ACL reconstruction: comparison between transtibial and anteromedial portal techniques

  • Alcindo Silva
  • Ricardo Sampaio
  • Elisabete Pinto



The purpose of this study was to compare the transtibial reconstruction technique of the anterior cruciate ligament (ACL) with the anteromedial (AM) portal technique in their ability to place the femoral and tibial tunnels within the ACL footprints.


Forty patients were sequentially enrolled in two different surgical techniques, 20 patients in the transtibial and 20 patients in the AM portal technique. All patients underwent computed tomography scan of the operated knee. The center of the femoral tunnel aperture on the lateral femoral condyle was measured according to the quadrant method. On the tibial side, the center of the tibial tunnel was measured in the sagittal plane. These measurements were compared with the center of the normal AM and PL bundles.


There were no differences in the center of the femoral tunnels on the Blumensaat’s line between the two groups (mean 23.5% (4.2) for the transtibial technique and 26.0% (4.3) for the AM portal technique (P = n.s.). In the height of the femoral condyle, the center of the tunnels was significantly lower in the AM portal technique group [mean 34.7% (3.8) vs. 24.0% (7.9) (P < 0.001)]. In the tibia, the center of the tunnel in the sagittal plane was significantly posterior in the transtibial technique (mean 55.4% (4.9) vs. 44.4% (3.7) (P < 0.001).


The AM portal technique places the femoral and tibial tunnels more centrally in the ACL footprint when compared with the transtibial technique.

