Iatrogenic Injury to the Posterolateral Knee During Anterior Cruciate Ligament Reconstruction with Anteromedial Portal Technique

BACKGROUND: Femoral tunnel reaming through anteromedial portal, also known as transportal technique, allows for anatomic femoral tunnel placement in restoring anterior cruciate ligament (ACL) kinematics. This procedure may cause iatrogenic injury to the posterolateral structures of the knee. PURPOSE: This study aims to assess the risk of posterolateral structure injury in ACL reconstruction using transportal technique. METHODS: ACL reconstruction using transportal technique was performed in 20 patients. Clinical and radiological examination was performed preoperatively and 1 month postoperatively. Clinical examination included any pain or paresthesia on posterolateral area of the knee, varus alignment of the knee, abnormal gait, and specific tests for posterolateral stability. Radiological evaluation was plain radiography and stress radiography for posterolateral stability, and magnetic resonance imaging (MRI) for assessing structural damage. RESULTS: Post-operative evaluation showed pain in posterolateral area in five patients, numbness on posterolateral knee in one patient, both pain and numbness in two patients and lateral gastrocnemius muscle injury on MRI in six patients. We did not find varus knee alignment and abnormal gait. Specific tests were negative in post-operative evaluation. Post-operative radiographic imaging did not show the sign of lateral widening. CONCLUSION: Femoral tunnel drilling using transportal technique in ACL reconstruction is safe even it might risk to damage lateral gastrocnemius muscle, according to clinical and MRI findings.

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Accessory Anteromedial Portal may not Provide Clinically Superior Results Compared with the Anteromedial Portal in Anterior Cruciate Ligament Reconstruction

The Journal of Knee Surgery ◽

10.1055/s-0037-1607074 ◽

2017 ◽

Vol 31 (08) ◽

pp. 716-722

Author(s):

Shu-Ming Ye ◽

Jue-Hua Jing ◽

Hao Lv ◽

Ji-Sen Zhang ◽

Xin-Zhong Xu ◽

...

Keyword(s):

Acl Reconstruction ◽

Femoral Tunnel ◽

Pivot Shift ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

Pivot Shift Test ◽

Single Bundle ◽

Anteromedial Portal ◽

Anterior Cruciate

AbstractTechniques using the anteromedial portal (AMP) and accessory anteromedial portal (AAMP) are commonly used in anterior cruciate ligament (ACL) reconstruction. The aim of this study was to investigate the radiological and clinical outcomes of arthroscopic single-bundle ACL reconstruction using the AMP or AAMP technique to drill the femoral tunnel. The records of 157 patients who underwent single-bundle ACL reconstruction using the AMP or AAMP technique between 2011 and 2015 were reviewed. The femoral tunnel clock-face position and femoral tunnel and tibial tunnel anterior–posterior (AP) inclination angles were assessed on axial or AP magnetic resonance images. At last follow-up, the Lachman test and pivot-shift test were used to evaluate AP and rotational stability, respectively. The Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) form were used to evaluate clinical and functional results. No statistically significant differences were found between the groups in patient age, sex, follow-up period, or affected side distribution. The mean femoral tunnel inclination angle was 31.13 ± 8.06 degrees in the AMP group and 30.17 ± 9.02 degrees in the AAMP group (p = 0.513). The tibial tunnel inclination angle in the AMP group (16.28 ± 7.89 degrees) was not different from that in the AAMP group (13.70 ± 6.08 degrees). No significant differences were observed between the two groups in the Lachman test, pivot-shift test, Lysholm knee scoring scale, or IKDC scores. The AAMP technique was not clinically superior to the AMP technique in ACL reconstruction. This is a retrospective comparative study and its level of evidence is III.

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Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison With the Transtibial and Anteromedial Portal Techniques

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211054509 ◽

2021 ◽

Vol 9 (11) ◽

pp. 232596712110545

Author(s):

