Gonzalo Samitier

Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up

Drilling of the femoral tunnel with the transtibial (TT) technique is widely used in bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Recent studies suggest higher knee stability with the use of the anteromedial portal (AMP). The purpose of this study was to compare functional and clinical outcomes of BPTB ACL reconstruction using the TT or the AMP technique for drilling the femoral tunnel. All ACL reconstructions between January 2003 and April 2006 were approached for eligibility. Forty-seven patients met inclusion criteria (21 TT group and 26 AMP group). Blinded assessments of IKDC score, knee stability and range of motion, one-leg hop test, mid-quadriceps circumference, VAS for satisfaction with surgery, Lysholm and Tegner scores, and SF-12 questionnaire were obtained for both groups. Data on preoperative and postoperative surgical timing were retrospectively reviewed through the charts. The AMP group demonstrated a significantly lower recovery time from surgery to walking without crutches (p < 0.01), to return to normal life (p < 0.03), to return jogging (p < 0.03), to return training (p < 0.03), and to return to play (p < 0.03). Knee stability values measured with KT-1000, Lachman test, pivot-shift sign, and objective IKDC score assessments were significantly better for the AMP compared to TT group (p < 0.002, p < 0.03, p < 0.02, p < 0.015, respectively). No differences were found for VAS for satisfaction with surgery, Lysholm, Tegner, and SF-12 between both groups. The use of the AMP technique significantly improved the anterior-posterior and rotational knee stability, IKDC scores, and recovery time from surgery compared to the TT technique.

The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction

The transtibial (TT) drilling of the femoral tunnel in the bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction was found to place the tunnel non-anatomically. The use of the anteromedial portal (AMP) for the femoral drilling would provide the surgeon with more freedom to anatomically place the tunnel in the real femoral ACL footprint. The purpose of this study was to compare the clinical outcomes of BPTB ACL reconstruction using the AMP or the TT technique for the femoral tunnel drilling. A Medline search was not able to identify any study directly comparing the clinical outcomes of the AMP and the TT techniques. The literature search identified experimental and quasi-experimental studies published from 1966 to March 2009 where at least one group underwent arthroscopic autologous BPTB ACL reconstructions using either the AMP or the TT technique for the femoral tunnel drilling. Overall IKDC, Lysholm score, activity level, range of motion, single-leg hoop test, Lachman test, Pivot shift sign test, KT-1000 arthrometer measurements, and radiographic assessments were indirectly compared between the two groups (AMP versus TT). Twenty-one studies, involving a total of 859 patients (257 in the AMP and 602 in the TT group), were included in this analysis. The AMP group demonstrated significantly earlier return to run and significantly greater range of motion, Lachman test values, and KT-1000 arthrometer measurements in the 1–2-year follow-up, although no differences were found for both the 3–5 and the 6–10-year follow-ups for any of these parameters. In contrast, the TT group demonstrated significantly higher activity level for the 3–5 and 6–10-year follow-up. The use of the AMP elicited greater knee stability and range of motion values, and earlier return to run compared to the TT technique. These results may indicate a potential benefit of the AMP over the TT technique. However, as the benefits of the AMP were not obtained in the mid and long-term follow-ups, overall there is no definitive evidence at this point to conclude that one technique is superior to the other. Randomized controlled trials directly comparing the use of both techniques with long-term follow-ups will help clarify which one, if any, provides best clinical outcomes.

Meniscal allograft transplantation. Part 1: systematic review of graft biology, graft shrinkage, graft extrusion, graft sizing, and graft fixation

PurposeTo provide a systematic review of the literature regarding five topics in meniscal allograft transplantation: graft biology, shrinkage, extrusion, sizing, and fixation.MethodsA systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies).ResultsSixty-two studies were finally included: 30 biology, 3 graft shrinkage, 11 graft extrusion, 17 graft size, and 6 graft fixation (some studies were categorized in more than one topic). These studies corresponded to 22 animal studies, 22 in vitro human studies, and 23 in vivo human studies (7 level II, 10 level III, and 6 level IV).ConclusionsThe principal conclusions were as follows: (a) Donor cells decrease after MAT and grafts are repopulated with host cells form synovium; (b) graft preservation alters collagen network (deep freezing) and causes cell apoptosis with loss of viable cells (cryopreservation); (c) graft shrinkage occurs mainly in lyophilized and gamma-irradiated grafts (less with cryopreservation); (d) graft extrusion is common but has no clinical/functional implications; (e) overall, MRI is not superior to plain radiograph for graft sizing; (f) graft width size matching is more important than length size matching; (g) height appears to be the most important factor influencing meniscal size; (h) bone fixation better restores contact mechanics than suture fixation, but there are no differences for pullout strength or functional results; and (i) suture fixation has more risk of graft extrusion compared to bone fixation.Level of evidenceSystematic review of level II–IV studies, Level IV.

Reply to: comments on Alentorn-Geli et al.: anteromedial portal (AMP) versus transtibial (TT) drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up.

Dear Editor, We read with great interest the comments on our article entitled “Anteromedial portal (AMP) versus transtibial (TT) drilling techniques in ACL reconstruction: a blinded crosssectional study at twoto five-year follow-up” [1] by Sunil Gurpur Kini. In his first concern, Dr. Kini states that the TT group in our study may have more knee laxity because of a too vertical tibial starting point considering that we drilled at 20° in the coronal plane. Studies referenced by Dr. Kini to support his first concern reported a tibial tunnel orientation of 60–70° in the coronal plane, but these angles were considered from the horizontal line, whereas the 20° in our study was considered from the vertical line [4, 5, 7]. Other authors perform the tibial tunnel with a mean angulation of 60.6°, ranging up to 74.2° [9]. Thus, we can not assume our tibial tunnel significantly differs from the existing literature. Dr. Kini highlighted the excellent cadaveric study by Bedi et al. [3] comparing the AMP and TT drilling. The TT drilling was performed with oblique positioning of the tibial guide at 60° in the coronal plane, reaching a mean femoral angulation of 54.81° ± 7.17°, corresponding approximately to 10:45 in a clock position. The TT group in our study had the femoral tunnel in the 11 (or 13) o’clock position, which we believe is comparable with the interesting study by Bedi et al. Although both TT and AMP drilling may produce a femoral tunnel close to ACL footprints, the tibial starting point to achieve this position in the TT drilling must be more medial and could be too close to the tibial joint line. This may result in a short tibial tunnel and enlarged tibial tunnel aperture, which may in turn compromise the graft fixation and incorporation [6]. In addition, a too medialised tibial tunnel starting point during the TT technique may result in an increased risk of injury to the MCL, and may produce a more lateral and posterior tibial tunnel intraarticular entry point resulting in a less effective reconstruction from a biomechanical point of view [8]. In his other concern, Dr. Kini discusses the risk of a short femoral tunnel and the increased risk of posterior wall blow out with the AMP technique. In our experience with the AMP technique, the posterior wall blow out is extremely rare. Using the Acufex Endoscopic femoral drill guide (Smith and Nephew®), a security distance can be systematically left in the posterior wall of the femoral condyle, thus preventing its rupture. The posterior wall Eduard Alentorn-Geli and Gonzalo Samitier contributed equally to this work. E. Alentorn-Geli : P. Alvarez :R. Cugat Artroscopia Garcia-Cugat, Hospital Quiron, Barcelona, Spain