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The three techniques for femoral tunnel placement in anterior cruciate ligament reconstruction: transtibial, anteromedial portal, and outside-in techniques
Arthrosc Orthop Sports Med 2015;2:77-85
Published online July 1, 2015;  https://doi.org/10.14517/aosm14021
© 2015 Arthroscopy and Orthopedic Sports Medicine.

Nam-Ki Kim, Jong-Min Kim

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Correspondence to: Jong-Min Kim, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea. Tel: +82-2-3010-3897, Fax: +82-2-488-7877, E-mail: jmkim@amc.seoul.kr
Received December 23, 2014; Revised March 11, 2015; Accepted March 11, 2015.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
A femoral tunnel can be created using the transtibial (TT), anteromedial (AM) portal, or outside-in technique. TT technique has a tendency to produce a femoral tunnel in non-anatomic location and a graft may be placed too anteriorly and vertically. Postoperative complications including graft failure and rotational instability have been reported following TT technique. Modified TT techniques were developed for more horizontal and oblique femoral tunnel. Although, modified TT techniques create the femoral tunnel closer to the anterior cruciate ligament (ACL) footprint than the conventional TT technique, they result in shorter tibial tunnel and widening of the intra-articular aperture of tibial tunnel. ACL reconstruction techniques have been transformed into anatomical and tibial tunnel-independent techniques. The AM portal technique uses an accessory AM portal to drill the femoral tunnel separately. It allows more accurate placement of the femoral tunnel guide. However, the AM portal technique has complications such as short femoral socket, posterior wall blowout of the femoral socket. The outside-in technique allows more freedom with positioning of the femoral tunnel and can be performed in retrograde fashion. It is especially useful in revision ACL reconstruction for skeletally immature patients and for those with less than 130˚ of limited range of flexion.
Keywords : Anterior cruciate ligament; Reconstruction; Transtibial technique; Anteromedial portal technique; Outside-in technique
References
  1. Siegel L, Vandenakker-Albanese C, Siegel D. Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Clin J Sport Med 2012;22:349-55.
    Pubmed CrossRef
  2. Cimino F, Volk BS, Setter D. Anterior cruciate ligament injury:diagnosis, management, and prevention. Am Fam Physician 2010;82:917-22.
    Pubmed
  3. Sim JA, Gadikota HR, Li JS, Li G, Gill TJ. Biomechanical evaluation of knee joint laxities and graft forces after anterior cruciate ligament reconstruction by anteromedial portal, outside-in, and transtibial techniques. Am J Sports Med 2011;39:2604-10.
    Pubmed KoreaMed CrossRef
  4. Scopp JM, Jasper LE, Belkoff SM, Moorman CT 3rd. The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004;20:294-9.
    Pubmed CrossRef
  5. Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 2002 Richard O'Connor Award paper. Arthroscopy 2003;19:297-304.
    Pubmed CrossRef
  6. Zavras TD, Race A, Bull AM, Amis AA. A comparative study of 'isometric' points for anterior cruciate ligament graft attachment. Knee Surg Sports Traumatol Arthrosc 2001;9:28-33.
    Pubmed CrossRef
  7. Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum EB. The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med 1996;24:335-41.
    Pubmed CrossRef
  8. Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194-9.
    Pubmed CrossRef
  9. Alentorn-Geli E, Lajara F, Samitier G, Cugat R. The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010;18:101337.
    Pubmed CrossRef
  10. Heming JF, Rand J, Steiner ME. Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 2007;35:1708-15.
    Pubmed CrossRef
  11. Streich NA, Reichenbacher S, Bari? A, Buchner M, Schmitt H. Long-term outcome of anterior cruciate ligament reconstruction with an autologous four-strand semitendinosus tendon autograft. Int Orthop 2013;37:279-84.
    Pubmed KoreaMed CrossRef
  12. Wang H, Fleischli JE, Zheng NN. Transtibial versus anteromedial portal technique in single-bundle anterior cruciate ligament reconstruction: outcomes of knee joint kinematics during walking. Am J Sports Med 2013;41:1847-56.
    Pubmed CrossRef
  13. Lee JK, Lee S, Seong SC, Lee MC. Anatomic single-bundle ACL reconstruction is possible with use of the modified transtibial technique: a comparison with the anteromedial transportal technique. J Bone Joint Surg Am 2014;96:664-72.
