Advertisement

Anteromedial Portal Drilling Yielded Better Survivorship of Anterior Cruciate Ligament Reconstructions When Comparing Recent Versus Early Surgeries With This Technique

      Purpose

      To compare anteromedial (AM) and transtibial (TT) femoral drilling hole techniques in primary anterior cruciate ligament reconstruction, using the Danish Knee Ligament Reconstruction Register, comparing revision rates and clinical outcomes from 2 time periods, 2007 to 2010 and 2012 to 2015.

      Methods

      A total of 8,386 primary anterior cruciate ligament reconstructions were registered between January 2007 to December 2010 and 8,818 in the period January 2012 to December 2015. Revision ACL was the primary endpoint. Secondary endpoints were the objective and subjective clinical outcomes. Crude and adjusted relative risks (RRs) with 95% confidence interval (CIs) were calculated.

      Results

      The adjusted RR for revision surgery in the AM (2007-10) group compared with the TT (2007-10) group was 1.45 (95% CI, 1.17-1.78; P < .05), but when comparing the AM (2012-15) group with TT (2012-15) group, the RR was 0.99 (95% CI, 0.68-1.45; P = .96). One-year postoperative objective stability testing showed an RR = 1.38 (95% CI, 1.19-1.60; P < .01) for rotational stability and an RR = 1.37 (95% CI, 0.99-1.89; P < .01) for sagittal stability when comparing AM (2007-10) to TT (2007-10). No significant difference in objective stability was found in the more recent period. Lastly, comparing the subjective scores, the AM (2012-15) had a significantly higher Tegner score 1 year postoperatively compared with the TT-group (2012-15).

      Conclusions

      This study found an increased RR of revision anterior cruciate ligament and rotational and sagittal instability 1 year postoperatively for the AM technique in the period from 2007 to 2010. However, there was no significant difference in revision surgery and objective measures between the techniques from 2012 to 2015. Nevertheless, a higher activity level was found in the AM group. The results could indicate that the results found in the period 2007 to 2010 may have been caused by a learning curve when introducing a new and more complex procedure (AM).

      Level of Evidence

      Level III, retrospective comparative trial.
      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

        • Kopf S.
        • Forsythe B.
        • Wong A.K.
        • et al.
        Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography.
        J Bone Joint Surg Am. 2010; 92: 1427-1431
        • Strauss E.J.
        • Barker J.U.
        • McGill K.
        • Cole B.J.
        • Bach 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
        • O’Donnell J.B.
        • Scerpella T.A.
        Endoscopic anterior cruciate ligament reconstruction: Modified technique and radiographic review.
        Arthroscopy. 1995; 11: 577-584
        • Alentorn-Geli E.
        • Lajara F.
        • Samitier G.
        • Cugat R.
        The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1013-1037
        • 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
        • Gavriilidis I.
        • Motsis E.K.
        • Pakos E.E.
        • Georgoulis A.D.
        • Mitsionis G.
        • Xenakis T.A.
        Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: A cadaveric study.
        Knee. 2008; 15: 364-367
        • Marchant B.G.B.
        • Noyes F.R.
        • Barber-Westin S.D.
        • Fleckenstein C.
        Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions.
        Am J Sports Med. 2010; 38: 1987-1996
        • Alentorn-geli E.
        • Samitier G.
        Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: A blinded cross-sectional study at two- to five-year follow-up.
        2010: 747-754
        • Herbort M.
        • Lenschow S.
        • Fu F.H.
        • Petersen W.
        • Zantop T.
        ACL mismatch reconstructions: Influence of different tunnel placement strategies in single-bundle ACL reconstructions on the knee kinematics.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1551-1558
      1. Lind Martin, Wagner Rahr Lene, Lund Bent JWB. Dansk Korsbånds Rekonstruktions Register Årsrapport 2015. 2015;(December):71.

