International Orthopaedics

, Volume 34, Issue 5, pp 747–754 | Cite as

Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up

  • Eduard Alentorn-Geli
  • Gonzalo Samitier
  • Pedro Álvarez
  • Gilbert Steinbacher
  • Ramón CugatEmail author
Original Paper


Drilling of the femoral tunnel with the transtibial (TT) technique is widely used in bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Recent studies suggest higher knee stability with the use of the anteromedial portal (AMP). The purpose of this study was to compare functional and clinical outcomes of BPTB ACL reconstruction using the TT or the AMP technique for drilling the femoral tunnel. All ACL reconstructions between January 2003 and April 2006 were approached for eligibility. Forty-seven patients met inclusion criteria (21 TT group and 26 AMP group). Blinded assessments of IKDC score, knee stability and range of motion, one-leg hop test, mid-quadriceps circumference, VAS for satisfaction with surgery, Lysholm and Tegner scores, and SF-12 questionnaire were obtained for both groups. Data on preoperative and postoperative surgical timing were retrospectively reviewed through the charts. The AMP group demonstrated a significantly lower recovery time from surgery to walking without crutches (p < 0.01), to return to normal life (p < 0.03), to return jogging (p < 0.03), to return training (p < 0.03), and to return to play (p < 0.03). Knee stability values measured with KT-1000, Lachman test, pivot-shift sign, and objective IKDC score assessments were significantly better for the AMP compared to TT group (p < 0.002, p < 0.03, p < 0.02, p < 0.015, respectively). No differences were found for VAS for satisfaction with surgery, Lysholm, Tegner, and SF-12 between both groups. The use of the AMP technique significantly improved the anterior-posterior and rotational knee stability, IKDC scores, and recovery time from surgery compared to the TT technique.


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Femoral Tunnel Tibial Tunnel International Knee Documentation Committee 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was made possible by Mutualidad de Futbolistas, Federación Española de Fútbol - Delegación Cataluña. We also thank Marta Pulido, MD for the contributions in the edition of the manuscript and editorial assistance, and Sergi Mojal, PhD for statistical review.


