Comparison of Anteromedial and Transtibial ACL Reconstruction Using Expandable Fixation

Abstract

The influence of anatomical or nonanatomical femoral tunnel position on tunnel widening and clinical outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction is not fully understood. This retrospective study examined the influence of tunnel width and placement on anterior knee stability and clinical outcomes after ACL reconstruction using the AperFix System (Cayenne Medical Inc, Scottsdale, Arizona), a direct expandable fixation technique with autologous hamstring grafts. The records of 80 patients (79 men and 1 woman) who underwent ACL reconstruction were evaluated. In 38 patients, anatomical femoral tunnel placement was performed via an accessory medial portal (anteromedial group); in the remaining 42 patients, the femoral tunnel was positioned nonanatomically using a transtibial technique (transtibial group). Mean follow-up was 40.7 months (range, 27-60 months). Postoperative knee kinetics were measured, and clinical outcomes were assessed using International Knee Documentation Committee, Lysholm, and Tegner scores. Femoral tunnel widening was measured by comparing postoperative radiographs with final follow-up radiographs. Femoral tunnel width was significantly greater (P<.001) and anterior knee translation was significantly higher (P=.01) in the transtibial group. Lysholm and Tegner scores were not significantly different (P>.05) between the 2 groups. These findings suggest that femoral tunnel widening is associated with increased anterior joint laxity when a direct fixation technique is used for ACL reconstruction, particularly in nonanatomically positioned femoral tunnels. Anatomical femoral tunnel placement provides better anterior stability and less tunnel widening than transtibial tunnel placement; however, these benefits did not produce a detectable advantage in clinical outcomes measures. [Orthopedics. 2017; 40(3):e532-e537.].

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

“…Among the 25 clinical studies, 12 ** (48%) used the Lachman test as a benchmark to examine postoperative ACL sagittal laxity grade, and 13 studies † † (including the 12 studies that performed the Lachman test) used the pivotshift test to examine rotational stability of the knee at the final follow-up (Supplemental Table S3). Of the 25 clinical studies, 9 3,17,21,24,28,37,49,51,87 (36% of all clinical studies) described KT-1000 arthrometer results (Figure 2C and Supplemental Table S3). Based on these studies, the maximum manual displacement was 2.27 mm in the TT group and 1.54 mm in the AM group.…”

“…The Tegner score was analyzed as a continuous variable in 6 articles 3,6,21,51,72,76 (24% of all clinical studies), where 417 patients were included in the comparison between the TT and AM techniques (Figure 3B). The overall Tegner score was 6.22 for patients in the TT group and 6.78 for those in the AM group.…”

No Difference in Outcomes Between Suspensory (Fixed-Loop Cortical Button) Versus Expandable Anteromedial Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Autologous Hamstring Tendons: A Prospective, Randomized, Controlled Study in Male Patients

“…Mulcahey et al 28 compared transtibial and anteromedial insertion of AperFix system and found a significant improvement in IKDC scores in the anteromedial cohort but no significant differences in postoperative KT-1000 measurements between transtibial (1.571 AE 0.22 mm) and anteromedial cohort (1.246 AE 0.09 mm). Ozel et al 21 in contrast, reported significantly greater femoral tunnel width and anterior knee translation in the transtibial group (42 patients) in comparison with anteromedial group (38 patients) in a mean follow up period of 40.7 months; Lysholm and Tegner scores were not significantly different between the 2 groups. In this study, femoral tunnel widening was measured by comparing postoperative radiographs with final follow-up radiographs.…”

“…12 Expandable femoral fixation devices [13][14][15][16][17][18][19][20] recently have been introduced to theoretically provide a stronger aperture fixation with (1) circumferential compression of the hamstring's graft at both the femoral and tibial tunnels and (2) a theoretical "double-band ACL equivalent through a single tunnel." 19 In comparison with other fixation techniques for hamstring's autografts, the expandable systems have shown either similar [16][17][18] or superior clinical results 20 and in some cases less tunnel enlargement, 21 especially when they are inserted through the anteromedial portal.…”

A Review on Finite Element Modeling and Simulation of the Anterior Cruciate Ligament Reconstruction

“…Which of the two approaches leads to better clinical outcome is still a topic of debate (Chen et al, 2017). Some researchers reported that the anteromedial technique gives better functional outcomes and knee stability (Mandal et al, 2012;Brown et al, 2013), but on the other hand, there is plenty of support that transtibial technique has similar outcomes (Arno et al, 2016;Ozel et al, 2017). Apart from the different techniques pertaining to the femoral tunnel, there are various approaches regarding the grafts used as substitutes of the original ACL, operative techniques, fixation devices and initial graft tension (or pretension), which will be presented in this study.…”