Advertisement

Tibial Tunnel Placement Accuracy During Anterior Cruciate Ligament Reconstruction: Independent Femoral Versus Transtibial Femoral Tunnel Drilling Techniques

      Purpose

      This study aimed to compare the accuracy of tibial tunnel placement using independent femoral (IF) versus transtibial (TT) techniques.

      Methods

      Ten matched pairs of cadaveric knees were randomized so that one knee in the pair underwent arthroscopic TT drilling of the femoral tunnel and the other underwent IF drilling through an accessory medial portal. For both techniques, an attempt was made to place the femoral and tibial tunnels as close to the center of the respective anterior cruciate ligament (ACL) footprints as possible. Preoperative and postoperative computed tomography using a technique optimized for ligament evaluation allowed comparison of the anatomic ACL tibial footprint to the tibial tunnel aperture. The percentage of tunnel aperture contained within the native footprint, as well as the distance from the center of the tunnel aperture to the center of the footprint, was measured. Additionally, graft obliquity relative to the tibial plateau was evaluated in the sagittal plane.

      Results

      The percentage of tibial tunnel aperture contained within the native footprint averaged 71.6% ± 17.2% versus 52.1% ± 23.4% (P = .04) in the IF and TT groups, respectively. The distance from the center of the footprint to the center of the tibial tunnel aperture was 3.50 ± 1.6 mm and 4.40 ± 1.7 mm (P = .27) in the IF and TT groups, respectively. TT drilling placed 6 of 10 tunnels posterior to the center of the footprint versus 3 of 10 tunnels in IF drilling. The graft obliquity angles were 54.8° in TT specimens and 47.5° in IF specimens (P = .09).

      Conclusions

      This study adds to the literature suggesting that TT drilling with an 8-mm reamer has deleterious effects on tibial tunnel aperture and position. IF drilling, which does not involve repeated reaming of the tibial tunnel, is associated with the placement of a higher percentage of the tunnel aperture within the native tibial footprint. There was not a significant difference between the IF and TT techniques in their ability to place the center of the tibial aperture near the center of the footprint or in graft obliquity.

