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ACL Reconstruction Graft Angle and Outcomes: Transtibial vs Anteromedial Reconstruction

  • Original Article
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HSS Journal ®

Abstract

Background

The importance of creating an anatomic anterior cruciate ligament (ACL) reconstruction has been receiving significant attention. The best technique by which to achieve this anatomic reconstruction continues to be debated. The two most common methods are the transtibial (TT) and anteromedial (AM) techniques. Each has its advantages and disadvantages, and the literature comparing the two remains uncertain.

Questions/Purposes

In this prospective comparative study, we aimed to compare the ACL graft and tunnel angles achieved using the anatomic transtibial (TT) and anteromedial (AM) techniques; compare the ACL graft and tunnel angles in knees that have undergone ACL reconstruction and knees with intact ACLs; and determine whether differences in the graft or tunnel angle produce differences in clinical outcomes, as measured using both physical exam and patient-reported outcomes, after ACL reconstruction.

Methods

Patients who underwent primary ACL reconstruction with bone–tendon–bone grafts using a TT or AM technique were included. Femoral graft angle (FGA), tibial graft angle (TGA), and sagittal orientation of the reconstructed ACL and contralateral native ACL were measured on post-operative magnetic resonance imaging. Post-operatively, patients underwent measurement of knee stability and completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) survey.

Results

Twenty-nine patients were enrolled (AM group, 14; TT group, 15); at follow-up, KOOS data were available for 26 patients (13 in each group). There were no differences in sagittal ACL graft angle between groups or in comparison with the normal knee. The FGA was more vertical after TT reconstructions; the TGA was comparable between groups. There were no significant differences in 2-year post-operative physical exam measurements or in KOOS scores.

Conclusion

Anatomic ACL angle was restored after reconstruction with both the TT and AM techniques, despite different FGAs. No significant differences in clinical outcome were noted between groups on physical exam or KOOS at 2 years after surgery. These results suggest that TT reconstruction results in a graft position similar to that seen in AM reconstruction and that the location of the intra-articular tunnel aperture matters more than the orientation of the tunnel.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA

    Austin V. Stone MD, PhD

  2. Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St., Chicago, IL, 60616, USA

    Jorge Chahla MD, PhD, Brandon J. Manderle MD, Alexander Beletsky BA, Charles A. Bush-Joseph MD & Nikhil N. Verma MD

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  1. Austin V. Stone MD, PhD
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  2. Jorge Chahla MD, PhD
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  3. Brandon J. Manderle MD
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  6. Nikhil N. Verma MD
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Correspondence to Nikhil N. Verma MD.

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Conflict of Interest

Austin V. Stone, MD, PhD; Jorge Chahla, MD, PhD; Brandon J. Manderle, MD; and Alexander Beletsky, BA, declare that they have no conflicts of interest. Charles A. Bush-Joseph, MD, reports editorial or governing board membership at the American Journal of Sports Medicine and American Orthopaedic Society for Sports Medicine, stock or stock options from Cresco Labs, and educational support from Medwest Associates, outside the submitted work. Nikhil N. Verma, MD, reports research support from Arthrex, Inc.; publishing royalties from Arthroscopy and Vindico Medical-Orthopedics Hyperguide; research support from DJ Orthopaedics and Orthospace; board or committee membership from the American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, and Arthroscopy Association of North America; editorial or governing board membership at Journal of Knee Surgery and SLACK Incorporated; stock or stock options from CyMedica and Omeros; and personal fees and stock or stock options from Minivasive, outside the submitted work.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

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Informed consent was obtained from all patients for being included in this study.

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Additional information

Level of Evidence: Level IV: Prospective Comparative Cohort Study.

Work performed at: Midwest Orthopaedics at Rush

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Stone, A.V., Chahla, J., Manderle, B.J. et al. ACL Reconstruction Graft Angle and Outcomes: Transtibial vs Anteromedial Reconstruction. HSS Jrnl 16 (Suppl 2), 256–263 (2020). https://doi.org/10.1007/s11420-019-09707-w

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  • DOI: https://doi.org/10.1007/s11420-019-09707-w

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