Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review

Background: The drilling technique used to make a femoral tunnel is critically important for determining outcomes after anterior cruciate ligament (ACL) reconstruction. The 2 most common methods are the transtibial (TT) and anteromedial (AM) techniques. Purpose: To determine whether graft orientation and placement affect clinical outcomes by comparing clinical and radiological outcomes after single-bundle ACL reconstruction with the AM versus TT technique. Study Design: Systematic review; Level of evidence, 3. Methods: Articles in PubMed, EMBASE, the Cochrane Library, ISI Web of Science, Scopus, and MEDLINE were searched from inception until April 25, 2020, using the following Boolean operators: transtibial OR trans-tibial AND (anteromedial OR trans-portal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament. Results: Of 1270 studies retrieved, 39 studies involving 11,207 patients were included. Of these studies, 14 were clinical, 13 were radiological, and 12 were mixed. Results suggested that compared with the TT technique, the AM technique led to significantly improved anteroposterior and rotational knee stability, International Knee Documentation Committee (IKDC) scores, and recovery time from surgery. A higher proportion of negative Lachman ( P = .0005) and pivot-shift test ( P = .0001) results, lower KT-1000 arthrometer maximum manual displacement ( P = .00001), higher Lysholm score ( P = .001), a higher incidence of IKDC grade A/B ( P = .05), and better visual analog scale score for satisfaction ( P = .00001) were observed with the AM technique compared with the TT technique. The AM drilling technique demonstrated a significantly shorter tunnel length ( P = .00001). Significant differences were seen between the femoral and tibial graft angles in both techniques. Low overall complication and revision rates were observed for ACL reconstruction with the AM drilling technique, similar to the TT drilling technique. Conclusion: In single-bundle ACL reconstruction, the AM drilling technique was superior to the TT drilling technique based on physical examination, scoring systems, and radiographic results. The AM portal technique provided a more reproducible anatomic graft placement compared with the TT technique.

LATERAL MENISCUS TEARS IN ACL INJURED KNEE

Anterior cruciate ligament (ACL) tears can be associated with injuries to the lateral meniscus (LM) in about 20-30% cases. The lateral meniscus is more mobile than the medial and besides contributing to load transmission, it also stabilizes the knee in pivot-shift testing. The LM tears more often in the acute setting and its incidence does not rise in cases of chronic ACL instability. Lateral meniscus tears can be minor or major depending how severely the knee function gets impaired. Major tears are the complete radial tears, longitudinal bucket handle tears and posterior root tears. Male gender, high body mass index and contact injury mechanism are all risk factors for an LM tear. Anatomic factors which can contribute to LM tears include a high posterior tibial slope, varus malalignment and greater asymmetry between medial and lateral slopes. The lateral meniscus must be saved and repaired whenever possible to prevent residual knee instability and progressive lateral compartment arthritis, which can set in soon after a meniscectomy. The development of techniques and technology have rendered most tears amenable to repair. Longitudinal tears can be repaired by the all-inside or inside-out technique and the needles and devices must be inserted through a high anteromedial or transpatellar portal to prevent injury to the popliteal neurovascular structures. A lateral safety incision must always be used for inside-out repairs. Radial tears can be repaired by two horizontal sutures, a cross stich, a cross-tag or a hash-tag suture configuration. Lateral meniscus posterior root repairs are repaired by transtibial technique, either by drilling an independent anatomic tunnel or the sutures pulled out via the ACL tibial tunnel. The lateral meniscus has high healing rates and repairs yield improvement in functional outcome, beside delaying radiographic arthritis.

A comparative study of functional outcome of transtibial and transportal femoral tunneling techniques for arthroscopic ACL reconstruction

Introduction: Acl reconstruction has revolutionarised the sports medicine world lately. Various methods of reconstruction have been advocated in the literature recently. ACL injury results in severe morbidity to an athletes career. The aim for anatomical reconstruction is to harvest the ACL graft at a more anatomical location on both the tibia and the femur. The purpose of this study is to compare the functional outcomes of the two methods of the graft harvestis to compare the functional outcomes of the two methods of the graft harvest Hypotheses: 60 patients were included in the study with complete ACL tear and were assessed at 3 6 and 9 months on the basis of various scores and relevant elements. Methods: All patients who were planned for arthroscopic ACL reconstruction surgery from the OPD, who were willing and fit the inclusion criteria were included in the study. They were then examined clinically with special tests i.e. Lachman’s test, anterior drawer test, pivot shift test and McMurray’s test and the findings were recorded including any associated meniscal injuries. They were then evaluated using 3 different evaluation systems i.e. IKDC, Lysholm and pain VAS. Results: Average mean age of the patients undergoing ACL reconstruction was (26%) in Transtibial and 23.3%. 90% of them were males. Majority of them were males (58%). The average IKDC score of transportal patients was significantly higher than transtibial patients at 6 months followup [P=0.001]. The average Lysholm knee score of transportal patients was significantly higher than the transtibial patients [P=0.047]. The average pain on VAS score of transportal group was significantly lower than transtibial at 6 months followup [P<0.001]. Complication of instability was more common in transtibial patients, 11(36.7%), when compared to transportal patients, 9(30%), however this difference was not significant [P=0.58]. Conclusion: Our study clearly stated that the transportal technique for acl reconstruction fetched superior results as compared to the transtibial technique in terms of knee instability, pain and other domains.