D. Landry Jarvis ◽

Danica D. Vance ◽

Emily K. Reinke ◽

Jonathan C. Riboh

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Calculated Data ◽

Significant Finding ◽

Anteromedial Portal ◽

Significant Difference ◽

Anterior Cruciate ◽

Tunnel Angle

Background: Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most commonly used technique for pubescent patients. The transtibial (TT) drilling technique creates vertical and central femoral tunnels to minimize the physeal area of injury at the expense of a nonanatomic femoral tunnel. The hybrid TT (HTT) technique offers the potential of an anatomic femoral position with tunnel geometry similar to that using the TT technique. Purpose/Hypothesis: The purpose was to perform a radiographic comparison of the HTT technique with TT and anteromedial portal (AM) techniques in adolescent patients undergoing transphyseal ACL reconstruction. It was hypothesized that femoral tunnels created during HTT would be similar to TT tunnels but significantly more vertical and central than AM tunnels. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively screened primary transphyseal ACL reconstructions performed in adolescents at our institution between 2013 and 2019. The youngest 20 eligible patients were selected from each technique cohort: TT, AM, and HTT. Postoperative radiographs were assessed for the coronal femoral tunnel angle, as well as the location of the tunnel-physis penetration on the anteroposterior and lateral views. Physeal lesion surface area was calculated. Data were compared among the 3 groups using 1-way analysis of variance followed by pairwise comparisons. Results: Included were 47 patients with a mean ± SD age of 14.3 ± 1.2 years (n = 9 with TT, 18 with AM, and 20 with HTT techniques). The coronal tunnel angle was significantly more vertical in the TT (60.7° ± 7.2°) and HTT (54.4° ± 5.7) groups as compared with the AM group (48.8° ± 5.9; P = .0037 and P = .02, respectively). There was no significant difference between the TT and HTT groups ( P = .066). The only significant finding regarding femoral tunnel location was that the HTT tunnels (28.9% ± 4.8%) penetrated the physis more centrally than did the AM tunnels (20.0% ± 5.1%; P = .00002) on lateral radiographs. Conclusion: The HTT technique presents an option for transphyseal ACL reconstruction, with femoral tunnel obliquity and estimated physeal disruption similar to that of the TT technique and significantly less than that of the AM technique. The HTT technique also results in the most central physeal perforation of all techniques, predominantly in the sagittal plane.

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Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison to Transtibial and Anteromedial Portal Techniques

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00089 ◽

2021 ◽

Vol 9 (7_suppl3) ◽

pp. 2325967121S0008

Author(s):

D.Landry Jarvis ◽

Danica D. Vance ◽

Jonathan C. Riboh

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Sagittal Plane ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Calculated Data ◽

Anteromedial Portal ◽

Significant Difference ◽

Text Figure ◽

Anterior Cruciate

Background: Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most commonly used technique for pubescent patients. The principles of creating vertical and central femoral tunnels are well accepted to minimize physeal area of injury and are typically accomplished with a transtibial (TT) technique. This, however, may come at the expense of a non-anatomic tunnel. The hybrid transtibial (HTT) technique offers the potential of combining an anatomic femoral position with tunnel geometry similar to the TT technique but has never been assessed in a clinical cohort. Hypothesis/Purpose: We hypothesized that tunnels created by a HTT technique would be similar in orientation and physeal location to TT tunnels, but significantly more vertical and central than tunnels created with an anteromedial portal (AM). Methods: We retrospectively screened all ACL reconstructions performed in children aged 10 to 16 years, at our institution between 2013 to 2019, with the requirements of having a transphyseal reconstruction and an available post-operative radiographs. Radiographs were then assessed for the coronal femoral tunnel angle (FTA), as well as the location of the tunnel-physis penetration on the AP (LTAP) and lateral (LTL) views. Physeal lesion surface area was calculated. Data were compared between the three groups using ANOVA. Results: Forty-seven patients met eligibility criteria with 9 TT, 18 AM, and 20 HTT patients. Mean patient age was 14.3 +/- 1.2 years. The FTA was significantly more vertical in the TT (60.7o +/-7.2) and HTT (54.4o +/- 5.7) groups as compared to the AM group (48.8o +/- 5.9); p = 0.0037 and p = 0.02 respectively. There was no significant difference between the TT and HTT groups ( p = 0.066). The LTAP was not significantly different between groups (p = 0.097). The LTL demonstrated that the HTT tunnels penetrated the physis at a more central location in the sagittal plane (28.9% +/- 4.8%) than the AM tunnels (20.0% +/- 5.1%, p = 0.00002), but was statistically indistinguishable from the TT (24.4%+/- 4.0%, p= 0.066) tunnels. Conclusion: The hybrid transtibial technique presents an option for transphyseal ACL reconstruction, with femoral tunnel obliquity and estimated physeal disruption similar to the TT technique, significantly less than the AM technique. The HTT also results in the most central physeal perforation of all techniques, predominantly in the sagittal plane. With the known ability of the HTT technique to recreate an anatomic femoral footprint, this may represent the “best of both worlds” for transphyseal ACL reconstruction. Tables/Figures: [Figure: see text][Figure: see text][Figure: see text][Figure: see text]

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Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction

The Journal of Knee Surgery ◽

10.1055/s-0040-1710521 ◽

2020 ◽

Author(s):

Takanori Iriuchishima ◽

Bunsei Goto

Keyword(s):

Systematic Review ◽

Surgical Technique ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

Target Point ◽

Single Bundle ◽

Anterior Cruciate ◽

Transportal Technique

AbstractThe purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms “anterior cruciate ligament reconstruction,” “anatomic or anatomical,” and “single bundle.” Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow–deep direction (32.3%) and in a high–low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.