    Pubmed CrossRef
  14. Bedi A, Musahl V, Steuber V, et al. Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy 2011;27:380-90.
    Pubmed CrossRef
  15. Golish SR, Baumfeld JA, Schoderbek RJ, Miller MD. The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: a cadaveric study. Arthroscopy 2007;23:1187-92.
    Pubmed CrossRef
  16. Silva A, Sampaio R, Pinto E. Placement of femoral tunnel between the AM and PL bundles using a transtibial technique in singlebundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2010;18:1245-51.
    Pubmed CrossRef
  17. Howell SM, Gittins ME, Gottlieb JE, Traina SM, Zoellner TM. The relationship between the angle of the tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament reconstruction. Am J Sports Med 2001;29:567-74.
    Pubmed
  18. Chhabra A, Diduch DR, Blessey PB, Miller MD. Recreating an acceptable angle of the tibial tunnel in the coronal plane in anterior cruciate ligament reconstruction using external landmarks. Arthroscopy 2004;20:328-30.
    Pubmed CrossRef
  19. Youm YS, Cho SD, Lee SH, Youn CH. 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 2014;42:2941-7.
    Pubmed CrossRef
  20. Bottoni CR, Rooney RC, Harpstrite JK, Kan DM. Ensuring accurate femoral guide pin placement in anterior cruciate ligament reconstruction. Am J Orthop (Belle Mead NJ) 1998;27:764-6.
    Pubmed
  21. Franceschi F, Papalia R, Rizzello G, Del Buono A, Maffulli N, Denaro V. Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study. Arthroscopy 2013;29:1330-7.
    Pubmed CrossRef
  22. Hensler D, Working ZM, Illingworth KD, Thorhauer ED, Tashman S, Fu FH. Medial portal drilling: effects on the femoral tunnel aperture morphology during anterior cruciate ligament reconstruction. J Bone Joint Surg Am 2011;93:2063-71.
    Pubmed CrossRef
  23. Chalmers PN, Mall NA, Cole BJ, Verma NN, Bush-Joseph CA, Bach BR Jr. Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: a systematic review. Arthroscopy 2013;29:1235-42.
    Pubmed CrossRef
  24. Azboy I, Demirta? A, Gem M, Kıran S, Alemdar C, Bulut M. A comparison of the anteromedial and transtibial drilling technique in ACL reconstruction after a short-term follow-up. Arch Orthop Trauma Surg 2014;134:963-9.
    Pubmed CrossRef
  25. Lubowitz JH. Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy 2009;25:95-101.
    Pubmed CrossRef
  26. Hantes ME, Zachos VC, Liantsis A, Venouziou A, Karantanas AH, Malizos KN. 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 2009;17:880-6.
    Pubmed CrossRef
  27. Ilahi OA, Ventura NJ, Qadeer AA. Femoral tunnel length:accessory anteromedial portal drilling versus transtibial drilling. Arthroscopy 2012;28:486-91.
    Pubmed CrossRef
  28. Gadikota HR, Sim JA, Hosseini A, Gill TJ, Li G. The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint. Am J Sports Med 2012;40:882-8.
    Pubmed KoreaMed CrossRef
  29. Ahn JH, Lee YS, Lee SH. Creation of an anatomic femoral tunnel with minimal damage to the remnant bundle in remnantpreserving anterior cruciate ligament reconstruction using an outside-in technique. Arthrosc Tech 2014;3:e175-9.
    Pubmed KoreaMed CrossRef
  30. Lubowitz JH, Ahmad CS, Anderson K. All-inside anterior cruciate ligament graft-link technique: second-generation, noincision anterior cruciate ligament reconstruction. Arthroscopy 2011;27:717-27.
    Pubmed CrossRef
  31. Kim JG, Wang JH, Ahn JH, Kim HJ, Lim HC. Comparison of femoral tunnel length between transportal and retrograde reaming outside-in techniques in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2013;21:830-8.
    Pubmed CrossRef
  32. Chang MJ, Chang CB, Won HH, Je MS, Kim TK. Anteromedial portal versus outside-in technique for creating femoral tunnels in anatomic anterior cruciate ligament reconstructions. Arthroscopy 2013;29:1533-9.
    Pubmed CrossRef
  33. Breland R, Metzler A, Johnson DL. Indications for 2-incision anterior cruciate ligament surgery. Orthopedics 2013;36:70811.
    Pubmed CrossRef
  34. Mall NA, Paletta GA. Pediatric ACL injuries: evaluation and management. Curr Rev Musculoskelet Med 2013;6:132-40.
    Pubmed KoreaMed CrossRef
  35. Brown CH Jr, Spalding T, Robb C. Medial portal technique for single-bundle anatomical anterior cruciate ligament (ACL) reconstruction. Int Orthop 2013;37:253-69.
    Pubmed KoreaMed CrossRef


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