  1. 1.
    Alentorn-Geli E, Lajara F, Samitier G, Cugat R (2009) The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traum Arthrosc. Nov. 10 [Epub ahead of print] doi: 10.1007/s00167-009-0964-0
  2. 2.
    Allen CR, Giffin JR, Harner CD (2003) Revision anterior cruciate ligament reconstruction. Orthop Clin North Am 34:79–98CrossRefPubMedGoogle Scholar
  3. 3.
    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
  4. 4.
    Aune AK, Holm I, Risberg MA, Jensen HK, Steen H (2001) Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. Am J Sports Med 29:722–728PubMedGoogle Scholar
  5. 5.
    Bach BR (1989) Arthroscopy assisted patellar tendon substitution for anterior cruciate ligament reconstruction. Am J Knee Surg 2:3–20Google Scholar
  6. 6.
    Basdekis G, Abisafi C, Christel P (2008) Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy 24:459–464PubMedGoogle Scholar
  7. 7.
    Beard DJ, Anderson JL, Davies S, Price AJ, Dodd CAF (2001) Hamstrings versus patella tendon for anterior cruciate ligament reconstruction: a randomised controlled trial. Knee 8:45–50CrossRefPubMedGoogle Scholar
  8. 8.
    Bottoni CR, Rooney RC, Harpstrite JK, Kan DM (1998) Ensuring accurate femoral guide pin placement in anterior cruciate ligament reconstruction. Am J Orthop 27:764–766PubMedGoogle Scholar
  9. 9.
    Cascio BM, Culp L, Cosgarea AJ (2004) Return to play after anterior cruciate ligament reconstruction. Clin Sports Med 23:395–408CrossRefPubMedGoogle Scholar
  10. 10.
    Cha PS, Chhabra A, Harner CD (2005) Single-bundle anterior cruciate ligament reconstruction using the medial portal technique. Oper Tech Orthop 15:89–95CrossRefGoogle Scholar
  11. 11.
    Chhabra A, Kline AJ, Nilles KM, Harner CD (2006) Tunnel expansion after anterior cruciate ligament reconstruction with autogenous hamstrings: a comparison of the medial portal and transtibial techniques. Arthroscopy 22:1107–1112PubMedCrossRefGoogle Scholar
  12. 12.
    Clancy WG, Nelson DA, Reider B, Narechania RG (1982) Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am 64:352–359PubMedGoogle Scholar
  13. 13.
    Dargel J, Schmidt-Wiethoff R, Mader K, Koebke J, Schneider T (2009) Femoral bone tunnel placement using the transtibial tunnel for the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traum Arthrosc 17:220–227CrossRefGoogle Scholar
  14. 14.
    Delay BS (2001) Current practices and opinion in ACL reconstruction and rehabilitation: results of a survey of the American Orthopaedic Society for Sports Medicine. Am J Knee Surg 14:85–91PubMedGoogle Scholar
  15. 15.
    Duquin TR, Wind WM, Fineberg MS, Smolinski RJ, Buyea CM (2009) Current trends in anterior cruciate ligament reconstruction. J Knee Surg 22:7–12CrossRefPubMedGoogle Scholar
  16. 16.
    Gavriilidis I, Motsis EK, Pakos EE, Georgoulis AD, Mitsionis G, Xenakis TA (2008) Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study. Knee 15:364–367CrossRefPubMedGoogle Scholar
  17. 17.
    George MS, Huston LJ, Spindler KP (2007) Endoscopic versus rear-entry anterior cruciate ligament reconstruction: a systematic review. Clin Orthop Rel Res 455:158–161CrossRefGoogle Scholar
  18. 18.
    Giron F, Buzzi R, Aglietti P (1999) Femoral tunnel position in anterior cruciate ligament reconstruction using three techniques. A cadaver study. Arthroscopy 15:750–756PubMedCrossRefGoogle Scholar
  19. 19.
    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
  20. 20.
    Gorschewsky O, Klakow A, Riechert K, Pitzl M, Becker R (2005) Clinical comparison of the Tutoplast allograft and autologous patellar tendon (bone-patellar tendon-bone) for the reconstruction of the anterior cruciate ligament. Two- and 6-year results. Am J Sports Med 33:1202–1209CrossRefPubMedGoogle Scholar
  21. 21.
    Hantes ME, Zachos VC, Liantsis A, Venouziou A, Karantanas AH, Malizos KN (2009) Differences in graft orientation using the transtibial and anteromedial portal technique in anterior cruciate ligament reconstruction: a magnetic resonance imaging study. Knee Surg Sports Traum Arthrosc 17(8):880–886Google Scholar
  22. 22.
    Hardin GT, Bach BR, Bush-Joseph CA, Farr J (1992) Endoscopic single-incision anterior cruciate ligament reconstruction using patellar tendon autograft. Am J Knee Surg 5:144–155Google Scholar
  23. 23.
    Harner CD, Fu F, Irrgang JJ, Vogrin TM (2001) Anterior and posterior cruciate ligament reconstruction in the new millennium: a global perspective. Knee Surg Sports Traum Arthrosc 9:330–336CrossRefGoogle Scholar
  24. 24.
    Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ (2001) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 50:463–474PubMedGoogle Scholar
  25. 25.
    Harner CD, Honkamp NJ, Ranawat AS (2008) Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 24:113–115PubMedCrossRefGoogle Scholar
  26. 26.
    Hefti F, Muller W, Jakob RP, Staubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234CrossRefPubMedGoogle Scholar
  27. 27.
    Heming JF, Rand J, Steiner ME (2007) Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 35:1708–1715CrossRefPubMedGoogle Scholar
  28. 28.
    Howell SM, Clark JA (1992) Tibial tunnel placement in anterior cruciate ligament reconstructions and graft impingement. Clin Orthop 283:187–195PubMedGoogle Scholar
  29. 29.
    Howell SM, Clark JA, Farley TE (1992) Serial magnetic resonance study assessing the effects of impingement on the MR image of the patellar tendon graft. Arthroscopy 8:350–358PubMedCrossRefGoogle Scholar
  30. 30.
    Howell SM, Taylor MA (1993) Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. J Bone Joint Surg Am 75:1044–1055PubMedGoogle Scholar
  31. 31.