Level of evidence



ACL reconstruction Anteromedial portal technique Transtibial technique 


  1. 1.
    Abebe ES, Moorman CT 3rd, Dziedzic TS, Spritzer CE, Cothran RL, Taylor DC, Garrett WE Jr, DeFrate LE (2009) Femoral tunnel place-ment during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel–independent techniques. Am J Sports Med 37:1904–1911PubMedCrossRefGoogle Scholar
  2. 2.
    Aglietti P, Zaccherotti G, Menchetti PP, De Biase P (1995) A comparison of clinical and radiological parameters with two arthroscopic techniques for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 3:2–8PubMedCrossRefGoogle Scholar
  3. 3.
    Anderson AF, Snyder RB, Lipscomb AB Jr (2001) Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med 29:272–279PubMedGoogle Scholar
  4. 4.
    Andriacchi TP, Briant PL, Bevill SL, Koo S (2006) Rotational changes at the knee after ACL injury cause cartilage thinning. Clin Orthop Relat Res 442:39–44PubMedCrossRefGoogle Scholar
  5. 5.
    Arnold MP, Kooloos J, van Kampen A (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 9:194–199PubMedGoogle Scholar
  6. 6.
    Aune AK, Holm I, Risberg MA, Jensen HK, Steen H (2001) Fourstrand hamstring tendon autograft compared with patellar tendonbone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. Am J Sports Med 29:722–728PubMedGoogle Scholar
  7. 7.
    Bedi A, Musahl V, Steuber V, Kendoff D, Choi D, Allen AA, Pearle AD, Altchek DW (2011) Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy 27:380–390PubMedCrossRefGoogle Scholar
  8. 8.
    Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL: radiographic quadrant method. Am J Knee Surg 10:14–21PubMedGoogle Scholar
  9. 9.
    Cain EL Jr, Clancy WG Jr (2002) Anatomic endoscopic anterior cruciate ligament reconstruction with patella tendon autograft. Orthop Clin North Am 33:717–725PubMedCrossRefGoogle Scholar
  10. 10.
    Chhabra A, Diduch DR, Blessey PB, Miller MD (2004) Recreating an acceptable angle of the tibial tunnel in the coronal plane in anterior cruciate ligament reconstruction using external landmarks. Arthroscopy 20:328–330PubMedCrossRefGoogle Scholar
  11. 11.
    Colombet P, Robinson J, Christel P, Franceschi JP, Djian P, Bellier G, Sbihi A (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22:984–992PubMedCrossRefGoogle Scholar
  12. 12.
    Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T (2009) Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 17:220–227PubMedCrossRefGoogle Scholar
  13. 13.
    DeFrate LE, Papannagari R, Gill TJ, Moses JM, Pathare NP, Li G (2006) The 6 degrees of freedom kinematics of the knee after anterior cruciate ligament deficiency: an in vivo imaging analysis. Am J Sports Med 34:1240–1246PubMedCrossRefGoogle Scholar
  14. 14.
    Fetto JF, Marshall JL (1980) The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 147:29–38PubMedGoogle Scholar
  15. 15.
    Fink C, Hoser C, Hackl W, Navarro RA, Benedetto KP (2001) Long-term outcome of operative or nonoperative treatment of anterior cruciate ligament rupture: is sports activity a determining variable? Int J Sports Med 22:304–309PubMedCrossRefGoogle Scholar
  16. 16.
    Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM (2005) Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament injured knee. Am J Sports Med 33:335–346PubMedCrossRefGoogle Scholar
  17. 17.
    Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr (2003) Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 31:2–11PubMedGoogle Scholar
  18. 18.
    Galla M, Uffmann J, Lobenhoffer P (2004) Femoral fixation of hamstring tendon autografts using the TransFix device with additional bone grafting in an anteromedial portal technique. Arch Orthop Trauma Surg 124:281–284PubMedCrossRefGoogle Scholar
  19. 19.
    Georgoulis AD, Papadonikolakis A, Papageorgiou CD, Mitsou A, Stergiou N (2003) Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament-deficient and reconstructed knee during walking. Am J Sports Med 31:75–79PubMedGoogle Scholar
  20. 20.
    Golish SR, Baumfeld JA, Schoderbek RJ, Miller MD (2007) The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: A cadaveric study. Arthroscopy 23:1187–1192PubMedCrossRefGoogle Scholar
  21. 21.
    Hantes ME, Dailiana Z, Zachos VC, Varitimidis SE (2006) Anterior cruciate ligament reconstruction using the Bio-TransFix femoral fixation device and anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc 14:497–501PubMedCrossRefGoogle Scholar
  22. 22.
    Ho JY, Gardiner A, Shah V, Steiner ME (2009) Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy 25:464–472PubMedCrossRefGoogle Scholar
  23. 23.
    Howell SM, Hull ML (2009) Checkpoints for judging tunnel and anterior cruciate ligament graft placement. J Knee Surg 22:161–170PubMedCrossRefGoogle Scholar
  24. 24.
    Kanaya A, Ochi M, Deie M, Adachi N, Nishimori M, Nakamae A (2009) A intraoperative evaluation of anteroposterior and rotational stabilities in anterior cruciate ligament reconstruction: lower femoral tunnel placed single-bundle versus double-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc 17:907–913PubMedCrossRefGoogle Scholar
