023

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  • Author's Reply

    Asheesh Bedi
    Arthroscopy: The Journal of Arthroscopic and Related Surgery September 2010 (Vol. 26, Issue 9, Page 1148)

Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 26, Issue 9 , Pages 1147-1148, September 2010

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