Excellence in Research:A Hybrid Transtibial Technique Combines the Strengths of theAnteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial

Objectives: Improved biomechanical and clinical outcomes have been reported when femoral anterior cruciate ligament (ACL) tunnels are centered on the native footprint. The anteromedial (AM) portal technique achieves improved aperture position when compared to a transtibial (TT) approach but sacrifices technical ease and creates a shorter more acutely angulated tunnel. A hybrid transtibial technique (HTT) technique using medial portal guidance of a flexible transtibial guide wire without the need for knee hyperflexion may combine the strengths of both the AM and TT approaches. The authors hypothesized that this HTT technique would achieve anatomic femoral tunnel apertures similar to the AM technique, but with longer and less angulated femoral tunnels similar to a TT technique. Methods: A prospective randomized controlled trial was implemented where 30 consecutive patients with acute, primary ACL tears were randomized to receive a TT, AM or HTT technique for their reconstruction. A total of 46 patients were assessed for eligibility in the investigation (Figure 1). All patients underwent 3D CT scans of the operative knee 6 weeks postoperatively to characterize tunnel positions. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as the graft bending angle in the sagittal and coronal plane were measured. Results: There were no significant differences between the patient demographics of the three groups. Tibial tunnel lengths and aperture positions were identical between the three groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regards to both height (p=0.75) and depth (p=0.72). On the other hand, compared to the AM portal and HTT techniques, respectively, femoral apertures created by the TT technique were significantly higher (p<0.001 and p<0.001) and shallower (p=0.001 and p<0.001) in the notch. The average femoral tunnel lengths varied significantly between the three groups measuring 35.16 mm, 41.64 mm, and 54.13 mm for the AM, HTT and TT groups, respectively (p<0.001). Lastly, there were no differences between the average coronal (164.0 degrees versus 158.8 degrees, p=0.190) and sagittal (114.0 degrees versus 111.0 degrees, p=0.358) graft bending angles between the TT and HTT groups, respectively. By contrast, compared to the TT and HTT groups, respectively, the graft bending angles created with an AM technique were significantly more acutely angled in the coronal (146.3 degrees, p<0.001, p<0.006) and sagittal (100.5 degrees, p=0.014, p=0.013) planes. Conclusion: The HTT technique achieves femoral aperture positions equally as anatomic as an AM portal technique, but with longer and less acutely oriented grafts similar to a transtibial approach. These advantages will decrease the incidence of graft tunnel mismatch as well as reduce the amount of stress imparted onto the graft by avoiding an acute graft bending angle. As such, this hybrid approach may represent a beneficial combination of both transtibial and AM portal techniques.

Estudo tomográfico do posicionamento femoral em reconstruções, por técnica transtibial, do LCA

Artigo Original: Tomographic Study of Femoral Positioning in Anterior Cruciate Ligament Reconstruction Using the Transtibial Technique. Autores: Robson Rocha da Silva, Marcos Almeida Matos, Valonie Carlos Neves Brasileiro Costa, Vitor Hugo Abreu Azevedo de Morais and Luiz Eduardo Lago de Castro. Publicado em : Knee Surg Relat Res. 2017 Sep; 29 (3):195-202.

EXTRA-ARTICULAR RECONSTRUCTION ASSOCIATED WITH THE ANTERIOR CRUCIATE LIGAMENT IN BRAZIL

ABSTRACT Objective: To assess the knowledge and technical preferences of Brazilian knee surgeons in relation to the treatment of Anterior Cruciate Ligament (ACL) injuries using intra-articular reconstruction in combination with extra-articular reconstruction. Methods: A questionnaire consisting of 16 questions about intra-articular ACL reconstruction in combination with extra-articular procedures and about the Anterolateral Ligament (ALL) was applied at the 48th Brazilian Congress of Orthopedics. Results: One hundred thirty-seven surgeons answered the questionnaire. Most surgeons perform 10-30 ACL reconstructions per year, with the transtibial technique appearing as the most common. Most surgeons find some percentage of residual pivot-shift after reconstructions, but the minority performs extra-articular procedures on a routine basis. The main indications for extra-articular reconstruction are revision and profuse pivot-shift cases. Most surgeons consider the ALL a true ligament, but 46.7% with less biomechanical importance and 32.3% with greater importance in knee stability. However, 91.4% had a positive perception of the reconstruction of this structure. Conclusion: Although the preferred technique is still the transtibial procedure, combined anatomical reconstructions already make up more than 50% of cases. Extra-articular reconstructions associated with the ACL are still performed by the minority of Brazilian surgeons, but 91.4% of them report having had a positive perception with their reconstruction. Level of Evidence III, Descriptive Study.