Background:

Anterior cruciate ligament reconstruction (ACLR) provides functional stability to an injured knee. While multiple techniques can be used to drill the femoral tunnel during ACLR, a single technique has yet to be proven as clinically superior. One marker of postoperative functional stability is subsequent meniscal tears; a lower risk of subsequent meniscal surgery could be expected with improved knee stability.

Purpose:

To determine if there is a meniscal protective effect when using an anteromedial portal (AMP) femoral tunnel drilling technique versus transtibial (TT) drilling.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Data from Kaiser Permanente’s ACLR registry were used to identify patients who had a primary isolated ACLR between 2009 and 2018; those with previous surgery in the index knee and meniscal pathology at the time of ACLR were excluded. The exposure of interest was TT (n = 2711) versus AMP (n = 5172) drilling. Multivariable Cox proportional hazard regression was used to evaluate the risk of a subsequent ipsilateral meniscal reoperation with adjustment for age, sex, femoral fixation, and graft choice. We observed a shift in surgeon practice from the TT to AMP over the study time frame; therefore, the relationship between technique and surgeon experience on meniscal reoperation was evaluated using an interaction term in the model.

Results:

At the 9-year follow-up, the crude cumulative meniscal reoperation probability for AMP procedures was 7.76%, while for TT it was 5.88%. After adjustment for covariates, we observed a higher risk for meniscal reoperation with AMP compared with TT (hazard ratio [HR], 1.53; 95% CI, 1.05-2.23). When stratifying by surgeon experience, this adverse association was observed for patients who had their procedure performed by surgeons with less AMP experience (no previous AMP ACLR: HR, 1.26; 95% CI, 0.84-1.91) while a protective association was observed for patients who had their procedure with more experienced surgeons (40 previous AMP ACLRs: HR, 0.34; 95% CI, 0.13-0.92).

Conclusion:

Drilling the femoral tunnel via the AMP was associated with a higher risk of subsequent meniscal surgery compared with TT drilling. However, when AMP drilling was used by surgeons experienced with the technique, a meniscal protective effect was observed.

中文翻译：

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前交叉韧带重建后前内侧入口与胫骨隧道钻孔和半月板再手术风险之间的关联：一项队列研究

背景：

前交叉韧带重建 (ACLR) 为受伤的膝关节提供功能稳定性。虽然在 ACLR 期间可以使用多种技术来钻股骨隧道，但尚未证明一种技术在临床上具有优越性。术后功能稳定性的一个标志是随后的半月板撕裂；随着膝关节稳定性的提高，可以预期后续半月板手术的风险会降低。

目的：

确定在使用前内侧入路 (AMP) 股骨隧道钻孔技术与小腿 (TT) 钻孔技术时是否存在半月板保护作用。

学习规划：

队列研究；证据等级，2。

方法：

来自 Kaiser Permanente 的 ACLR 登记处的数据被用于识别 2009 年至 2018 年间患有原发性孤立 ACLR 的患者；那些在 ACLR 时曾在指数膝关节和半月板病理学上接受过手术的患者被排除在外。感兴趣的暴露是 TT (n = 2711) 与 AMP (n = 5172) 钻井。多变量 Cox 比例风险回归用于评估随后同侧半月板再次手术的风险，并根据年龄、性别、股骨固定和移植物选择进行调整。我们观察到在研究期间外科医生实践从 TT 到 AMP 的转变；因此，使用模型中的交互项评估技术和外科医生在半月板再手术中的经验之间的关系。

结果：

在 9 年的随访中，AMP 手术的粗累积半月板再手术概率为 7.76%，而 TT 为 5.88%。调整协变量后，我们观察到与 TT 相比，AMP 的半月板再手术风险更高（风险比 [HR]，1.53；95% CI，1.05-2.23）。当根据外科医生的经验进行分层时，对于由 AMP 经验较少的外科医生进行手术的患者（之前没有 AMP ACLR：HR，1.26；95% CI，0.84-1.91）观察到这种不良关联，而对于患者则观察到保护关联他们与更有经验的外科医生一起进行手术（40 个以前的 AMP ACLR：HR，0.34；95% CI，0.13-0.92）。

结论：

与 TT 钻孔相比，通过 AMP 钻股骨隧道与随后进行半月板手术的风险更高有关。然而，当有经验的外科医生使用 AMP 钻孔技术时，观察到半月板保护作用。