Skip to main content

Femoral tunnel position in chronic anterior cruciate ligament rupture reconstruction: randomized controlled trial comparing anatomic, biomechanical and clinical outcomes

European Journal of Orthopaedic Surgery & Traumatology volume 29, pages 1501–1509 (2019)Cite this article

Abstract

Purpose

The aim of this study was to compare the outcomes between anteromedial (AM) and transtibial (TT) femoral tunnel positioning techniques for the reconstruction of chronic anterior cruciate ligament (ACL) rupture.

Materials and methods

It is a randomized prospective study of 106 patients who underwent ACL reconstruction because of a chronic ACL rupture (55 AMT, 51 TT). Minimum follow-up was 2 years. Demographic, clinical and radiological data, including MRI grafts’ anatomy and biomechanics intraoperative navigation system evaluation, were analyzed. Also, International Knee Documentation Committee score, Tegner Knee score, Lysholm Knee Score, Short-Form Health Survey and 4-point Likert Scale were evaluated.

Results

The AM technique achieves a more anatomic graft than TT technique in both sagittal and coronal plane (6° approximately). Immediate postoperative biomechanical evaluation of the graft showed both techniques significantly improved translational and rotational laxity (p = 0.000). AMT showed superiority only in controlling internal rotation (p = 0.016). Both techniques reported significant improvement in all evaluated score scales, without differences between techniques. Independently of the femoral tunnel positioning technique, patients with cartilage lesion had worse clinical outcomes.

Conclusions

Our findings suggest that AMT achieves a more anatomical and biomechanically accurate graft allowing better control over internal rotation laxity; however, this does not lead to better clinical outcomes if we compare with TT in the reconstruction of chronic ACL rupture. Patients with chronic ACL rupture and cartilage lesion had worse clinical outcomes, independently the femoral tunnel positioning technique.

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
Fig. 3

References

  1. Riboh JC, Hasselblad V, Godin JA, Mather RC 3rd (2013) Transtibial versus independent drilling techniques for anterior cruciate ligament reconstruction: a systematic review, meta-analysis, and meta-regression. Am J Sports Med 41:2693–2702. https://doi.org/10.1177/0363546513506979

    Article  PubMed  Google Scholar 

  2. Liu A, Sun M, Ma C, Chen Y, Xue X, Guo P et al (2017) Clinical outcomes of transtibial versus anteromedial drilling techniques to prepare the femoral tunnel during anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25:2751–2759. https://doi.org/10.1007/s00167-015-3672-y

    Article  PubMed  Google Scholar 

  3. Duquin TR, Wind WM, Fineberg MS, Smolinski RJ, Buyea CM (2009) Current trends in anterior cruciate ligament reconstruction. J Knee Surg 22:7–12. https://doi.org/10.1055/s-0030-1247719

    Article  PubMed  Google Scholar 

  4. Kim HS, Seon JK, Jo AR (2013) Current trends in anterior cruciate ligament reconstruction. Knee Surg Relat Res 25:165–173. https://doi.org/10.5792/ksrr.2013.25.4.165

    Article  PubMed  PubMed Central  Google Scholar 

  5. Vaishya R, Agarwal AK, Ingole S, Vijay V (2015) Current trends in anterior cruciate ligament reconstruction: a review timing of surgery. Cureus 7:387. https://doi.org/10.7759/cureus.378

    Article  Google Scholar 

  6. Chen H, Tie K, Qi Y, Li B, Chen B, Chen L (2017) Anteromedial versus transtibial technique in single-bundle autologous hamstring acl reconstruction: a meta-analysis of prospective randomized controlled trials. J Orthop Surg Res 12:167. https://doi.org/10.1186/s13018-017-0671-3

    Article  PubMed  PubMed Central  Google Scholar 

  7. Chen Y, Chua KH, Singh A, Tan JH, Chen X, Tan SH et al (2015) Outcome of single-bundle hamstring anterior cruciate ligament reconstruction using the anteromedial versus the transtibial technique: a systematic review and meta-analysis. Arthroscopy 31:1784–1794. https://doi.org/10.1016/j.arthro.2015.06.001

