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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 2  |  Page : 100-103

Original report: Transtibial and transportal techniques of anterior cruciate ligament reconstruction provide similar functional outcome: A comparative study conducted at an armed forces hospital


1 Department of Orthopaedics CH (WC), Chandimandir, Haryana, India
2 Department of Orthopaedics, Base Hospital, Lucknow, Uttar Pradesh, India

Date of Submission02-Sep-2017
Date of Acceptance27-Jun-2018
Date of Web Publication10-Jan-2019

Correspondence Address:
Lt Col Munish Sood
CH (WC), Chandimandir - 134 107, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_55_17

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  Abstract 

Background: The debate about the best arthroscopic technique for the anterior cruciate ligament (ACL) reconstruction surgery using semitendinosus (ST) quadruple graft is still unresolved. The aim of the present study was to compare the results of arthroscopic ACL reconstruction surgery techniques (transtibial [TT] and anteromedial portal [AMP]) using ST quadruple graft in terms of functional outcome. Materials and Methods: A total of 50 male patients with ACL tear were operated using the arthroscopic technique. The patients were divided into two groups (TT group and AMP group) and studied prospectively. The TT group (n = 24) included the patients in which femoral tunnel was prepared using the tibial tunnel. While the AMP group B (n = 26) included the patients in which femoral tunnel was prepared through the anteromedial arthroscopic portal. All these patients were assessed regularly and at follow-up of 1 year functionally using Lysholm Knee Score. Two groups were matched in terms of age, mode of injury, and side involved. Results: The average age of the patients in Group TT and AMP was 31.2 years (range: 22–43 years) and 30.6 years (range: 21–45 years), respectively. The mean Lysholm score improved significantly (P < 0.001) from 55.19 (range: 38–66) preoperatively to 82.65 (range 69–100) at the final follow-up in Group TT and 53.54 (range: 38–66) preoperatively to 82.04 (range: 59–100) at the final follow-up in group AMP. However, there was no significant difference in the mean Lysholm score while comparing the two groups at the final follow-up. Conclusion: ACL reconstruction surgery using ST quadruple graft with TT and transportal techniques provide similar functional outcome at 1-year follow-up.

Keywords: Anterior cruciate ligament, semitendinosus quadruple graft, transportal, transtibial technique


How to cite this article:
Sud A, Sood M, Vikas R. Original report: Transtibial and transportal techniques of anterior cruciate ligament reconstruction provide similar functional outcome: A comparative study conducted at an armed forces hospital. J Mar Med Soc 2018;20:100-3

How to cite this URL:
Sud A, Sood M, Vikas R. Original report: Transtibial and transportal techniques of anterior cruciate ligament reconstruction provide similar functional outcome: A comparative study conducted at an armed forces hospital. J Mar Med Soc [serial online] 2018 [cited 2019 Mar 24];20:100-3. Available from: http://www.marinemedicalsociety.in/text.asp?2018/20/2/100/249765


  Introduction Top


Anterior cruciate ligament (ACL) reconstruction is the best treatment modality for any patient who has ACL deficient knee associated with the history of instability. The hamstring tendons are the commonly used autograft in ACL reconstruction surgery. The anatomical placement of the tibial and femoral tunnels for the ACL reconstruction is considered as one of the critical factors for the success of the surgery. Furthermore, various studies have demonstrated that non - anatomic ACL graft placement is the most common technique error leading to recurrent instability and failure of surgery following ACL reconstruction.[1],[2]

The transtibial (TT) technique of drilling the femoral tunnel was commonly used in the 1990s for the ACL reconstruction surgery.[3] However, the TT technique was criticized because of vertical placement of the graft, leading to a non - anatomic reconstruct.[4]

In the recent years, the trend has shifted toward the anteromedial arthroscopic portal (AMP) technique of femoral drilling. This technique is considered to have advantages of horizontal and anatomical placement of graft and its nondependence on the tibial tunnel for the placement of femoral tunnel.[4],[5]

In our search of data on the PubMed, we found few studies comparing the TT technique and AMP technique of femoral drilling for ACL reconstruction.[6],[7],[8] Furthermore, there is no study from India and Armed Forces, comparing these two techniques.

In the present study, we have compared the functional outcome after ACL reconstruction with quadruple semitendinosus graft (ST graft) using TT and AMP technique of femoral drilling.


