Transportal central femoral tunnel placement has a significantly higher revision rate than transtibial AM femoral tunnel placement in hamstring ACL reconstruction
It is proposed that central femoral ACL graft placement better controls rotational stability. This study evaluates the consequence of changing the femoral tunnel position from the AM position drilled transtibially to the central position drilled transportally. The difference in ACL graft failure is reported.
This prospective consecutive patient single surgeon study compares the revision rates of 1016 transtibial hamstring ACL reconstructions followed for 6–15 years with 464 transportal hamstring ACL reconstructions followed for 2–6 years. Sex, age, graft size, time to surgery, meniscal repair and meniscectomy data were evaluated as contributing factors for ACL graft failure to enable a multivariate analysis. To adjust for the variable follow-up a multivariate hazard ratio, failure per 100 graft years and Kaplan–Meier survivorship was determined.
With transtibial ACLR 52/1016 failed (5.1%). With transportal ACLR 32/464 failed (6.9%). Significant differences between transportal and transtibial ACLR were seen for graft diameter, time to surgery, medial meniscal repair rates and meniscal tissue remaining after meniscectomy. Adjusting for these the multivariate hazard ratio was 2.3 times higher in the transportal group (p = 0.001). Central tunnel placement resulted in a significantly 3.5 times higher revision rate compared to an anteromedial tunnel placement per 100 graft years (p = 0.001). Five year survival was 980/1016 (96.5%) for transtibial versus 119/131 (90.5%) for transportal. Transportal ACLR also showed a significantly higher earlier failure rate with 20/32 (61%) of the transportal failing in the first year compared with 14/52 (27%) for transtibial. (p = 0.001.)
Transportal central femoral tunnel ACLR has a higher failure rate and earlier failure than transtibial AM femoral tunnel ACLR.
Level of evidence
Level II—prospective comparative study.
KeywordsACL reconstruction ACL failure ACL surgical technique
MC performed all the surgery and followed all the patients. He was involved in patient evaluation and statistical evaluation. He edited the final manuscript. He agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. SS reviewed the results and statistical analysis and wrote the manuscript. TR collected all the revision’s from MC’s database. He reviewed patient clinical records on all 1480 patients to ensure the data was accurate and was involved in the statistical analysis.
No external source of funding was used.
Compliance with Ethical Standards
Conflict of Interest
Mark Clatworthy receives consulting fees from Johnson and Johnson and fellowship support from Johnson and Johnson and Athrex and royalties from Athrex Steffen Sauer and Tim Roberts have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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