Medial portal technique for single-bundle anatomical Anterior Cruciate Ligament (ACL) reconstruction

Abstract

The aim of the paper is to describe the medial portal technique for anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Placement of an ACL graft within the anatomical femoral and tibial attachment sites is critical to the success and clinical outcome of ACL reconstruction. Non-anatomical ACL graft placement is the most common technical error leading to recurrent instability following ACL reconstruction. ACL reconstruction has commonly been performed using a transtibial tunnel technique in which the ACL femoral tunnel is drilled through a tibial tunnel positioned in the posterior half of the native ACL tibial attachment site. ACL reconstruction performed using a transtibial tunnel technique often results in a vertical ACL graft, which may fail to control the combined motions of anterior tibial translation and internal tibial rotation which occur during the pivot-shift phenomenon. The inability of a vertically oriented ACL graft to control these combined motions may result in the patient experiencing continued symptoms of instability due to the pivot-shift phenomenon. The medial portal technique in which the ACL femoral tunnel is drilled through an anteromedial or accessory anteromedial portal allows consistent anatomical ACL tunnel placement. This paper describes the advantages of the medial portal technique, indications for the technique, patient positioning, proper portal placement, anatomical femoral and tibial tunnel placement, graft tensioning and fixation.

Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study

“…The radiographic assessment by Bernard and Hertel of the ACL position showed that the ligament was relatively high and vertical. We now drill the femoral tunnel through an anteromedial portal to achieve a lower, more horizontal and, hence, more anatomical position of the ACL [19,20]. However, the clinical relevance of this is still the subject of debate; at present, none of these procedures fully restores both kinematics and biomechanics of the knee [21].…”

Arthroscopic anterior cruciate ligament reconstruction with central quadriceps tendon bone (CQTB) graft: An outcome study in fifty Indian patients

“…The femoral tunnel was prepared using the Antero-medial arthroscopy portal technique. 11 As the average graft diameter was 9mm, a 7 or 6 mm femoral tunnel offset guide was used to locate the femoral tunnel through anteromedial portal. Femoral tunnel was drilled at 2 or 10 o' clock position through this anteromedial portal over a guide wire.…”

Current Trends in ACL Reconstruction Surgery in the United Kingdom

“…There were 14 further surgeons who had abandoned the "double bundle" technique citing that they did not believe this to be a "gold standard" approach in eight responses, with four surgeons citing results being no better than single tunnel technique, one surgeon citing the fact that they perform all-inside surgical method, and one surgeon stating that they still use "double bundle" when there is a large footprint to cover, though did not give specific parameters for which they may change operative strategy. Just less than 60% of surgeons who responded use a separate incision/arthroscopy port site (as described by Brown et al [2]) to aid placement of the tunnels (n = 100) with 35% using transtibial drilling method, n = 58. Six respondents use a retrograde reaming technique to position the femoral tunnel (Arthrex FlipCutter).…”