  Materials and Methods Top


This was a prospective, comparative, observational study conducted at a service hospitals between December 2013 and December 2015. The consecutive patients were included in the study, and the group was assigned alternatively. All the patients with ACL injury were assessed clinically and with Lysholm knee scoring preoperatively.[9] A preoperative radiograph of the knee was done to rule out any limb malalignment or preexisting osteoarthritis. A preoperative MRI scan was done to assess associated injuries to other ligaments and menisci. Informed written consent was taken from all the patients for the arthroscopic procedure.

The patients with ACL injury requiring surgical intervention in the form of ACL reconstruction were divided into two groups: TT group (n = 24), in which femoral tunnel was prepared using the tibial tunnel and AMP group (n = 26), in which femoral tunnel was prepared through the anteromedial arthroscopic portal.

All the patients underwent arthroscopic single-bundle ACL reconstruction using the quadrupled ST graft from the ipsilateral knee. The inclusion criteria were serving personnel with isolated ACL tear symptomatic with knee instability, age 20–45 years, and no malalignment of the limb on preoperative radiographs. The exclusion criteria were patients with injuries to the other knee ligaments, patients with significant meniscal injuries requiring meniscectomy or repair, patients with significant chondral damage found arthroscopically, patients requiring both semitendinosis and gracilis due to inadequate length of the semitendinosis graft alone, patients with partial ACL tear who needed ACL augmentation, and patients with preexisting osteoarthritis of the knee.

The sample size was estimated based on the difference in final functional outcome score (International Knee Documentation Committee score) and standard deviation of the previous studies.[10] At a power of 80% and confidence interval (CI) of 95%, the sample size was 20. We have included more patients to increase the power of the study.

Surgical technique

Transtibial technique[3]

Standard arthroscopic portals were made, and routine arthroscopic evaluation of the knee joint was done. The complete tear of ACL was confirmed. A 3-cm vertical incision was made proximal and medial to the insertion of pes anserinus. Insertions of ST and gracilis tendons were identified, and ST graft was harvested using a closed-ended tendon stripper. The free ends of the tendon were sutured together using ethibond number 5 suture. The tendons were looped around an ethibond number 5, thus creating a quadrupled graft. An endobutton (Smith and Nephew, Mumbai, India Ltd.™) was loaded onto the quadrupled graft.

The tibial tunnel was drilled in a routine manner using an ACL tibial guide at the footprint of ACL. The femoral offset was passed through the tibial tunnel and guidewire was passed through this offset and then through the femur with previous ACL site as the entry point. A 4.5 mm cannulated drill bit was used to create a tunnel in the femur. The reaming of the tunnel was done with the femoral reamer depending on the length of the femoral tunnel and the size of the quadrupled ST tendon. The graft was passed through the tibial and femoral tunnel using ethibond number 5. The endobutton was flipped outside the femoral tunnel onto the cortex. The free ends of the graft exiting out of the tibial tunnel were pulled and the knee joint moved through the full range of motion for the cycling. A bioabsorbable interference screw (Smith and Nephew, Mumbai, India Ltd.™) was used for tibial side fixation.

Anteromedial portal technique[11]

An anterolateral and far medial arthroscopic portals were made, and routine arthroscopic evaluation of the knee was done. ST graft was harvested, and the quadruple graft was prepared similar to the Technique 1. The femoral offset was passed through the anteriormedial portal and guidewire was passed through this offset and then through the femur with previous ACL site as the entry point with the knee in hyperflexion. A 4.5 mm cannulated drill bit was used to create a tunnel in the femur. The reaming of the tunnel was done with the femoral reamer depending on the length of the femoral tunnel and the size of the quadrupled ST tendon. The tibial tunnel was drilled in a routine manner using an ACL tibial guide at the footprint of ACL.

The graft was passed through the tibial and femoral tunnel using ethibond number 5. The endobutton (Smith and Nephew, Mumbai, India Ltd.™) was flipped outside the femoral tunnel onto the cortex. The free ends of the graft exiting out of the tibial tunnel were pulled, and the joint moved through the full range of motion for the cycling. With maximal stretch on the free end of the graft, it is fixed using bioabsorbable screws (Smith and Nephew, Mumbai, India Ltd.™).

The technical details of the procedure regarding the method used for the tunnel placement were not shared with the patients.

Rehabilitation

All the patients underwent a uniform rehabilitating program. During the first 7 days, patients underwent the full range of motion at knee joint, static quadriceps exercises, and full weight bearing ambulation with a brace as per pain tolerance. This regimen was continued for up to 6 weeks. At 6 weeks, static cycling was introduced in addition to the existing physiotherapy. At 3 months, light jogging was allowed. At 6 months, patients were advised to undergo endurance exercises. Patients were advised to return to sports or preinjury status after 9 months.