  25. 25.
    Kato Y, Ingham SJ, Kramer S, Smolinski P, Saito A, Fu FH (2010) Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surg Sports Traumatol Arthrosc 18:2–10PubMedCrossRefGoogle Scholar
  26. 26.
    Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum EB (1996) The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med 24:335–341PubMedCrossRefGoogle Scholar
  27. 27.
    Kohn D, Busche T, Carls J (1998) Drill hole position in endoscopic anterior cruciate ligament reconstruction: results of an advanced arthroscopy course. Knee Surg Sports Traumatol Arthrosc 6(Suppl 1):S13–S15PubMedCrossRefGoogle Scholar
  28. 28.
    Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL-Y (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy 19:297–304PubMedCrossRefGoogle Scholar
  29. 29.
    Lohmander LS, Ostenberg A, Englund M, Roos H (2004) High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum 50:3145–3152PubMedCrossRefGoogle Scholar
  30. 30.
    Lorenz S, Elser F, Mitterer M, Obst T, Imhoff AB (2009) Radiologic evaluation of the insertion sites of the 2 functional bundles of the anterior cruciate ligament using 3-dimensional computed tomography. Am J Sports Med 37:2368–2376PubMedCrossRefGoogle Scholar
  31. 31.
    Lubowitz JH (2009) Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy 25:95–101PubMedCrossRefGoogle Scholar
  32. 32.
    Miller CD, Gerdeman AC, Hart JM, Bennett CG, Golish SR, Gaskin C, Miller MD (2011) A comparison of 2 drilling techniques on the femoral tunnel for anterior cruciate ligament reconstruction. Arthroscopy 27:372–379PubMedCrossRefGoogle Scholar
  33. 33.
    Musahl V, Plakseychuk A, VanScyoc A, Sasaki T, Debski RE, McMahon PJ, Fu FH (2005) Varying femoral tunnels between the anatomical footprint and isometric positions: effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med 33:712–718PubMedCrossRefGoogle Scholar
  34. 34.
    Nishimoto K, Kuroda R, Mizuno K, Hoshino Y, Nagamune K, Kubo S, Yagi M, Yamaguchi M, Yoshiya S, Kurosaka M (2009) Analysis of the graft bending angle at the femoral tunnel aperture in anatomic double bundle anterior cruciate ligament reconstruction: a comparison of the transtibial and the far anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc 17:270–276PubMedCrossRefGoogle Scholar
  35. 35.
    Papannagari R, Gill TJ, Defrate LE, Moses JM, Petruska AJ, Li G (2006) In vivo kinematics of the knee after anterior cruciate ligament reconstruction: a clinical and functional evaluation. Am J Sports Med 34:2006–2012PubMedCrossRefGoogle Scholar
  36. 36.
    Scopp JM, Jasper LE, Belkoff SM, Moorman CT 3rd (2004) The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20:294–299PubMedCrossRefGoogle Scholar
  37. 37.
    Silva A, Sampaio R, Pinto E (2010) Placement of femoral tunnel between the AM and PL bundles using a transtibial technique in single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1245–1251PubMedCrossRefGoogle Scholar
  38. 38.
    Staubli HU, Rauschning W (1994) Tibial attachment area of the anterior cruciate ligament in the extended knee position: anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo. Knee Surg Sports Traumatol Arthrosc 2:138–146PubMedCrossRefGoogle Scholar
  39. 39.
    Takahashi M, Doi M, Abe M, Suzuki D, Nagano A (2006) Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med 34:787–792PubMedCrossRefGoogle Scholar
  40. 40.
    Tashman S, Collon D, Anderson K, Kolowich P, Anderst W (2004) Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med 32:975–983PubMedCrossRefGoogle Scholar
  41. 41.
    Yamamoto Y, Hsu WH, Woo SL, Van Scyoc AH, Takakura Y, Debski RE (2004) Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med 32:1825–1832PubMedCrossRefGoogle Scholar
  42. 42.
    Yunes M, Richmond JC, Engels EA, Pinczewski LA (2001) Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: a meta-analysis. Arthroscopy 17:248–257PubMedCrossRefGoogle Scholar
  43. 43.
    Zantop T, Diermann N, Schumacher T, Schanz S, Fu FH, Petersen W (2008) Anatomical and nonanatomical double-bundle anterior cruciate ligament reconstruction: importance of femoral tunnel location on knee kinematics. Am J Sports Med 36:678–685PubMedCrossRefGoogle Scholar
  44. 44.
    Zantop T, Petersen W (2008) Double bundle revision of a malplaced single bundle vertical ACL reconstruction: ACL revision surgery using a two femoral tunnel technique. Arch Orthop Trauma Surg 128:1287–1294PubMedCrossRefGoogle Scholar
  45. 45.
    Zantop T, Wellmann M, Fu FH, Petersen W (2008) Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 36:65–72PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Alcindo Silva
    • 1
  • Ricardo Sampaio
    • 2
  • Elisabete Pinto
    • 3
  1. 1.Orthopedics DepartmentHospital Militar D. Pedro VPortoPortugal
  2. 2.Hospital da BoavistaPortoPortugal
  3. 3.Department of Hygiene and EpidemiologyMedical School of University of PortoPortoPortugal

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