    Article  PubMed  Google Scholar 

  8. 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 42:2941–2947. https://doi.org/10.1177/0363546514551922

    Article  PubMed  Google Scholar 

  9. Silberberg Muiño J, Nilo Fulvi A, Vera G, Gutiérrez García JL, Giménez Salvay M, Maroa Salvucci M et al (2018) Tibial tunnel widening associated with anterior cruciate ligament reconstruction using autogenous hamstrings: a comparison between antero-medial portal and transtibial techniques. Rev Esp Cir Ortop Traumatol 62:190–196. https://doi.org/10.1016/j.recot.2017.11.005

    Article  PubMed  Google Scholar 

  10. Noh JH, Roh YH, Yang BG, Yi SR, Lee SY (2013) Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: transtibial technique versus anteromedial portal technique. Arthroscopy 29:882–890. https://doi.org/10.1016/j.arthro.2013.01.025

    Article  PubMed  Google Scholar 

  11. Guglielmetti LG, Cury Rde P, de Oliveira VM, de Camargo OP, Severino NR, Fucs PM (2014) Anterior cruciate ligament reconstruction: a new cortical suspension device for femoral fixation with transtibial and transportal techniques. J Orthop Surg Res 19:110. https://doi.org/10.1186/s13018-014-0110-7

    Article  Google Scholar 

  12. Bohn MB, Sørensen H, Petersen MK, Søballe K, Lind M (2014) Rotational laxity after anatomical acl reconstruction measured by 3-d motion analysis: a prospective randomized clinical trial comparing anatomic and nonanatomic acl reconstruction techniques. Knee Surg Sports Traumatol Arthrosc 23:3473–3481. https://doi.org/10.1007/s00167-014-3156-5

    Article  PubMed  Google Scholar 

  13. MacDonald P, Kim C, McRae S, Leiter J, Khan R, Whelan D (2018) no clinical differences between anteromedial portal and transtibial technique for femoral tunnel positioning in anterior cruciate ligament reconstruction: a prospective randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 26:1335–1342. https://doi.org/10.1007/s00167-017-4664-x

    Article  PubMed  Google Scholar 

  14. McAllister DR, Foster B, Martin DE, Veitch AJ, Dorey FJ, Petrigliano F et al (2014) Outcome of chronic isolated anterior cruciate ligament reconstruction. J Knee Surg 27:383–392. https://doi.org/10.1055/s-0033-1364099

    Article  PubMed  Google Scholar 

  15. Andernord D, Karlsson J, Musahl V, Bhandari M, Fu FH, Samuelsson K (2013) Timing of surgery of the anterior cruciate ligament. Arthroscopy 29:1863–1871. https://doi.org/10.1016/j.arthro.2013.07.270

    Article  PubMed  Google Scholar 

  16. Smith TO, Davies L, Hing CB (2010) Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 18:304–311. https://doi.org/10.1007/s00167-009-0965-z

    Article  PubMed  Google Scholar 

  17. 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 39:2611–2618. https://doi.org/10.1177/0363546511420128

    Article  PubMed  Google Scholar 

  18. Zaffagnini S, Urrizola F, Signorelli C, Grassi A, Di Sarsina TR, Lucidi GA, Marcheggiani Muccioli GM et al (2016) Current use of navigation system in acl surgery: a historical review. Knee Surg Sports Traumatol Arthrosc 24:3396–3409. https://doi.org/10.1007/s00167-016-4356-y

    CAS  Article  PubMed  Google Scholar 

  19. Chalmers PN, Mall NA, Cole BJ, Verma NN, Bush-Joseph CA, Bach BR Jr (2013) Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: a systematic review. Arthroscopy 29:1235–1242. https://doi.org/10.1016/j.arthro.2013.02.015

    Article  PubMed  Google Scholar 

  20. Zhang Q, Zhang S, Li R, Liu Y, Cao X (2012) Comparison of two methods of femoral tunnel preparation in single-bundle anterior cruciate ligament reconstruction: a prospective randomized study. Acta Cir Bras 27(8):572–576. https://doi.org/10.1590/S0102-86502012000800010