Follow-up

The technical details of the procedure regarding the method used for the tunnel placement were not shared with the patients and the assessor. The functional scoring was done by a resident or another surgeon who were not aware of the femoral tunnel placement technique used in the patients, and the intraoperative notes were not shared with them.

Statistical methods

Both groups were compared demographically using Chi-square test while complications and functional outcome were compared using independent t-test in terms of P value, the degree of freedom (Df), and 95% CI of this difference. P < 0.05 was considered statistically significant.


  Results Top


The study included 24 patients who were operated using TT techniques (Group TT) and 26 patients using the anteromedial portal (Group AMP). All patients were male, serving soldiers. The average age in Group TT was 31.2 years (range 22–43 years) and 30.6 years (range: 21–45 years) in Group AMP, which was comparable in both groups.

The patients were evaluated functionally using Lysholm knee scores [Table 1]. The mean preoperative Lysholm score in Group TT and AMP were 53.54 (range: 38–66) and 55.19 (range: 38–66), respectively, and the two groups were comparable in terms of the mean score (P = 0.87, CI − 22.59–19.29, and Df 48). The mean Lysholm score at 1-year follow-up in Group TT and AMP was 82.04 (59–100) and 82.65 (69–100) which were comparable in terms of the mean score (P = 0.95, CI − 22.65–21.43, and Df 48). However, there was a statistically significant improvement in clinical scores as compared to preoperative scores in both groups. TT (P = <0.001, CI − 32.16–−24.84, and Df 23) and AMP (P < 0.001, CI − 32.08–−22.84, and Df 25).
Table 1: Comparison of Lysholm knee score in transtibial and anteromedial portal group

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There was impingement due to the anterior tunnel placement requiring notchplasty in three patients of AMP group. One patient had damage to the articular surface of the medial condyle in AMP group. One patient of AMP group had a postoperative infection which was managed with antibiotics based on aspirate culture reports. One patient of TT group had reinjury due to a fall during vaulting horse (P = 0.10, CI − 0.03–0.33, and Df 48).


  Discussion Top


The present study was a prospective study to evaluate the functional outcome using two techniques of ACL reconstructions in patients with isolated ACL injury. All of our patients were young male serving military personnel who had the sustained injury during either training or sports activities. Both groups were matched in terms of age, gender, mode of injury, side involved, activity level, the size of graft, and type of fixation.

The overall postoperative Lysholm score of 50 patients (both TT and AMP groups) was 82.35. At the final follow-up of 1-year, the AMP group had a mean Lysholm score of 82.65, whereas in the TT group, it was 82.04. These differences in the functional outcome between the two groups was not significant as analyzed using the independent t-test. This result of our study is similar to the various other studies which also have documented similar results in terms of functional outcome while comparing the two groups.[12],[13],[14],[15] However, on comparing our scores to other studies,[12],[13],[14],[15] we found a lower postoperative Lysholm score [Table 2]. This functional scoring system being subjective, consideration should be given to the fact that many of the personnel may not want to return to vigorous physical activities due to personal reasons.
Table 2: Comparison of the clinical results with other studies

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In the present study, three patients required notchplasty due to the anterior impingement in AMP group. One patient had damage to the articular surface of the medial femoral condyle in AMP group. One patient had a low-grade infection which settled down with antibiotics AMP group. One reconstruction in the TT group failed as the patient returned to all activities and had a reinjury while doing a vaulting horse and needed revision. There was no failure in the AMP group. Overall, there was a revision rate of 2%. The revision was done because of reinjury. Overall in our case series, AMP group has the higher rate of complication as compared to the TT group. This finding of our series can be due to the learning curve as we switched from TT technique to transportal technique at the start of the study.

The limitations of the study are short follow-up because of which we were not able to assess return to the preinjury level and sports activities. Further, we have not assessed our patients in terms of rotatory stability at the time of final follow-up. We believe that long-term studies with larger number of patients may give further insight in this debate.


