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Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel.

Methods

Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups.

Results

There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004).

Conclusion

There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.

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Abbreviations

ACL:

Anterior cruciate ligament

TT:

Transtibial

TP:

Transportal

OI:

Outside-in

GBA:

Graft bending angle

AM:

Anteromedial

PL:

Posterolateral

SNQ:

Signal/noise quotient

MRI:

Magnetic resonance imaging

ICC:

Intraclass/interclass correlation coefficients

FAM:

Far anteromedial

References

  1. Musahl V, Plakseychuk A, VanScyoc A et al (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 33:712–718

    Article  PubMed  Google Scholar 

  2. Sadoghi P, Kropfl A, Jansson V, Muller PE et al (2011) Impact of tibial and femoral tunnel position on clinical results after anterior cruciate ligament reconstruction. Arthroscopy 27(3):355–364

    Article  PubMed  Google Scholar 

  3. Piasecki CP, Bach BR, Espinoza Orias AA, Verma NN (2011) Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique? Am J Sports Med 39(6):1306–1315

    Article  PubMed  Google Scholar 

  4. Steiner ME (2009) Independent drilling of tibial and femoral tunnels in anterior cruciate ligament reconstruction. J Knee Surg 22(2):171–176

    Article  PubMed  Google Scholar 

  5. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL (2002) Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 30(5):660–666

    Article  PubMed  Google Scholar 

  6. Amano H, Toritsuka Y, Uchida R, Mae T, Ohzono K, Shino K (2014) Outcome of anatomical double-bundle ACL reconstruction using hamstring tendons via an outside-in approach. Knee Surg Sports Traumatol Arthrosc 23(4):1222–1230

    Article  PubMed  Google Scholar 

  7. Garofalo R, Mouhsine E, Chambat P, Siegrist O (2006) Anatomic anterior cruciate ligament reconstruction: the two-incision technique. Knee Surg Sports Traumatol Arthrosc 14:510–516

    Article  PubMed  Google Scholar 

  8. Harner CD, Honkamp NJ, Ranawat AS (2008) Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 24:113–115

    Article  PubMed  Google Scholar 

  9. Lubowitz JH, Konicek J (2010) Anterior cruciate ligament femoral tunnel length: cadaveric analysis comparing anteromedial portal versus outside-in technique. Arthroscopy 26:1357–1362

    Article  PubMed  Google Scholar 

  10. Lubowitz JH, Akhavan S, Waterman BR, Aalami-Harandi A, Konicek J (2013) Technique for creating the anterior cruciate ligament femoral socket: optimizing femoral footprint anatomic restoration using outside-in drilling. Arthroscopy 29:522–528

    Article  PubMed  Google Scholar 

  11. Ahn JH, Lee YS, Jeong HJ, Park JH, Cho Y, Kim KJ, Ko TS (2017) Comparison of transtibial and retrograde outside-in techniques of anterior cruciate ligament reconstruction in terms of graft nature and clinical outcomes: a case control study using 3 T MRI. Arch Orthop Trauma Surg 137(3):357–365

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  13. Kopf S, Pombo MW, Shen W, Irrgang JJ, Fu FH (2011) The ability of 3 different approaches to restore the anatomic anteromedial bundle femoral insertion site during anatomic anterior cruciate ligament reconstruction. Arthroscopy 27:200–206

    Article  PubMed  Google Scholar 

  14. Nishimoto K, Kuroda R, Mizuno K, Hoshino Y, Nagamune K, Kubo S et al (2008) 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(3):270–276

    Article  PubMed  Google Scholar 

  15. Shin YS, Ro KH, Lee JH, Lee DH (2013) Location of the femoral tunnel aperture in single-bundle anterior cruciate ligament reconstruction: comparison of the transtibial, anteromedial portal, and outside-in techniques. Am J Sports Med 41(11):2533–2539

    Article  PubMed  Google Scholar 

  16. Silva A, Sampaio R, Pinto E (2011) ACL reconstruction: comparison between transtibial and anteromedial portal techniques. Knee Surg Sports Traumatol Arthrosc 20(5):896–903