    Article  PubMed  Google Scholar 

  21. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med 40:512–520. https://doi.org/10.1177/0363546511426416

    Article  PubMed  Google Scholar 

  22. Mirzatolooei F (2012) Comparison of short term clinical outcomes between transtibial and transportal transfix® femoral fixation in hamstring acl reconstruction. Acta Orthop Traumatol Turc 46:361–366. https://doi.org/10.3944/AOTT.2012.2679

    Article  PubMed  Google Scholar 

  23. Yanasse RH, Lima AA, Antoniassi RS, Ezzedin DA, Laraya MH, Mizobuchi RR (2016) Transtibial technique versus two incisions in anterior cruciate ligament reconstruction: tunnel positioning, isometricity and functional evaluation. Rev Bras Ortop 51:274–281. https://doi.org/10.1016/j.rboe.2016.04.001

    Article  PubMed  PubMed Central  Google Scholar 

  24. Han K, Hyun R, Kim J, Hee D (2017) The transportal technique shows better clinical results than the transtibial techniques for single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26:2371–2380. https://doi.org/10.1007/s00167-017-4786-1

    Article  Google Scholar 

  25. Helito CP, Camargo DB, Sobrado MF, Bonadio MB, Giglio PN, Pécora JR et al (2018) Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-4934-2

    Article  PubMed  Google Scholar 

  26. Salci L, Ayeni O, Farrokhyar F, Dao D, Ogilvie R, Peterson D (2016) Impact of surgical waitlist on quality of life 29:346–354. https://doi.org/10.1055/s-0035-1564596

  27. Tanaka Y, Kita K, Takao R, Amano H, Uchida R, Shiozaki Y et al (2018) Chronicity of anterior cruciate ligament deficiency, part 1: effects on the tibiofemoral relationship before and immediately after anatomic acl reconstruction with autologous hamstring grafts. Orthop J Sports Med. 6:1–11. https://doi.org/10.1177/2325967117750813

    Article  Google Scholar 

Download references

Acknowledgements

We would like to thank Dr. Enric Caceres and the Department of Radiology, University Hospital of Vall d´Hebron, Barcelona, Spain, to analyzed all knee magnetic resonance images of the patients included in our study.

Author information

Affiliations

  1. Knee Unit, Department of Traumatology and Orthopaedic Surgery, University Hospital of Vall d’ Hebron, Universitat Autónoma de Barcelona, Passeig de la Vall d’Hebron, 119-129, 08035, Barcelona, Spain

    Joan Minguell, M. M. Reverte-Vinaixa, A. Sallent, A. Gargallo-Margarit & E. Castellet

  2. Knee Unit, Department of Traumatology and Orthopaedic Surgery, Clínica Corachán, Carrer de Buïgas, 19, 08017, Barcelona, Spain

    Joan Minguell

  3. Knee and Spine Unit, Department of Traumatology and Orthopedic Surgery, University Hospital of Mutua Terrassa (DNR), Plaça del Doctor Robert, 5, 08221, Terrassa, Barcelona, Spain

    Jorge H. Nuñez

Authors
  1. Joan Minguell
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jorge H. Nuñez
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. M. Reverte-Vinaixa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Sallent
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. Gargallo-Margarit
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. E. Castellet
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jorge H. Nuñez.

Ethics declarations

Conflict of interest

No conflicts of interest were declared by the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Minguell, J., Nuñez, J.H., Reverte-Vinaixa, M.M. et al. Femoral tunnel position in chronic anterior cruciate ligament rupture reconstruction: randomized controlled trial comparing anatomic, biomechanical and clinical outcomes. Eur J Orthop Surg Traumatol 29, 1501–1509 (2019). https://doi.org/10.1007/s00590-019-02455-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-019-02455-x

Keywords

  • Anterior cruciate ligament
  • Surgery
  • Navigation
  • Anteromedial technique
  • Transtibial technique