Anterior Cruciate Ligament Tunnel Placement Using the Pathfinder Guide

Patel, Karan A.; Chhabra, Anikar; Makovicka, Justin L.; Bingham, Joshua S.; Piasecki, Dana P.; Hartigan, David E.

doi:10.1016/j.eats.2017.05.009

Cited by 10 publications

(6 citation statements)

References 21 publications

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“…Traditional transtibial drilling of the femoral tunnel for ACLR results in longer and more vertical tunnel trajectories in the coronal plane versus AM or outside-in techniques, implying increased safety in the context of open physes. 7 , 19 However, transtibial drilling has been shown to consistently result in less accurate positioning of the femoral tunnel with respect to the native ACL footprint, as well as reduced knee rotational stability compared with the tibial-independent drilling technique. 20 , 21 Thus, a hybrid transtibial technique appears to offer the best of both worlds, consistently reproducing the native ACL trajectory and footprint while reducing tunnel obliquity (and the associated risk of physeal injury) and maintaining the technical advantages of traditional transtibial ACLR.…”

Section: Discussionmentioning

confidence: 99%

“…The flexible guide pin and plastic sheath are then inserted through the tibial tunnel and captured in the guide within the joint ( Fig 9 ). 19 Slight knee extension is often required to align the pin and the slot in the guide in the sagittal plane. Once the guide-pin complex is centered on the ACL footprint, the pin is advanced 1 to 2 mm to secure the starting point.…”

Section: Surgical Techniquementioning

confidence: 99%

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Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft

Johnston

Gregory

et al. 2020

Arthroscopy Techniques

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Significant controversy exists regarding the optimal surgical technique for anterior cruciate ligament (ACL) reconstruction in adolescents with 1 to 3 years of skeletal growth remaining. Graft choice and physeal injury remain primary concerns given significantly elevated rates of failure of hamstring autograft reconstructions in this population, as well as risks of leg-length discrepancy and growth axis deviation. Traditional (more vertical) transtibial drilling of the femoral tunnel can reduce risks of physeal injury but has been shown to have less accuracy restoring the native femoral ACL footprint and associated incomplete knee stabilization. On the other hand, anteromedial and outside-in drilling yields improvements in the tunnel location and biomechanics but at the cost of a more oblique trajectory and greater risk of physeal injury. A hybrid transtibial pin technique using a Pathfinder guide facilitates femoral drilling with the “best of both worlds,” allowing for reproduction of the native ACL footprint and a more physeal-respecting femoral tunnel. When combined with an all–soft tissue quadriceps tendon autograft and suspensory fixation, the hybrid transtibial method yields a reliable, safe, and robust construct with promising results for the young athlete. We describe our preferred graft harvest, tunnel drilling, and fixation techniques to minimize physeal risks and optimize outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Surgical Techniquementioning

confidence: 99%

Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft

Johnston

Gregory

et al. 2020

Arthroscopy Techniques

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“…The ACL is the most commonly injured ligament of the knee requiring surgical reconstruction, which requires the creation of a femoral tunnel via a separate anteromedial (AM) portal or transtibial (TT) technique. 5 The HTT was first named in 2017 and uses the medial portal guidance of a TT guide wire without knee hyperflexion. 3 This technique offers anatomic tunnel placement while maintaining the relative ease of a TT technique, which may represent a beneficial combination of both the AM portal and TT technique.…”

Section: Video Transcriptmentioning

confidence: 99%

The Hybrid Transtibial Technique Using the LARS Device in Primary Anterior Cruciate Ligament Reconstruction

