Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review

Abstract

Background: The drilling technique used to make a femoral tunnel is critically important for determining outcomes after anterior cruciate ligament (ACL) reconstruction. The 2 most common methods are the transtibial (TT) and anteromedial (AM) techniques. Purpose: To determine whether graft orientation and placement affect clinical outcomes by comparing clinical and radiological outcomes after single-bundle ACL reconstruction with the AM versus TT technique. Study Design: Systematic review; Level of evidence, 3. Methods: Articles in PubMed, EMBASE, the Cochrane Library, ISI Web of Science, Scopus, and MEDLINE were searched from inception until April 25, 2020, using the following Boolean operators: transtibial OR trans-tibial AND (anteromedial OR trans-portal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament. Results: Of 1270 studies retrieved, 39 studies involving 11,207 patients were included. Of these studies, 14 were clinical, 13 were radiological, and 12 were mixed. Results suggested that compared with the TT technique, the AM technique led to significantly improved anteroposterior and rotational knee stability, International Knee Documentation Committee (IKDC) scores, and recovery time from surgery. A higher proportion of negative Lachman ( P = .0005) and pivot-shift test ( P = .0001) results, lower KT-1000 arthrometer maximum manual displacement ( P = .00001), higher Lysholm score ( P = .001), a higher incidence of IKDC grade A/B ( P = .05), and better visual analog scale score for satisfaction ( P = .00001) were observed with the AM technique compared with the TT technique. The AM drilling technique demonstrated a significantly shorter tunnel length ( P = .00001). Significant differences were seen between the femoral and tibial graft angles in both techniques. Low overall complication and revision rates were observed for ACL reconstruction with the AM drilling technique, similar to the TT drilling technique. Conclusion: In single-bundle ACL reconstruction, the AM drilling technique was superior to the TT drilling technique based on physical examination, scoring systems, and radiographic results. The AM portal technique provided a more reproducible anatomic graft placement compared with the TT technique.

Effect of the TT and AM approaches in anterior cruciate ligament reconstruction on femoral tunnel and efficacy analysis

“…But Hussein M et al's [39] study showed that the AM approach was superior to the TT approach in terms of knee rotational stability. Similarly, the studies by Loucas M et al [27] and Mao Y et al [28] also showed that the transam approach created a femoral tunnel with superior knee rotational stability than the TT approach. Currently, it is still controversial whether the two approaches differ in terms of knee stability and clinical function, and further studies in a multicenter, large sample size are awaited to provide the basis for choosing the optimal surgical approach.…”

“…Similarly Riboh JC et al [25] and Geng Y et al [26] studies showed no signi cant difference between the two approaches in terms of knee function after ACL reconstruction. However, Loucas M et al [27] and Mao Y et al [28] suggested that the creation of a femoral tunnel via an AM approach after ACL reconstruction provides better knee function than a TT approach. We also found no signi cant difference between the two groups in terms of the Lachman test, the pivot shift test, at 6 months after surgery and at the last follow-up.…”

Posteriorly positioned femoral grafts decrease long-term failure in anterior cruciate ligament reconstruction, femoral and tibial graft positions did not affect long-term reported outcome

“…All patients in this study were operated with the trans-tibial technique. Several studies have shown that the anteromedial technique achieves a more anatomic tunnel placement, improved antero-posterior and rotational knee stability [ 10 , 26 , 33 , 38 , 42 , 48 , 51 , 58 ]. However, there is inconsistency between these different studies if the improved graft anatomy of the anteromedial technique leads to better reported and clinical outcome.…”

Hamstring tendon autografts and allografts show comparable clinical outcomes and knee stability after anterior cruciate ligament reconstruction in patients over fifty years old with no signs of osteoarthritis progression

“…If the meniscal injury was stable, it was left that way; if it was unstable, a hyperselective meniscectomy of the injured area was performed. Hamstring graft harvesting was then performed through a 2-cm skin incision on the upper medial tibia [14].…”