Skip to main content
SpringerLink
Log in

No difference in revision rates between anteromedial portal and transtibial drilling of the femoral graft tunnel in primary anterior cruciate ligament reconstruction: early results from the New Zealand ACL Registry

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The use of an accessory anteromedial portal to drill the femoral graft tunnel in primary anterior cruciate ligament (ACL) reconstruction was introduced in the 2000s in an effort to achieve a more anatomic femoral tunnel position. However, some early studies reported an increase in revision ACL reconstruction compared to the traditional transtibial technique. The aim of this study was to analyse recent data recorded by the New Zealand ACL Registry to compare outcomes of ACL reconstruction performed using the anteromedial portal and transtibial techniques.

Methods

Analysis was performed on primary isolated single-bundle ACL reconstructions recorded between 2014 and 2018 by the New Zealand ACL Registry. Patients were categorised into two groups according to whether an anteromedial portal or transtibial technique was used to drill the femoral graft tunnel. The primary outcome was revision ACL reconstruction and was compared between both groups through univariate and multivariate survival analyses. The secondary outcomes that were analysed included subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Marx activity score.

Results

Six thousand one hundred and eighty-eight primary single-bundle ACL reconstructions were performed using either the anteromedial portal or transtibial drilling techniques. The mean time of follow-up was 23.3 (SD ± 14.0) months. Similar patient characteristics such as mean age (29 years, SD ± 11), sex (males = 58% versus 57%) and time to surgery (median 4 months, IQR 5) were observed between both groups. The rate of revision ACL reconstruction was 2.6% in the anteromedial portal group and 2.2% in the transtibial group (n.s.). The adjusted risk of revision ACL reconstruction was 1.07 (95% CI 0.62–1.84, n.s.). Patients in the anteromedial portal group reported improved scores for subscales of the KOOS and higher Marx activity scores at 1-year post-reconstruction.

Conclusion

There was no difference in the risk of revision ACL reconstruction between the two femoral tunnel drilling techniques at short-term follow-up. We observed minor differences in patient-reported outcomes at 1-year follow-up favouring the anteromedial portal technique, which may not be clinically relevant. Surgeons can achieve good clinical outcomes with either drilling technique.

Level of evidence

III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Davarinos N, O’Neill BJ, Curtin W (2014) A brief history of anterior cruciate ligament reconstruction. Adv Orthop Surg 2014:1–6

    Google Scholar 

  2. Ellman MB, Sherman SL, Forsythe B, LaPrade RF, Cole BJ, Bach BR Jr (2015) Return to play following anterior cruciate ligament reconstruction. J Am Acad Orthop Surg 23(5):283–296

    Google Scholar 

  3. Fu FH, Bennett CH, Lattermann C, Ma CB (1999) Current concepts current trends in anterior cruciate ligament reconstruction part 1: biology and biomechanics of reconstruction. Am J Sports Med 27(6):821–830

    CAS  Google Scholar 

  4. McCulloch PC, Lattermann C, Boland AL, Bach BR (2007) An illustrated history of anterior cruciate ligament surgery. J Knee Surg 20(2):95–104

    Google Scholar 

  5. Morris RC, Hulstyn MJ, Fleming BC, Owens BD, Fadale PD (2016) Return to play following anterior cruciate ligament reconstruction. Clin Sports Med 35(4):655–668

    Google Scholar 

  6. Aga C, Kartus JT, Lind M, Lygre SHL, Granan LP, Engebretsen L (2017) Risk of revision was not reduced by a double-bundle ACL reconstruction technique: results from the Scandinavian Registers. Clin Orthop Relat Res 475(10):2503–2512

    Google Scholar 

  7. Andernord D, Björnsson H, Petzold M, Eriksson BI, Forssblad M, Karlsson J et al (2014) Surgical predictors of early revision surgery after anterior cruciate ligament reconstruction: results from the Swedish National Knee Ligament Register on 13,102 patients. Am J Sports Med 42(7):1574–1582

    Google Scholar 

  8. Björnsson H, Andernord D, Desai N, Norrby O, Forssblad M, Petzold M et al (2015) No Difference in revision rates between single- and double-bundle anterior cruciate ligament reconstruction: a comparative study of 16,791 patients from the Swedish national knee ligament register. Arthroscopy 31(4):659–664

    Google Scholar 

  9. Middleton KK, Hamilton T, Irrgang JJ, Karlsson J, Harner CD, Fu FH (2014) Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1. Knee Surg Sports Traumatol Arthrosc 22(7):1467–1482

    CAS  Google Scholar 

  10. Murawski CD, Wolf MR, Araki D, Muller B, Tashman S, Fu FH (2013) Anatomic anterior cruciate ligament reconstruction: current concepts and future perspective. Cartilage 4(3):27–37

    Google Scholar 

  11. Shino K, Suzuki T, Iwahashi T, Mae T, Nakamura N, Nakata K et al (2010) The resident’s ridge as an arthroscopic landmark for anatomical femoral tunnel drilling in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 18(9):1164–1168