    Article  PubMed  Google Scholar 

  17. Tashiro Y, Okazaki K, Uemura M, Toyoda K et al (2014) Comparison of transtibial and transportal techniques in drilling femoral tunnels during anterior cruciate ligament reconstruction using 3D-CAD models. Open Access J Sports Med 4:65–72

    Article  Google Scholar 

  18. Tompkins M, Milewski MD, Brockmeier SF et al (2012) Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling. Am J Sports Med 40(6):1313–1321

    Article  PubMed  Google Scholar 

  19. Wang JH, Kim JG, Lee DK, Lim HC, Ahn JH (2011) Comparison of femoral graft bending angle and tunnel length between transtibial technique and transportal technique in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 20(8):1584–1593

    Article  PubMed  Google Scholar 

  20. Natsuume T, Shino K, Nakata K, Nakamura N et al (2001) Endoscopic reconstruction of the anterior cruciate ligament with quadrupled hamstring tendons. A correlation between MRI changes and restored stability of the knee. J Bone Jt Surg Br 83(6):834–837

    Article  CAS  Google Scholar 

  21. Segawa H, Omori G, Tomita S, Koga Y (2001) Bone tunnel enlargement after anterior cruciate ligament reconstruction using hamstring tendons. Knee Surg Sports Traumatol Arthrosc 9(4):206–210

    Article  CAS  PubMed  Google Scholar 

  22. Toritsuka Y, Shino K, Horibe S, Mitsuoka T et al (2004) Second-look arthroscopy of anterior cruciate ligament grafts with multistranded hamstring tendons. Arthroscopy 20(3):287–293

    Article  PubMed  Google Scholar 

  23. Ahn JH, Jeong HJ, Lee YS, Park JH, Lee JH, Ko TS (2016) Graft bending angle is correlated with femoral intraosseous graft signal intensity in anterior cruciate ligament reconstruction using the outside-in technique. Knee 23(4):1–8

    Article  Google Scholar 

  24. Tomihara T, Hashimoto Y, Taniuchi M, Shimada N (2015) Relationship between femoral tunnel location and graft bending angle in outside-in and transportal technique for ACL double bundle reconstruction in 3D-CT study. Arch Orthop Trauma Surg 135(6):839–846

    Article  PubMed  Google Scholar 

  25. Tashiro Y, Irarrázaval S, Osaki K, Iwamoto Y, Fu FH (2016) Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25(1):1–9

    Google Scholar 

  26. Alentorn-Geli E, Samitier G, Álvarez P, Steinbacher G et al (2010) Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up. Int Orthop 34(5):747–754

    Article  PubMed  PubMed Central  Google Scholar 

  27. Koutras G, Papadopoulos P, Terzidis IP, Gigis I et al (2013) Short- term functional and clinical outcomes after ACL reconstruction with hamstrings autograft: transtibial versus anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc 21(8):1904–1909

    Article  PubMed  Google Scholar 

  28. Niki Y, Nagai K, Harato K, Suda Y et al (2017) Effects of femoral bone tunnel characteristics on graft-bending angle in double- bundle anterior cruciate ligament reconstruction: a comparison of the outside-in and transportal techniques. Knee Surg Sports Traumatol Arthrosc 25(4):1191–1198

    Article  PubMed  Google Scholar 

  29. Sim JA, Kim JM, Lee S, Song EK, Seon JK (2018) No difference in graft healing or clinical outcome between trans-portal and outside-in techniques after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26(8):2338–2344

    Article  PubMed  Google Scholar 

  30. Youm YS, Cho SD, Lee SH, Youn CH (2014) Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Am J Sports Med 42(12):2941–2947

    Article  PubMed  Google Scholar 

  31. Weiler A, Peters G, Mäurer J, Frank NU et al (2001) Biomechanical properties and vascularity of an anterior cruciate ligament graft can be predicted by contrast-enhanced magnetic resonance imaging. Am J Sports Med 29(6):751–761

    Article  CAS  PubMed  Google Scholar 

  32. Li H, Tao H, Cho S, Chen S, Yao Z, Chen S (2012) Difference in graft maturity of the reconstructed anterior cruciate ligament 2 years postoperatively: a comparison between autografts and allografts in young men using clinical and 3.0-T magnetic resonance imaging evaluation. Am J Sports Med 40:1519–1526

