Skip to main content

Transtibial versus low anteromedial portal drilling for anterior cruciate ligament reconstruction: a radiographic study of femoral tunnel position

Knee Surgery, Sports Traumatology, Arthroscopy volume 21, pages 846–850 (2013)Cite this article

Abstract

Purpose

The purpose of this study is to compare femoral tunnel positions after ACL reconstruction by the transtibial (TT) approach versus the low anteromedial approach using radiographs from a single surgeon.

Methods

The standard postoperative knee radiographs of 50 patients with an ACL reconstruction were studied. Two groups were determined according to the technique used. The low anteromedial portal group and the transtibial portal group. The femoral bone tunnel was identified radiographically, and its position determined in the lateral and A–P view. Coronal and sagittal obliquity of the tunnel was measured and compared among both groups.

Results

In the sagittal plane, femoral bone tunnels averaged 54° ± 6° for the TT technique and 59° ± 12° (p = 0.07) for the low anteromedial portal technique. In the coronal plane, the bone tunnels drilled through the low anteromedial portal showed a significantly more oblique femoral tunnel position (50° ± 6°) compared to TT drilling (58° ± 9°), p ≤ 0.05.

Conclusion

Drilling the femoral tunnel through the low anteromedial portal resulted in a more oblique femoral tunnel position compared to the TT technique. Clinically, the low anteromedial portal may allow to better restore the anatomic orientation of the ACL.

Level of evidence

Case series, Level IV.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. Alentorn-Geli E, Lajara F, Samitier G, Cugat R (2010) The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18(8):1013–1037

    PubMed  Article  Google Scholar 

  2. Araujo PH, van Eck CF, Macalena JA, Fu FH (2011) Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(8):1239–1242

    PubMed  Article  Google Scholar 

  3. 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(3):380–390

    PubMed  Article  Google Scholar 

  4. Bedi A, Raphael B, Maderazo A, Pavlov H, Williams RJ III (2010) Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy 26(3):342–350

    PubMed  Article  Google Scholar 

  5. Behrend H, Stutz G, Kessler MA, Rukavina A, Giesinger K, Kuster MS (2006) Tunnel placement in anterior cruciate ligament (ACL) reconstruction: quality control in a teaching hospital. Knee Surg Sports Traumatol Arthrosc 14(11):1159–1165

    PubMed  Article  CAS  Google Scholar 

  6. Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10(1):14–22

    Google Scholar 

  7. Bowers AL, Bedi A, Lipman JD, Potter HG, Rodeo SA, Pearle AD, Warren RF, Altchek DW (2011) Comparison of anterior cruciate ligament tunnel positon and graft obliquity with transtibial and anteromedial portal femoral tunnel reaming techniques using high resolution magnetic resonance imaging. Arthroscopy 27(11):1511–1522

    PubMed  Article  Google Scholar 

  8. Chang CB, Choi JY, Koh IJ, Lee KH, Kim TH (2011) Comparison of femoral tunnel position and length in anterior cruciate ligament reconstruction: modified transtibial versus anteromedial portal techniques. Arthroscopy 27(10):1389–1394

    PubMed  Article  Google Scholar 

  9. Chang CB, Yoo JH, Chung BJ, Seong SC, Kim TK (2010) Oblique femoral tunnel placement can increase risk of short femoral tunnel and cross-pin protrusion in anterior cruciate ligament reconstruction. Am J Sports Med 38(6):1237–1245

    PubMed  Article  Google Scholar 

  10. Cole J, Brand JC Jr, Caborn DN, Johnson DL (2000) Radiographic analysis of femoral tunnel position in anterior cruciate ligament reconstruction. Am J Knee Surg 13(4):218–222

    PubMed  CAS  Google Scholar 

  11. Colvin AC, Shen W, Musahl V, Fu FH (2009) Avoiding pitfalls in anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 17(8):956–963

    PubMed  Article  Google Scholar 

  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(3):220–227

    PubMed  Article  Google Scholar 

  13. Fu FH, Karlsson J (2010) A long journey to be anatomic. Knee Surg Sports Traumatol Arthrosc 18(9):1151–1153

    PubMed  Article  Google Scholar 

  14. Garofalo R, Moretti B, Kombot C, Moretti L, Mouhsine E (2007) Femoral tunnel placement in anterior cruciate ligament reconstruction: rationale of the two incision technique. J Orthop Surg Res 2(10):1–6