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Anatomıc femoral tunnel drilling in acl reconstruction without using of an accessory medial portal and evaluation of femoral tunnel positioning using 3-d computed tomography

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117s00076 ◽

2017 ◽

Vol 5 (2_suppl2) ◽

pp. 2325967117S0007

Author(s):

Fatih Karaaslan ◽

Sinan Karaoğlu

Keyword(s):

Computed Tomography ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

3D Ct ◽

Quadrant Method ◽

Anterior Cruciate ◽

Femoral Tunnel Drilling ◽

Transportal Technique

Background and Purpose: Characterization of the insertion site anatomy in anterior cruciate ligament reconstruction has recently received increased attention in the literature, coinciding with a growing interest in anatomic reconstruction. The purpose of this study is to report a modified novel transportal technique to approach the center of anatomical femoral footprint in anterior cruciate ligament (ACL) reconstruction and to investigate the accurate femoral tunnel position with 3-dimensional computed tomography (3D-CT). Materials-Methods: We evaluated 11 patients who underwent primary ACL reconstruction using a modified transportal technique to approach the center of anatomical femoral footprint in single bundle ACL reconstruction with hamstring autograft. Their femoral tunnel positions were investigated with 3D-CT postoperatively according to the quadrant method by three orthopedic surgeons. Results: According to the quadrant method with 3D-CT, the femoral tunnel was measured at a mean of 33,49% ± 5,59% from the proximal condylar surface (parallel to the Blumensaat line) and 32,93% ± 3,82% from the notch roof (perpendicular to the Blumensaat line) with good interobserver (intraclass correlation coefficients [ICC], 0,991and 0,858, respectively with 0,975 – 0,997%95 CI) and intraobserver reliability (ICC, 0.875 and 0.893, respectively with 0,663 – 0,956%95 CI). Conclusions: Our modified transportal technique is anticipated to provide anatomical placement of the femoral tunnel during ACL reconstruction than the former traditional transtibial techniques. This technique is reproducible and also easier to perform than classic transportal technique does not need extra arthroscopic portal. [Figure: see text]

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Evaluation of Tibial Tunnel Location with the Femoral Tunnel Created Behind the Resident's Ridge in Transtibial Anterior Cruciate Ligament Reconstruction

The Journal of Knee Surgery ◽

10.1055/s-0040-1722568 ◽

2021 ◽

Author(s):

Tsuneari Takahashi ◽

Tomohiro Saito ◽

Tatsuya Kubo ◽

Ko Hirata ◽

Hideaki Sawamura ◽

...

Keyword(s):

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

Bone Tunnel ◽

Femoral Bone ◽

Anterior Cruciate ◽

Tunnel Positions ◽

Tunnel Angle ◽

Coronal View

AbstractFew studies have determined whether a femoral bone tunnel could be created behind the resident's ridge by using a transtibial (TT) technique-single bundle (SB)-anterior cruciate ligament (ACL) reconstruction. The aim of this study was to clarify (1) whether it is possible to create a femoral bone tunnel behind the resident's ridge by using the TT technique with SB ACL reconstruction, (2) to define the mean tibial and femoral tunnel angles during anatomic SB ACL reconstruction, and (3) to clarify the tibial tunnel inlet location when the femoral tunnel is created behind resident's ridge. Arthroscopic TT-SB ACL reconstruction was performed on 36 patients with ACL injuries. The point where 2.4-mm guide pin was inserted was confirmed, via anteromedial portal, to consider a location behind the resident's ridge. Then, an 8-mm diameter femoral tunnel with a 4.5-mm socket was created. Tunnel positions were evaluated by using three-dimensional computed tomography (3D-CT) 1 week postoperatively. Quadrant method and the resident's ridge on 3D-CT were evaluated to determine whether femoral tunnel position was anatomical. Radiological evaluations of tunnel positions yielded mean ( ± standard deviation) X- and Y-axis values for the tunnel centers: femoral tunnel, 25.2% ± 5.1% and 41.6% ± 10.2%; tibial tunnel, 49.2% ± 3.5%, and 31.5% ± 7.7%. The bone tunnels were anatomically positioned in all cases. The femoral tunnel angle relative to femoral axis was 29.4 ± 5.5 degrees in the coronal view and 43.5 ± 8.0 degrees in the sagittal view. The tibial tunnel angle relative to tibial axis was 25.5 ± 5.3 degrees in the coronal view and 52.3 ± 4.6 degrees in the sagittal view. The created tibial bone tunnel inlet had an average distance of 13.4 ± 2.7 mm from the medial tibial joint line and 9.7 ± 1.7 mm medial from the axis of the tibia. Femoral bone tunnel could be created behind the resident's ridge with TT-SB ACL reconstruction. The tibial bone tunnel inlet averaged 13.4 mm from the medial tibial joint line and 9.7 mm medial from the tibia axis.