    Article  PubMed  Google Scholar 

  33. Miyawaki M, Hensler D, Illingworth KD, Irrgang JJ, Fu FH (2014) Signal intensity on magnetic resonance imaging after allograft double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 22(5):1002–1008

    Article  PubMed  Google Scholar 

  34. Muramatsu K, Hachiya Y, Izawa H (2008) Serial evaluation of human anterior cruciate ligament grafts by contrast-enhanced magnetic resonance imaging: comparison of allografts and autografts. Arthroscopy 24(9):1038–1044

    Article  PubMed  Google Scholar 

  35. Tashiro Y, Gale T, Sundaram V, Nagai K et al (2017) The graft bending angle can affect early graft healing after anterior cruciate ligament reconstruction: in vivo analysis with 2 years’ follow-up. Am J Sports Med 73(2):1829–1836

    Article  Google Scholar 

  36. Taketomi S, Nakagawa T, Takeda H, Nakajima K et al (2011) Anatomical placement of double femoral tunnels in anterior cruciate ligament reconstruction: anteromedial tunnel first or posterolateral tunnel first? Knee Surg Sports Traumatol Arthrosc 19(3):424–431

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  38. Lubowitz JH (2009) Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy 25:95–101

    Article  PubMed  Google Scholar 

  39. Nakamura M, Deie M, Shibuya H, Nakamae A, Adachi N, Aoyama H, Ochi M (2009) Potential risks of femoral tunnel drilling through the far anteromedial portal: a cadaveric study. Arthroscopy 25:481–487

    Article  PubMed  Google Scholar 

  40. Basdekis G, Abisafi C, Christel P (2009) Effect of knee flexion angle on length and orientation of posterolateral femoral tunnel drilled through anteromedial portal during anatomic double- bundle anterior cruciate ligament reconstruction. Arthroscopy 25:1108–1114

    Article  PubMed  Google Scholar 

  41. Robin BN, Jani SS, Marvil SC, Reid JB et al (2015) Advantages and Disadvantages of transtibial, anteromedial portal, and outside-in femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 31(7):1412–1417

    Article  PubMed  Google Scholar 

  42. Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10:14–21

    CAS  PubMed  Google Scholar 

  43. Shin YS, Ro KH, Jeon JH, Lee DH (2015) Graft-bending angle and femoral tunnel length after single-bundle anterior cruciate ligament reconstruction. J Bone Jt Surg Br 96(6):743–751

    Article  Google Scholar 

  44. Li H, Chen S, Tao H, Li H, Chen S (2014) Correlation analysis of potential factors influencing graft maturity after anterior cruciate ligament reconstruction. Orthop J Sports Med 2(10):2325967114553552

    Article  PubMed  PubMed Central  Google Scholar 

  45. Ma Y, Murawski CD, Rahnemai-Azar AA, Maldjian C (2015) Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 23(3):661–668

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan

    Masahiko Saito, Junichi Iwasaki & Tsuguo Morikawa

  2. Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan

    Arata Nakajima, Masato Sonobe, Hiroshi Takahashi & Yorikazu Akatsu

  3. Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan

    Tsutomu Inaoka & Koichi Nakagawa

  4. Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba, 260-8670, Japan

    Takahisa Sasho

  5. Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan

    Atsuya Watanabe & Yasuchika Aoki

Authors
  1. Masahiko Saito
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  2. Arata Nakajima
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  11. Takahisa Sasho
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Contributions

MS contributed to the design, acquisition of the data, analysis and interpretation, drafting and revising of the manuscript, and final approval. KN contributed to the conception, design, critical revision, and final approval of the article. AN, MS, HT, and TI made contributions to the conception and design through drafting. JI, TM, AW, YA, and TS contributed to the critical revision and final approval of the manuscript. YA examined the validity of data analysis. MS and KN take responsibility for the integrity of the work. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Masahiko Saito.

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Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the Medical Ethical Committee of Toho University Sakura Medical Center (no. 2015-063).

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Saito, M., Nakajima, A., Sonobe, M. et al. Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique. Knee Surg Sports Traumatol Arthrosc 27, 2468–2477 (2019). https://doi.org/10.1007/s00167-018-5240-8

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  • DOI: https://doi.org/10.1007/s00167-018-5240-8

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