  Conclusion Top


ACL reconstruction surgery using ST quadruple graft with TT and transportal techniques provide similar functional outcome at midterm follow-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kamath GV, Redfern JC, Greis PE, Burks RT. Revision anterior cruciate ligament reconstruction. Am J Sports Med 2011;39:199-217.  Back to cited text no. 1
    
2.
Marchant BG, Noyes FR, Barber-Westin SD, Fleckenstein C. Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions. Am J Sports Med 2010;38:1987-96.  Back to cited text no. 2
    
3.
Siegel MG, Barber-Westin SD. Arthroscopic-assisted outpatient anterior cruciate ligament reconstruction using the semitendinosus and gracilis tendons. Arthroscopy 1998;14:268-77.  Back to cited text no. 3
    
4.
Yau WP, Fok AW, Yee DK. Tunnel positions in transportal versus transtibial anterior cruciate ligament reconstruction: A case-control magnetic resonance imaging study. Arthroscopy 2013;29:1047-52.  Back to cited text no. 4
    
5.
Clockaerts S, Van Haver A, Verhaegen J, Vuylsteke K, Leenders T, Lagae KC, et al. Transportal femoral drilling creates more horizontal ACL graft orientation compared to transtibial drilling: A 3D CT imaging study. Knee 2016;23:412-9.  Back to cited text no. 5
    
6.
Osaki K, Okazaki K, Matsubara H, Kuwashima U, Murakami K, Iwamoto Y. Asymmetry in femoral tunnel socket length during anterior cruciate ligament reconstruction with transportal, outside-in, and modified transtibial techniques. Arthroscopy 2015;31:2365-70.  Back to cited text no. 6
    
7.
Liu A, Sun M, Ma C, Chen Y, Xue X, Guo P, et al. Clinical outcomes of transtibial versus anteromedial drilling techniques to prepare the femoral tunnel during anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017;25:2751-9.  Back to cited text no. 7
    
8.
de Abreu-e-Silva GM, Baumfeld DS, Bueno EL, Pfeilsticker RM, de Andrade MA, Nunes TA, et al. Clinical and three-dimensional computed tomographic comparison between ACL transportal versus ACL transtibial single-bundle reconstructions with hamstrings. Knee 2014;21:1203-9.  Back to cited text no. 8
    
9.
Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:150-4.  Back to cited text no. 9
    
10.
Mirzatolooei F. Comparison of short term clinical outcomes between transtibial and transportal transFix® femoral fixation in hamstring ACL reconstruction. Acta Orthop Traumatol Turc 2012;46:361-6.  Back to cited text no. 10
    
11.
Wagner M, Kääb MJ, Schallock J, Haas NP, Weiler A. Hamstring tendon versus patellar tendon anterior cruciate ligament reconstruction using biodegradable interference fit fixation: A prospective matched-group analysis. Am J Sports Med 2005;33:1327-36.  Back to cited text no. 11
    
12.
Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: A cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194-9.  Back to cited text no. 12
    
13.
Guler O, Mahırogulları M, Mutlu S, Cercı MH, Seker A, Cakmak S. Graft position in arthroscopic anterior cruciate ligament reconstruction: Anteromedial versus transtibial technique. Arch Orthop Trauma Surg 2016;136:1571-80.  Back to cited text no. 13
    
14.
Chen Y, Chua KH, Singh A, Tan JH, Chen X, Tan SH, et al. Outcome of single-bundle hamstring anterior cruciate ligament reconstruction using the anteromedial versus the transtibial technique: A systematic review and meta-analysis. Arthroscopy 2015;31:1784-94.  Back to cited text no. 14
    
15.
Charlton WP, Randolph DA Jr., Lemos S, Shields CL Jr. Clinical outcome of anterior cruciate ligament reconstruction with quadrupled hamstring tendon graft and bioabsorbable interference screw fixation. Am J Sports Med 2003;31:518-21.  Back to cited text no. 15
    
16.
Williams RJ 3rd, Hyman J, Petrigliano F, Rozental T, Wickiewicz TL. Anterior cruciate ligament reconstruction with a four-strand hamstring tendon autograft. J Bone Joint Surg Am 2004;86-A: 225-32.  Back to cited text no. 16
    
17.
Taylor DC, DeBerardino TM, Nelson BJ, Duffey M, Tenuta J, Stoneman PD, et al. Patellar tendon versus hamstring tendon autografts for anterior cruciate ligament reconstruction: A randomized controlled trial using similar femoral and tibial fixation methods. Am J Sports Med 2009;37:1946-57.  Back to cited text no. 17
    
18.
Ubale T, Assudani A, Sangnod PA, Gupta A, Pilankar S, Kale S. Comparative evaluation of functional outcome of transtibial and transportal femoral tunneling techniques of arthroscopic ACL reconstruction. Int J Contemp Med Res 2016;3:2605-7.  Back to cited text no. 18
    



 
 
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