Huang

Wang

et al. 2023

Video Journal of Sports Medicine

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Background: The recently published hybrid transtibial technique (HTT) using the Pathfinder Guide with a flexible transtibial technique (TT) guide wire may represent a beneficial combination of both the anteromedial portal and TT technique. The HTT has been described as especially suitable for anterior cruciate ligament (ACL) reconstruction in adolescents or ACL revision. However, we also found that the HTT worked for primary ACL reconstruction in adults also using the Ligament Advanced Reinforcement System (LARS). Indications: Acute ACL rupture in active patients who are eager to return to sports quickly. Technique Description: The HTT combined with the conventional LARS reconstruction procedure improves the placement of the femoral tunnel, which involves a guiding vessel clamp through the anteromedial portal combined with a 2.0 mm Kirschner wire via the tibial tunnel. Finally, we used a metal screw for fixation of the ligament. Results: The patient experienced satisfactory reconstruction of his ACL and regained active range of motion in 1 month and a full return to sports in 6 months. Discussion/Conclusion: The HTT using the LARS for primary ACL reconstruction is easy, safe, and reproducible. This combined technique has not yet been published and it may provide good functional results that allow patients to recover quickly and return to sports as soon as possible. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

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“…To leverage the strengths of both the TT and AMP techniques while mitigating the drawbacks inherent to both, a novel hybrid TT (HTT) approach to femoral tunnel drilling was developed in which a flexible TT guide wire is introduced through the tibial tunnel and captured by an over-the-top guide from the medial portal, circumventing the need for knee hyperflexion and to orient the graft in the most anatomic position without sacrificing the tunnel length or aperture. 18,27,32…”

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confidence: 99%

Clinical Outcomes of a Novel Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Large Single-Center Case Series With a Minimum 2-Year Follow-up

Hong,

Ifarraguerri,

Berk

et al. 2024

Orthopaedic Journal of Sports Medicine

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Background: A novel hybrid transtibial (HTT) approach to femoral tunnel drilling in anterior cruciate ligament reconstruction (ACLR) has been developed that circumvents the need for knee hyperflexion and orients the graft in the most anatomic position without sacrificing the tunnel length or aperture. Hypothesis: Patients who underwent ACLR utilizing the HTT technique would achieve excellent patient-reported outcome scores and experience low rates of graft failure and reoperations. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent primary ACLR at a single institution between 2005 and 2020 were retrospectively reviewed. Patients treated with the HTT, anteromedial portal (AMP), and transtibial (TT) approaches were matched based on age, sex, and body mass index ±3 kg/m2. Demographic and surgical data as well as femoral tunnel angle measurements on anteroposterior and lateral radiographs were collected for the 3 groups. However, clinical outcomes were only reported for the HTT group because of concerns of graft heterogeneity. Results: A total of 170 patients (median age, 26.5 years [interquartile range (IQR), 18.0-35.0 years]) who underwent ACLR using the HTT approach were included. The median coronal- and sagittal-plane femoral tunnel angles were 47° (IQR, 42°-53°) and 40° (IQR, 34°-46°), respectively. The sagittal-plane femoral tunnel angles in the HTT group were significantly more horizontal compared with those in the TT group ( P < .0001), whereas the coronal-plane femoral tunnel angles in the HTT group were found to be significantly more vertical compared with those in the AMP group ( P = .001) and more horizontal compared with those in the TT group ( P < .0001). The graft failure and reoperation rates in the HTT group at a minimum 2-year follow-up were 1.8% (3/170) and 4.7% (8/170), respectively. The complication rate was 6.5% (11/170), with the most common complication being subjective stiffness in 7 patients. The median Lysholm score was 89.5 (IQR, 79.0-98.0); the median International Knee Documentation Committee score was 83.9 (IQR, 65.5-90.8); and the median Veterans RAND 12-Item Health Survey physical and mental component summary scores were 55.0 (IQR, 52.6-55.9) and 56.2 (IQR, 49.1-59.3), respectively. Conclusion: ACLR using the HTT technique was associated with low graft retear and revision surgery rates and good patient-reported outcome scores at medium-term follow-up and demonstrated femoral tunnel obliquity on postoperative radiographs that correlated with optimal parameters previously reported in cadaveric and biomechanical studies.

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Anterior Cruciate Ligament Tunnel Placement Using the Pathfinder Guide

Cited by 10 publications

References 21 publications

Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft

Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft

The Hybrid Transtibial Technique Using the LARS Device in Primary Anterior Cruciate Ligament Reconstruction

Clinical Outcomes of a Novel Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Large Single-Center Case Series With a Minimum 2-Year Follow-up

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