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Correlation of Femoral Tunnel Length with Body Height, Limb Length, and Thigh Length in Indian Patients Undergoing Anterior Cruciate Ligament Reconstruction

Journal of Orthopaedic Surgery ◽

10.1177/1602400302 ◽

2016 ◽

Vol 24 (3) ◽

pp. 286-288

Author(s):

Ravi Gupta ◽

Anubhav Malhotra ◽

Pawan Kumar ◽

Gladson David Masih

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Body Height ◽

Limb Length ◽

Tunnel Length ◽

Indian Patients ◽

Anterior Cruciate ◽

Hamstrings Tendon

Purpose To measure the femoral tunnel length created through a far medial portal and determine its correlation with body height, limb length, and thigh length in 404 Indian patients undergoing anterior cruciate ligament (ACL) reconstruction. Methods 364 male and 40 female Indian patients aged 18 to 51 (mean, 26.8) years underwent ACL reconstruction by a single surgeon using the hamstrings tendon autograft. Their body height, limb length, and thigh length were measured by a single assessor, as was the femoral tunnel length. Results The mean femoral tunnel length was 34.5 mm. It was <30 mm in 28 patients and <25 mm in 2 patients. The correlation coefficients of the femoral tunnel length with body height, limb length, and thigh length were 0.485 (p<0.0001), 0.426 (p<0.0001), and 0.304 (p<0.0001). No patient had posterior wall blowout fracture. Conclusion The femoral tunnel length positively correlated with body height, limb length, and thigh length in 404 Indian patients.

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Computed Tomography Imaging Results of Single Band Anterior Cruciate Ligament Reconstruction: A Retrospective Study Comparing Fixed- and Adjustable-Length Loop Cortical Fixation on the First Day After Surgery

10.21203/rs.3.rs-660355/v1 ◽

2021 ◽

Author(s):

Lifeng Yin ◽

Hua Zhang ◽

Junbo Liu ◽

xingyu zhang ◽

zhengxing wen ◽

...

Keyword(s):

Computed Tomography ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Ct Images ◽

Graft Fixation ◽

Bone Preservation ◽

Anterior Cruciate ◽

Graft Insertion

Abstract Background: Cortical suspensory femoral fixation is commonly performed for graft fixation of the femur in anterior cruciate ligament (ACL) reconstruction using hamstring tendons. This study aimed to compare the morphology of femoral tunnel and graft insertion between fixed-length loop devices (FLD) and adjustable-length loop devices (ALD) using computed tomography (CT) images on the first day after hamstring ACL reconstruction. Methods: Overall, 94 patients who underwent ACL reconstruction from January 2016 to January 2021 were included. For femoral graft fixation, FLD (Smith & Nephew, ENDOBUTTON) and ALD (DePuy Synthes, Mitek sports medicine, RIGIDLOOP Adjustable cortical system) were used in 56 and 38 patients, respectively (FLD and ALD groups). For evaluation of the morphology of the humeral tunnel and graft depth, CT scans were performed immediately on the first postoperative day. The gap distance between the top of the graft and the socket tunnel end, the length of lateral bone preservation, and the depth of graft insertion were measured on the CT images. Results: The gap distance and bone preservation significantly differed between the two groups (1.90±1.81 mm and 14.35±4.67 mm in ALD groups; 7.08±2.63 mm and 7.35±3.62 mm in FLD groups, respectively; both P values < 0.01). The graft insertion depth did not significantly differ between the groups. Conclusion: The ALD group had a smaller gap distance, better bone preservation, and a similar graft insertion length in the femoral tunnel when compared to the FLD group. Based on these findings, ALD might be better for bone preservation and tunnel utilization in patients with short femoral tunnels. Trial registration: retrospectively registered

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