    Google Scholar 

  12. Steckel H, Starman JS, Baums MH, Klinger HM, Schultz W, Fu FH (2007) Anatomy of the anterior cruciate ligament double bundle structure: a macroscopic evaluation. Scand J Med Sci Sport 17(4):387–392

    CAS  Google Scholar 

  13. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL-Y (2002) Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 30(5):660–666

    Google Scholar 

  14. Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH (2006) Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc 14(10):982–992

    Google Scholar 

  15. Arnold MP, Kooloos J, Van Kampen A (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 9(4):194–199

    CAS  Google Scholar 

  16. Heming JF, Rand J, Steiner ME (2007) Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 35(10):1708–1715

    Google Scholar 

  17. Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett WE (2008) Reconstruction technique affects femoral tunnel placement in ACL reconstruction. Clin Orthop Relat Res 466(6):1467–1474

    Google Scholar 

  18. Lee DH, Kim HJ, Ahn HS, Il BS (2016) Comparison of femur tunnel aperture location in patients undergoing transtibial and anatomical single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 24(12):3713–3721

    Google Scholar 

  19. Marchant BG, Noyes FR, Barber-Westin SD, Fleckenstein C (2010) Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions. Am J Sports Med 38(10):1987–1996

    Google Scholar 

  20. Mulcahey MK, David TS, Epstein DM, Alaia MJ, Montgomery KD (2014) Transtibial versus anteromedial portal anterior cruciate ligament reconstruction using soft-tissue graft and expandable fixation. Arthroscopy 30(11):1461–1467

    Google Scholar 

  21. Burnham JM, Malempati CS, Carpiaux A, Ireland ML, Johnson DL (2017) Anatomic femoral and tibial tunnel placement during anterior cruciate ligament reconstruction: anteromedial portal all-inside and outside-in techniques. Arthrosc Tech 6(2):e275–e282

    Google Scholar 

  22. Farrow LD, Chen MR, Cooperman DR, Victoroff BN, Goodfellow DB (2007) Morphology of the femoral intercondylar notch. J Bone Jt Surg 89-A 89(10):2150–2155

    Google Scholar 

  23. Abebe ES, Moorman CT, Dziedzic TS, Spritzer CE, Cothran RL, Taylor DC et al (2009) Femoral tunnel placement during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques. Am J Sports Med 37(10):1904–1911

    Google Scholar 

  24. Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T (2009) Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 17(3):220–227

    Google Scholar 

  25. Gavriilidis I, Motsis EK, Pakos EE, Georgoulis AD, Mitsionis G, Xenakis TA (2008) Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study. Knee 15(5):364–367

    Google Scholar 

  26. Kopf S, Forsythe B, Wong AK, Tashman S, Irrgang JJ, Fu FH (2012) Transtibial ACL reconstruction technique fails to position drill tunnels anatomically in vivo 3D CT study. Knee Surg Sports Traumatol Arthrosc 20(11):2200–2207

    Google Scholar 

  27. Kopf S, Pombo MW, Shen W, Irrgang JJ, Fu FH (2011) The ability of 3 different approaches to restore the anatomic anteromedial bundle femoral insertion site during anatomic anterior cruciate ligament reconstruction. Arthroscopy 27(2):200–206

    Google Scholar 

  28. Lee KW, Hwang YS, Chi YJ, Yang DS, Kim HY, Choy WS (2014) Anatomic single bundle anterior cruciate ligament reconstruction by low accessory anteromedial portal technique: an in vivo 3D CT study. Knee Surg Relat Res 26(2):97–105

    Google Scholar 

  29. Tompkins M, Milewski MD, Brockmeier SF, Gaskin CM, Hart JM, Miller MD (2012) Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction. Am J Sports Med 40(6):1313–1321

    Google Scholar 

  30. Alentorn-Geli E, Samitier G, Álvarez P, Steinbacher G, Cugat R (2010) Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up. Int Orthop 34(5):747–754

    Google Scholar 

  31. Bedi A, Musahl V, Steuber V, Kendoff D, Choi D, Allen AA et al (2011) Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy 27(3):380–390

    Google Scholar 

  32. Chen H, Tie K, Qi Y, Li B, Chen B, Chen L (2017) Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials. J Orthop Surg Res 12(1):167

    Google Scholar 

  33. Steiner ME, Battaglia TC, Heming JF, Rand JD, Festa A, Baria M (2009) Independent drilling outperforms conventional transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 37(10):1912–1919

    Google Scholar 

  34. Desai N, Andernord D, Sundemo D, Alentorn-Geli E, Musahl V, Fu F et al (2017) Revision surgery in anterior cruciate ligament reconstruction: a cohort study of 17,682 patients from the Swedish National Knee Ligament Register. Knee Surg Sports Traumatol Arthrosc 25(5):1542–1554

    Google Scholar 

  35. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC (2013) Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the danish knee ligament reconstruction register. Arthroscopy 29(1):98–104