        • de Campos G.C.
        • Teixeira P.E.P.
        • Castro A.
        • Junior W.M.A.
        Femoral positioning influences ipsi- and contralateral anterior cruciate ligament rupture following its reconstruction: Systematic review and meta-analysis.
        World J Orthop. 2017; 8: 644
        • Diamantopoulos A.P.
        • Lorbach O.
        • Paessler H.H.
        Anterior cruciate ligament revision reconstruction: Results in 107 patients.
        Am J Sports Med. 2008; 36: 851-860
        • Loh J.C.
        • Fukuda Y.
        • Tsuda E.
        • Steadman R.J.
        • Fu F.H.
        • Woo S.L.Y.
        Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement.
        Arthroscopy. 2003; 19: 297-304
        • Chalmers P.N.
        • Mall N.A.
        • Cole B.J.
        • Verma N.N.
        • Bush-Joseph C.A.
        • Bach B.R.
        Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: A systematic review.
        Arthroscopy. 2013; 29: 1235-1242
        • Franceschi F.
        • Papalia R.
        • Rizzello G.
        • Del Buono A.
        • Maffulli N.
        • Denaro V.
        Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: Any clinical relevance? A retrospective comparative study.
        Arthroscopy. 2013; 29: 1330-1337
        • Wang H.
        • Fleischli J.E.
        • Zheng N.N.
        Transtibial versus anteromedial portal technique in single-bundle anterior cruciate ligament reconstruction: Outcomes of knee joint kinematics during walking.
        Am J Sports Med. 2013; 41: 1847-1856
        • Riboh J.C.
        • Hasselblad V.
        • Godin J.A.
        • Mather R.C.
        Transtibial versus independent drilling techniques for anterior cruciate ligament reconstruction: A systematic review, meta-analysis, and meta-regression.
        Am J Sports Med. 2013; 41: 2693-2702
        • Wang H.
        • Fleischli J.E.
        • Hutchinson I.D.
        • Zheng N.N.
        Knee moment and shear force are correlated with femoral tunnel orientation after single-bundle anterior cruciate ligament reconstruction.
        Am J Sports Med. 2014; 42: 2377-2385
        • Taşdemir Z.
        • Gülabi D.
        • Sağlam F.
        • Özal S.T.
        • Elmali N.
        Does the anteromedial portal provide clinical superiority compared to the transtibial portal in anterior cruciate ligament reconstruction in nonprofessional athletes in short-term follow-up?.
        Acta Orthop Traumatol Turc. 2015; 49: 483-491
        • Chen Y.
        • Chua K.H.
        • Singh A.
        • et al.
        Outcome of single-bundle hamstring anterior cruciate ligament reconstruction using the anteromedial versus the transtibial technique: A systematic review and meta-analysis.
        Arthroscopy. 2015; 31: 1784-1794
        • Azboy I.
        • Demirtaş A.
        • Gem M.
        • Kiran S.
        • Alemdar C.
        • Bulut M.
        A comparison of the anteromedial and transtibial drilling technique in ACL reconstruction after a short-term follow-up.
        Arch Orthop Trauma Surg. 2014; 134: 963-969
        • Group M.
        • Kaeding C.C.
        Transtibial ACL femoral tunnel preparation increases odds of repeat ipsilateral knee surgery.
        J Bone Joint Surg Am. 2013; 95: 2035-2042
        • Lind M.
        • Menhert F.
        • Pedersen A.B.
        The first results from the Danish ACL reconstruction registry: Epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 117-124
        • Roos E.M.
        • Toksvig-Larsen S.
        Knee injury and Osteoarthritis Outcome Score (KOOS)—validation and comparison to the WOMAC in total knee replacement.
        Health Qual Life Outcomes. 2003; 1: 17
        • Tegner Y.
        • Lysholm J.
        Rating systems in the evaluation of knee ligament injuries.
        Clin Orthop Relat Res. 1985; 198: 43-49
        • Kopf S.
        • Kauert R.
        • Halfpaap J.
        • Jung T.
        • Becker R.
        A new quantitative method for pivot shift grading.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 718-723
        • Ranstam J.
        • Lohmander L.S.
        • Frobell R.
        • Roos E.M.
        A randomized trial of treatment for acute anterior cruciate ligament tears.
        N Engl J Med. 2010; 4: 331-342
        • Rahr-Wagner L.
        • Thillemann T.M.
        • Pedersen A.B.
        • Lind M.C.
        Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: Results from the Danish Knee Ligament Reconstruction Register.
        Arthroscopy. 2013; 29: 98-104
        • Xu Y.
        • Liu J.
        • Kramer S.
        • et al.
        Comparison of in situ forces and knee kinematics in anteromedial and high anteromedial bundle augmentation for partially ruptured anterior cruciate ligament.
        Am J Sports Med. 2011; 39: 272-278
        • Bottoni C.R.
        • Rooney R.C.
        • Harpstrite J.K.
        • Kan D.M.
        Ensuring accurate femoral guide pin placement in anterior cruciate ligament reconstruction.
        Am J Orthop (Belle Mead NJ). 1998; 27: 764-766
        • Golish S.R.
        • Baumfeld J.A.
        • Schoderbek R.J.
        • Miller M.D.
        The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: A cadaveric study.
        Arthroscopy. 2007; 23: 1187-1192
        • Sadoghi P.
        • Kröpfl A.
        • Jansson V.
        • Müller P.E.
        • Pietschmann M.F.
        • Fischmeister M.F.
        Impact of tibial and femoral tunnel position on clinical results after anterior cruciate ligament reconstruction.
        Arthroscopy. 2011; 27: 355-364
        • Chang C.B.
        • Yoo J.H.
        • Chung B.J.
        Oblique femoral tunnel placement can increase risks of short femoral tunnel and cross-pin protrusion in anterior cruciate ligament reconstruction.
        Am J Sports Med. 2010; : 1237-1245
        • Lubowitz J.H.
        Ligament femoral socket: Pitfalls and solutions.
        Arthroscopy. 2009; 25: 95-101
        • 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; : 220-227
        • Chen H.
        • Tie K.
        • Qi Y.
        • Li B.
        • Chen B.
        • Chen L.
        Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: A meta-analysis of prospective randomized controlled trials.
        J Orthop Surg Res. 2017; 12: 1-10
        • Robin B.N.
        • Jani S.S.
        • Marvil S.C.
        • Reid J.B.
        • Schillhammer C.K.
        • Lubowitz J.H.
        Advantages and disadvantages of transtibial, anteromedial portal, and outside-in femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction: A systematic review.
        Arthroscopy. 2015; 31: 1412-1417
        • Rahr-Wagner L.
        • Thillemann T.M.
        • Lind M.C.
        • Pedersen A.B.
        Validation of 14,500 operated knees registered in the Danish Knee Ligament Reconstruction Register: Registration completeness and validity of key variables.
        Clin Epidemiol. 2013; 5: 219-228
        • Freedman K.B.
        • D’Amato M.J.
        • Nedeff D.D.
        • Kaz A.
        • Bach B.R.
        Arthroscopic anterior cruciate ligament reconstruction: A metaanalysis comparing patellar tendon and hamstring tendon autografts.
        Am J Sports Med. 2003; 31: 2-11

      Linked Article