    Google Scholar 

  15. 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 Traumatol Arthrosc 17(8):880–886

    PubMed  Article  Google Scholar 

  16. 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 50:463–474

    PubMed  CAS  Google Scholar 

  17. Hefzy MS, Grood ES, Noyes FR (1989) Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med 17(2):208–216

    PubMed  Article  CAS  Google Scholar 

  18. Hoser C, Tecklenburg K, Kuenzel KH, Fink C (2005) Postoperative evaluation of femoral tunnel position in ACL reconstruction: plain radiography versus computed tomography. Knee Surg Sports Traumatol Arthrosc 13(4):256–262

    PubMed  Article  Google Scholar 

  19. Illingworth KD, Hensler D, Working ZM, Macalena JA, Tashman S, Fu FH (2011) A simple evaluation of anterior cruciate ligament femoral tunnel position: the inclination angle and femoral tunnel angle. Am J Sports Med 39(12):2611–2618

    PubMed  Article  Google Scholar 

  20. Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD (1996) Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res 325:100–109

    PubMed  Article  Google Scholar 

  21. Karlsson J, Irrgang JJ, van Eck CF, Samuelsson K, Mejia HA, Fu FH (2011) Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique. Am J Sports Med 39(9):2016–2026

    PubMed  Article  Google Scholar 

  22. 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(7):771–778

    PubMed  Article  Google Scholar 

  23. 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. Richard O’Connor Award paper. Arthroscopy 19(3):297–304

    Google Scholar 

  24. Group MARS, Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, Allen CR, Cooper DE, DeBerardino TM, Lantz BB, Mann BJ, Stuart MJ (2010) Descriptive epidemiology of the multicenter ACL revision study (MARS) cohort. Am J Sports Med 38(10):1979–1986

    Article  Google Scholar 

  25. Noyes FR, Barber-Westin SD (2011) Anterior cruciate ligament graft placement recommendations and bone-patellar tendon-bone graft indications to restore knee stability. Instr Course Lect 60:499–521

    PubMed  Google Scholar 

  26. Scopp JM, Jasper LE, Belkoff SM, Moorman CT III (2004) The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20(3):294–299

    PubMed  Article  Google Scholar 

  27. 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(9):1245–1251

    PubMed  Article  Google Scholar 

  28. Sommer C, Friederich NF, Müller W (2000) Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 8(4):207–213

    PubMed  Article  CAS  Google Scholar 

  29. van Eck CF, Martins CA, Vyas SM, Celentano U, van Dijk CN, Fu FH (2010) Femoral intercondylar notch shape and dimensions in ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 8(9):1257–1262

    Article  Google Scholar 

  30. van Eck CF, Morse KR, Lesniak BP, Kropf EJ, Tranovich MJ, van Dijk CN, Fu FH (2010) Does the lateral intercondylar ridge disappear in ACL deficient patients? Knee Surg Sports Traumatol Arthrosc 18(9):1184–1188

    PubMed  Article  Google Scholar 

  31. Xu Y, Ao Y, Wang J, Yu J, Cui G (2011) Relation of tunnel enlargement and tunnel placement after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 27(7):923–932

    PubMed  Article  Google Scholar 

Download references

Conflict of interest

No conflict of interest to declare.

Author information

Affiliations

  1. Sports Medicine and Shoulder Surgery, Hospital for Special Surgery, New York, NY, USA

    Cecilia Pascual-Garrido

  2. Barton Lake Tahoe Sports Medicine Fellowship, Lake Tahoe, CA, USA

    Britta L. Swanson

  3. Department of Orthopedic Surgery, Tahoe Orthopedics and Sports Medicine, South Lake Tahoe, CA, USA

    Kyle E. Swanson

Authors
  1. Cecilia Pascual-Garrido
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Britta L. Swanson
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kyle E. Swanson
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Cecilia Pascual-Garrido.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Pascual-Garrido, C., Swanson, B.L. & Swanson, K.E. Transtibial versus low anteromedial portal drilling for anterior cruciate ligament reconstruction: a radiographic study of femoral tunnel position. Knee Surg Sports Traumatol Arthrosc 21, 846–850 (2013). https://doi.org/10.1007/s00167-012-1988-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-012-1988-4

Keywords

  • Transtibial
  • Low anteromedial
  • Tunnel position
  • ACL reconstruction