    Jepsen CF, Lundberg-Jensen AK, Faunoe P (2007) Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? A clinical, prospective, randomized, double-blind study. Arthroscopy 23:1326–1333PubMedCrossRefGoogle Scholar
  32. 32.
    Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD (1996) Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res 325:100–109CrossRefPubMedGoogle Scholar
  33. 33.
    Kohn D, Busche T, Carls J (1998) Drill hole position in endoscopic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 6:S13–S15CrossRefPubMedGoogle Scholar
  34. 34.
    Lee MC, Seong SC, Lee S, Chang CB, Park YK, Jo H, Kim CH (2007) Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 23:771–778PubMedCrossRefGoogle Scholar
  35. 35.
    Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (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
  36. 36.
    Lubowitz JH (2009) Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy 25:95–101PubMedCrossRefGoogle Scholar
  37. 37.
    Markolf KL, Hame SL, Hunter DM, Oakes DA, Zoric B, Gause P, Finerman GAM (2002) Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orhop Res 20:1016–1024CrossRefGoogle Scholar
  38. 38.
    Matsumoto A, Yoshiya S, Muratsu H, Yagi M, Iwasaki Y, Kurosaka M, Kuroda R (2006) A comparison of bone-patellar tendon-bone and bone-hamstring tendon-bone autografts for anterior cruciate ligament reconstruction. Am J Sports Med 34:213–219CrossRefPubMedGoogle Scholar
  39. 39.
    Meredick RB, Vance KJ, Appleby D, Lubowitz JH (2008) Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 36:1414–1421CrossRefPubMedGoogle Scholar
  40. 40.
    Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K (1999) Two-bundle reconstruction of the anterior cruciate ligament using a semitendinosus tendon with EndoButton: operative technique and preliminary results. Arthroscopy 15:618–624PubMedCrossRefGoogle Scholar
  41. 41.
    Paessler H, Rossis J, Mastrokalos D, Kotsovolos I (2004) Anteromedial versus transtibial technique for correct femoral tunnel placement during arthroscopic ACL reconstruction with hamstrings: an in vivo study. J Bone Joint Surg Br 86:S234Google Scholar
  42. 42.
    Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J (2007) A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med 35:564–574CrossRefPubMedGoogle Scholar
  43. 43.
    Romano VM, Graf BK, Keene JS, Lange RH (1993) Anterior cruciate ligament reconstruction: the effect of tibial tunnel placement on range of motion. Am J Sports Med 21:415–418CrossRefPubMedGoogle Scholar
  44. 44.
    Rue JP, Ghodadra N, Lewis PB, Bach BR (2008) Femoral and tibial tunnel position using a transtibial drilled anterior cruciate ligament reconstruction technique. J Knee Surg 21:246–249PubMedGoogle Scholar
  45. 45.
    Sajovic M, Vengust V, Komadina R, Tavcar R, Skaza K (2006) A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction. Five-year follow-up. Am J Sports Med 34:1933–1940CrossRefPubMedGoogle Scholar
  46. 46.
    Scopp JM, Jasper LE, Belkoff SM, Moorman CT (2004) The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20:294–299PubMedCrossRefGoogle Scholar
  47. 47.
    Shaieb MD, Kan DM, Chang SK, Marumoto JM, Richardson AB (2002) A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 30:214–220PubMedGoogle Scholar
  48. 48.
    Sohn DH, Garrett WE (2009) Transitioning to anatomic anterior cruciate ligament graft placement. J Knee Surg 22:155–160CrossRefPubMedGoogle Scholar
  49. 49.
    Steiner ME (2009) Independent drilling of tibial and femoral tunnels in anterior cruciate ligament reconstruction. J Knee Surg 22:171–176CrossRefPubMedGoogle Scholar
  50. 50.
    Steiner ME, Murray MM, Rodeo SA (2008) Strategies to improve anterior cruciate ligament healing and graft placement. Am J Sports Med 36:176–189Google Scholar
  51. 51.
    Tanzer M, Lenczner E (1990) The relationship of intercondylar notch size and content to notchplasty requirement in anterior cruciate ligament surgery. Arthroscopy 6:89–93PubMedCrossRefGoogle Scholar
  52. 52.
    Wagner M, Kääb MJ, Schallock J, Haas NP, Weiler A (2005) Hamstring tendon versus patellar tendon anterior cruciate ligament reconstruction using biodegradable interference fit fixation. A prospective matched-group analysis. Am J Sports Med 33:1327–1336CrossRefPubMedGoogle Scholar
  53. 53.
    Ware JE, Kosinski M, Keller SD (1996) A 12-item Short-Form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:220–233CrossRefPubMedGoogle Scholar
  54. 54.
    Wetzler MJ, Getelman MH, Friedman MJ, Bartolozzi AR (1998) Revision anterior cruciate ligament surgery: etiology of failures. Op Tech Sports Med 6:64–70CrossRefGoogle Scholar
  55. 55.
    Williams RJ, Hyman J, Petrigliano F, Rozental T, Wickiewicz TL (2004) Anterior cruciate ligament reconstruction with a fourstrand hamstring tendon autograft. J Bone Joint Surg Am 86:225–232CrossRefPubMedGoogle Scholar
  56. 56.
    Zaricznyj B (1987) Reconstruction of the anterior cruciate ligament of the knee using a doubled tendon graft. Clin Orthop 220:162–175PubMedGoogle Scholar
  57. 57.
    Zarins B, Sweeney HJ (1993) Técnica artroscópica. In: Zarins B, Cugat R (eds) Principios de artroscopia y cirugía artroscópica. Springer-Verlag Ibérica, Barcelona, pp 39–49Google Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Eduard Alentorn-Geli
    • 1
  • Gonzalo Samitier
    • 2
  • Pedro Álvarez
    • 1
    • 3
  • Gilbert Steinbacher
    • 3
  • Ramón Cugat
    • 1
    • 3
    • 4
    Email author
  1. 1.Artroscopia García-CugatHospital QuirónBarcelonaSpain
  2. 2.Hospital 9 de OctubreValenciaSpain
  3. 3.Mutualidad de FutbolistasFederación Española de Fútbol - Delegación CataluñaBarcelonaSpain
  4. 4.Department of OrthopaedicsHospital QuirónBarcelonaSpain

Personalised recommendations