      Clinical Relevance

      ACL reconstruction has continued to evolve in an attempt to restore the functional anatomy and biomechanical behavior of the knee. Tibial tunnel characteristics—such as location, aperture topography, and tunnel obliquity—are important factors to consider in ACL reconstruction. This study compares tibial tunnels after IF and TT techniques.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Gabriel M.T.
        • Wong E.K.
        • Woo S.L.
        • Yagi M.
        • Debski R.E.
        Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads.
        J Orthop Res. 2004; 22: 85-89
        • Yagi M.
        • Wong E.K.
        • Kanamori A.
        • Debski R.E.
        • Fu F.H.
        • Woo S.L.
        Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction.
        Am J Sports Med. 2002; 30: 660-666
        • Yasuda K.
        • Kondo E.
        • Ichiyama H.
        • et al.
        Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts.
        Arthroscopy. 2004; 20: 1015-1025
        • Kopf S.
        • Pombo M.W.
        • Shen W.
        • Irrgang J.J.
        • Fu F.H.
        The ability of 3 different approaches to restore the anatomic anteromedial bundle femoral insertion site during anatomic anterior cruciate ligament reconstruction.
        Arthroscopy. 2011; 27: 200-206
        • Pombo M.W.
        • Shen W.
        • Fu F.H.
        Anatomic double-bundle anterior cruciate ligament reconstruction: Where are we today?.
        Arthroscopy. 2008; 24: 1168-1177
        • Sohn D.H.
        • Garrett Jr., W.E.
        Transitioning to anatomic anterior cruciate ligament graft placement.
        J Knee Surg. 2009; 22: 155-160
        • Tompkins M.
        • Milewski M.D.
        • Brockmeier S.F.
        • Gaskin C.M.
        • Hart J.M.
        • Miller M.D.
        Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: Use of an accessory medial portal versus traditional transtibial drilling.
        Am J Sports Med. 2012; 40: 1313-1321
        • Bedi A.
        • Musahl V.
        • Steuber V.
        • et al.
        Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: An anatomic and biomechanical evaluation of surgical technique.
        Arthroscopy. 2011; 27: 380-390
        • Bowers A.L.
        • Bedi A.
        • Lipman J.D.
        • et al.
        Comparison of anterior cruciate ligament tunnel position and graft obliquity with transtibial and anteromedial portal femoral tunnel reaming techniques using high-resolution magnetic resonance imaging.
        Arthroscopy. 2011; 27: 1511-1522
        • Silva A.
        • Sampaio R.
        • Pinto E.
        ACL reconstruction: Comparison between transtibial and anteromedial portal techniques.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 896-903
        • Steiner M.E.
        • Battaglia T.C.
        • Heming J.F.
        • Rand J.D.
        • Festa A.
        • Baria M.
        Independent drilling outperforms conventional transtibial drilling in anterior cruciate ligament reconstruction.
        Am J Sports Med. 2009; 37: 1912-1919
        • Bhatia S.
        • Korth K.
        • Van Thiel G.
        • et al.
        Effect of reamer design on posteriorization of the tibial tunnel during endoscopic transtibial anterior cruciate ligament reconstruction.
        Am J Sports Med. 2013; 41: 1282-1289
        • Kopf S.
        • Forsythe B.
        • Wong A.K.
        • Tashman S.
        • Irrgang J.J.
        • Fu F.H.
        Transtibial ACL reconstruction technique fails to position drill tunnels anatomically in vivo 3D CT study.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 2200-2207
        • Illingworth K.D.
        • Hensler D.
        • Working Z.M.
        • Macalena J.A.
        • Tashman S.
        • Fu F.
        A simple evaluation of anterior cruciate ligament femoral tunnel position: The inclination angle and femoral tunnel angle.
        Am J Sports Med. 2011; 39: 2611-2618
        • Treme G.
        • Diduch D.R.
        • Billante M.J.
        • Miller M.D.
        • Hart J.M.
        Hamstring graft size prediction: A prospective clinical evaluation.
        Am J Sports Med. 2008; 36: 2204-2209
        • Zantop T.
        • Kubo S.
        • Petersen W.
        • Musahl V.
        • Fu F.H.
        Current techniques in anatomic anterior cruciate ligament reconstruction.
        Arthroscopy. 2007; 23: 938-947
        • Morgan C.D.
        • Kalman V.R.
        • Grawl D.M.
        Definitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction.
        Arthroscopy. 1995; 11: 275-288
        • Rue J.P.
        • Ghodadra N.
        • Bach Jr., B.R.
        Femoral tunnel placement in single-bundle anterior cruciate ligament reconstruction: A cadaveric study relating transtibial lateralized femoral tunnel position to the anteromedial and posterolateral bundle femoral origins of the anterior cruciate ligament.
        Am J Sports Med. 2008; 36: 73-79
        • Ebraheim N.A.
        • Liu J.
        • Patil V.
        • et al.
        Evaluation of skull thickness and insertion torque at the halo pin insertion areas in the elderly: A cadaveric study.
        Spine J. 2007; 7: 689-693
        • Tompkins M.
        • Keller T.C.
        • Millewski M.D.
        • et al.
        Anatomic Femoral Tunnels in PCL reconstruction: Inside-out versus outside- in drilling.
        Am J Sports Med. 2013; 41: 43-50
        • Staubli H.U.
        • Rauschning W.
        Tibial attachment area of the anterior cruciate ligament in the extended knee position. Anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo.
        Knee Surg Sports Traumatol Arthrosc. 1994; 2: 138-146
        • Behrendt S.
        • Richter J.
        Anterior cruciate ligament reconstruction: Drilling a femoral posterolateral tunnel cannot be accomplished using an over-the-top step-off drill guide.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1252-1256
        • Dargel J.
        • Schmidt-Wiethoff R.
        • Fischer S.
        • Mader K.
        • Koebke J.
        • Schneider T.
        Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: A radiographic evaluation.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 220-227
        • Strauss E.J.
        • Barker J.U.
        • McGill K.
        • Cole B.J.
        • Bach Jr., B.R.
        • Verma N.N.
        Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction?.
        Am J Sports Med. 2011; 39: 1263-1269
        • Piasecki D.P.
        • Bach Jr., B.R.
        • Espinoza Orias A.A.
        • Verma N.N.
        Anterior cruciate ligament reconstruction: Can anatomic femoral placement be achieved with a transtibial technique?.
        Am J Sports Med. 2011; 39: 1306-1315
        • Lorenz S.
        • Elser F.
        • Mitterer M.
        • Obst T.
        • Imhoff A.B.
        Radiologic evaluation of the insertion sites of the 2 functional bundles of the anterior cruciate ligament using 3-dimensional computed tomography.
        Am J Sports Med. 2009; 37: 2368-2376
        • Miller M.D.
        • Gerdeman A.C.
        • Miller C.D.
        • et al.
        The effects of extra-articular starting point and transtibial femoral drilling on the intra-articular aperture of the tibial tunnel in ACL reconstruction.
        Am J Sports Med. 2010; 38: 707-712
        • Jackson D.W.
        • Gasser S.I.
        Tibial tunnel placement in ACL reconstruction.
        Arthroscopy. 1994; 10: 124-131
        • Mall N.A.
        • Matava M.J.
        • Wright R.W.
        • Brophy R.H.
        Relation between anterior cruciate ligament graft obliquity and knee laxity in elite athletes at the National Football League combine.
        Arthroscopy. 2012; 28: 1104-1113
        • Ayerza M.A.
        • Múscolo D.L.
        • Costa-Paz M.
        • Makino A.
        • Rondón L.
        Comparison of sagittal obliquity of the reconstructed anterior cruciate ligament with native anterior cruciate ligament using magnetic resonance imaging.
        Arthroscopy. 2003; 19: 257-261
        • Van Eck C.F.
        • Schreiber V.M.
        • Mejia H.A.
        • et al.
        “Anatomic” anterior cruciate ligament reconstruction: A systematic review of surgical techniques and reporting of surgical data.
        Arthroscopy. 2010; 26: S2-S12
        • Siebold R.
        • Ellert T.
        • Metz S.
        • et al.
        Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement.
        Arthroscopy. 2008; 24: 154-161