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No difference in graft healing or clinical outcome between trans-portal and outside-in techniques after anterior cruciate ligament reconstruction

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of this study was to compare femoral tunnel geometry including tunnel position, length, and graft bending angle between trans-portal and outside-in techniques in anterior cruciate ligament (ACL) reconstruction and discover whether such differences in tunnel geometry could influence graft healing or clinical outcome.

Methods

Sixty-four patients with anatomical single-bundle ACL reconstruction performed with either trans-portal technique (32 patients, one centre) or outside-in technique (32 patients, the other centre) were included in this retrospective study. Femoral tunnel location and length, and graft bending angle at the femoral tunnel were analysed on 3D CT knee model. The location and length of the femoral tunnel and graft bending angle were compared between the two techniques. All patients underwent MRI scans at around 1 year following ACL reconstruction. It was found that all patients had intact ACL graft on MRI images. On oblique axial image taken after ACL reconstruction to determine graft healing at femoral and tibial tunnels and the intra-articular portion, graft signal intensity ratio was calculated by dividing signal intensity (SI) of the reconstructed ACL by that of posterior cruciate ligament (PCL) in the region of interest selected with Marosis software. Clinical outcomes regarding Tegner activity scores, the International Knee Documentation Committee (IKDC) evaluation scores, Lachman test, and pivot shift test results were also compared between the two groups.

Results

While the location of femoral tunnel was similar to each other in both groups, the femoral tunnel length was longer in the outside-in technique (37.0 vs. 32.4 mm, p = .02). Meanwhile, the outside-in technique showed significantly more acute graft tunnel angle than the trans-portal technique (106.7° vs. 113.8°, p = .01). However, signal intensity ratios of grafts (compared with SI of PCL) were similar in femoral and tibial tunnels and intra-articular portions. Moreover, there were no statistically significant differences in terms of IKDC scores (89.4 vs. 90.5, n.s.) or Tegner activity scores (6.2 vs. 6.4, n.s.) between the two groups. There was no significant difference in measurement of Lachman or Pivot shift test either between the two groups.

Conclusion

Even though the outside-in technique in ACL reconstruction created a more acute femoral graft bending angle and a longer femoral tunnel length than the trans-portal technique, these had no negative effect on graft healing. In addition, trans-portal and outside-in techniques in ACL reconstruction showed similar femoral tunnel positions and clinical outcomes. Acceptable graft healing and clinical outcomes can be obtained for both trans-portal and outside-in techniques in ACL reconstruction.

Level of evidence

III.

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Acknowledgements

This study was supported by a Grant (2014R1A1A2059147) of the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology, Republic of Korea.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Gil Hospital, Gachon University of Medicine and Science, Inchon, Korea

    Jae-Ang Sim

  2. Department of Orthopaedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea

    Jong-Min Kim

  3. Department of Orthopaedic Surgery, Seoul University Hospital, Seoul, Korea

    SahngHoon Lee

  4. Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 519-763, Korea

    Eun-Kyoo Song & Jong-Keun Seon

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  1. Jae-Ang Sim
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  2. Jong-Min Kim
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Correspondence to Jong-Keun Seon.

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Conflict of interest

The authors declare that we have no potential conflict of interest.

Funding

JKS have received research grant (2014R1A1A2059147) from the National Research Foundation of Korea, the Ministry of Education, Science and Technology, Republic of Korea.

Ethical approval

Institutional Review Board of Chonnam National University Hwasun Hospital approved the study design (2015–142).

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Written informed consents were obtained from all patients.

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Sim, JA., Kim, JM., Lee, S. et al. No difference in graft healing or clinical outcome between trans-portal and outside-in techniques after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26, 2338–2344 (2018). https://doi.org/10.1007/s00167-017-4655-y

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  • DOI: https://doi.org/10.1007/s00167-017-4655-y

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