    Google Scholar 

  36. Svantesson E, Sundemo D, Hamrin Senorski E, Alentorn-Geli E, Musahl V, Fu FH et al (2017) Double-bundle anterior cruciate ligament reconstruction is superior to single-bundle reconstruction in terms of revision frequency: a study of 22,460 patients from the Swedish National Knee Ligament Register. Knee Surg Sports Traumatol Arthrosc 25(12):3884–3891

    Google Scholar 

  37. Tejwani SG, Prentice HA, Wyatt RWB, Maletis GB (2018) Femoral tunnel drilling method: risk of reoperation and revision after anterior cruciate ligament reconstruction. Am J Sports Med 46(14):3378–3384

    Google Scholar 

  38. Eysturoy NH, Nielsen TG, Lind MC (2019) Anteromedial portal drilling yielded better survivorship of anterior cruciate ligament reconstructions when comparing recent versus early surgeries with this technique. Arthroscopy 35(1):182–189

    Google Scholar 

  39. New Zealand ACL Registry Annual Report 2017

  40. New Zealand ACL Registry Annual Report 2018

  41. Roos EM, Lohmander LS (2003) The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis The Knee injury and Osteoarthritis Outcome Score (KOOS). Health Qual Life Outcomes 1:64

    Google Scholar 

  42. Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF (2001) Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med 29(2):213–218

    CAS  Google Scholar 

  43. Harner CD, Honkamp NJ, Ranawat AS (2008) Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 24(1):113–115

    Google Scholar 

  44. Tibor L, Chan PH, Funahashi TT, Wyatt R, Maletis GB, Inacio MCS (2016) Surgical technique trends in primary ACL reconstruction from 2007 to 2014. J Bone Jt Surg 98(13):1079–1089

    Google Scholar 

  45. Jaecker V, Zapf T, Naendrup JH, Pfeiffer T, Kanakamedala AC, Wafaisade A et al (2017) High non-anatomic tunnel position rates in ACL reconstruction failure using both transtibial and anteromedial tunnel drilling techniques. Arch Orthop Trauma Surg 137(9):1293–1299

    Google Scholar 

  46. Basdekis G, Abisafi C, Christel P (2008) Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy 24(4):459–464

    Google Scholar 

  47. Robin BN, Jani SS, Marvil SC, Reid JB, Schillhammer CK, Lubowitz JH (2015) Advantages and disadvantages of transtibial, anteromedial portal, and outside-in femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 31(7):1412–1417

    Google Scholar 

  48. Clatworthy M, Sauer S, Roberts T (2019) Transportal central femoral tunnel placement has a significantly higher revision rate than transtibial AM femoral tunnel placement in hamstring ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27(1):124–129

    Google Scholar 

  49. Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Williams A (2015) The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Jt J 98-B(8):1020–1026

    Google Scholar 

  50. Van Eck CF, Gravare-Silbernagel K, Samuelsson K, Musahl V, Van Dijk CN, Karlsson J et al (2013) Evidence to support the interpretation and use of the anatomic anterior cruciate ligament reconstruction checklist. J Bone Jt Surg 95-A 95(20):e153

    Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge Charlotte Smith from the New Zealand ACL Registry for her ongoing support and assistance with data administration. RR would to like to acknowledge the Maurice and Phyllis Paykel Trust for providing student support.

Funding

No funding for this study.

Author information

Authors and Affiliations

  1. University of Auckland, 85 Park Road, Auckland, 1023, New Zealand

    Richard Rahardja, Mark Zhu, Andrew Paul Monk & Simon W. Young

  2. Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand

    Simon W. Young

  3. Department of Orthopaedic Surgery, Auckland Hospital, Auckland, New Zealand

    Mark Zhu & Andrew Paul Monk

  4. Forte Sports, Christchurch, New Zealand

    Hamish Love

  5. Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand

    Mark G. Clatworthy

Authors
  1. Richard Rahardja
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hamish Love
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mark G. Clatworthy
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Andrew Paul Monk
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Simon W. Young
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Richard Rahardja.

Ethics declarations

Conflicts of interest

We, the authors, declare that we have no conflicts of interest with relation to this study. MGC reports that he does consulting for Johnson & Johnson, receives fellowship funding from Johnson & Johnson and Arthrex, and receives royalties from Arthrex, none of which are related to this study.

Ethical approval

Health and Disability Ethics Committee exemption as an audit activity.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix

Appendix

See Table 5

Table 5 Patients with minimum 2-year follow-up—univariate analysis and multivariatea Cox proportional hazards regression
Full size table

.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rahardja, R., Zhu, M., Love, H. et al. No difference in revision rates between anteromedial portal and transtibial drilling of the femoral graft tunnel in primary anterior cruciate ligament reconstruction: early results from the New Zealand ACL Registry. Knee Surg Sports Traumatol Arthrosc 28, 3631–3638 (2020). https://doi.org/10.1007/s00167-020-05959-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-020-05959-w

Keywords

Search

Navigation