Clinical evaluation of anatomical reconstruction of the anterior cruciate ligament

Purpose. Evaluate clinical effectiveness of anatomical reconstruction of the anterior cruciate ligament (ACL) and determine the perspectives for practical health care.

Material and methods. The review included 706 patients who underwent arthroscopic reconstruction of the ACL and graft interference screw fixation between 2010 and 2018. ACL reconstruction was performed using either anteromedial portal (n = 396, Group I) or an isometric transtibial tunnel technique (n = 310, Group II). Outcomes were evaluated clinically and radiographically using the 2000 International Knee Documentation Committee (2000 IKDC) Subjective Knee Evaluation Form, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Lysholm scoring scale. Clinical and economic outcome measures included surgical time, rehabilitation and disability periods and period of recovery for sports performance.

Results. The knee anterior drawer test was equally negative and showed no significant differences in the groups. The Lachman test and the pivot shift test showed better results in Group I (p less 0.001). Contractures, atrophic femoral muscles (p less 0.05), synovitis (p less 0.01), vertical position of the femoral graft channels and pathologically extended bone channels with wind-wiper effect (p less 0.001) were more common among patients of Group II. Although knee function returned to normal, as rated with the 2000 IKDC Subjective Knee Evaluation Form, in 91.3 % of cases pathological changes in the knee (C) and severely impaired function (D) were 2.5 and 5 times less common in group I than in Group II (p less 0.05). Pain, symptoms and sport scores were significantly higher on the KOSS scale for Group I (p less 0.05). Surgical time was longer in patients of Group I (p less 0.05) who had shorter rehabilitation period (p less 0.05).

Conclusion. Anatomical reconstruction of ACL using anteromedial portal was shown to be a more reliable technique as compared to transtibial approach to ensure overall knee stability arranging adequate bone channels. The technique is capable to protect the graft from injury, reduce the likelihood of pain, synovitis, contractures, muscle atrophy, providing shorter rehabilitation, disability period and recovery for sport performance.

1. Abebe E.S., Moorman C.T. 3rd, Dziedzic T.S., Spritzer C.E., Cothran R.L., Taylor D.C., Garret W.E. Jr., DeFrate L.E. 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., 2009, vol. 37, no. 10, pp. 1904-1911. DOI:10.1177/0363546509340768

2. Aglietti P., Zaccherotti G., Menchetti P.P., De Biase P. A comparison of clinical and radiological parameters with two arthroscopic techniques for anterior cruciate ligament reconstruction. Knee Surg. Sports Traumatol. Arthrosc., 1995, vol. 3, no. 1, pp. 2-8. DOI:10.1007/BF01553517

3. Bernard M., Hertel P., Hornung H., Cierpinski T. Femoral insertion of the ACL. Radiographic quadrant method. Am. J. Knee Surg., 1997, vol. 10, no. 1, pp. 14-21; discussion 21-22.

4. Bowers A.L., Bedi A., Lipman J.D., Potter H.G., Rodeo S.A., Pearle A.D., Warren R.F., Altchek D.W. Comparison of anterior cruciate ligament tunnel position and graft obliquity with transtibial and anteromedial portal femoral tunnel reaming techniques using high-resolution magnetic resonance imaging. Arthroscopy, 2011, vol. 27, no. 11, pp. 1511-1522. DOI:10.1016/j.arthro.2011.07.007

5. Chambat P. ACL tear. Orthop. Traumatol. Surg. Res., 2013, vol. 99, no. 1 Suppl., pp. S43-S52. DOI:10.1016/j.otsr.2012.11.012.

6. Chen Y., Chua K.H., Singh A., Tan J.H., Chen X., Tan S.H., Tai B.C., Lingaraj K. Outcome of Single-Bundle Hamstring Anterior Cruciate Ligament Reconstruction Using the Anteromedial Versus the Transtibial Technique: A Systematic Review and Metaanalysis. Arthroscopy, 2015, vol. 31, no. 9, pp. 1784-1794. DOI:10.1016/j.arthro.2015.06.001

7. Rayan F., Nanjayan S.K., Quah C., Ramoutar D., Konan S., Haddad F.S. Review of evolution of tunnel position in anterior cruciate ligament reconstruction. World J. Orthop., 2015, vol. 6, no. 2, pp. 252-262. DOI: 10.5312/wjo.v6.i2.252

8. Fineberg M.S., Zarins B., Sherman O.H. Practical considerations in anterior cruciate ligament replacement surgery. Arthroscopy, 2000, vol. 16, no. 7, pp. 715-724. DOI:10.1053/jars.2000.8951

9. Harner C.D., Marks P.H., Fu F.H., Irrgang J.J. Anterior cruciate ligament reconstruction: endoscopic versus two-incision technique. , 1994, vol. 10, no. 5, pp. 502-512. DOI: 10.1016/s0749-8063(05)80004-0

10. Inderhaug E., Larsen A., Strand T., Waaler P.A., Solheim E. The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomic ACL reconstruction. Knee Surg. Sports Traumatol. Arthrosc., 2016, vol. 24, no. 1, pp. 154-160. DOI:10.1007/s00167-014-3355-0

11. Irrgang J.J., Anderson A.F., Boland A.L., Harner C.D., Kurosaka M., Neyret P., Richmond J.C., Shelborne K.D. Development and validation of the international knee documentation committee subjective knee form. Am. J. Sports Med., 2001, vol. 29, no. 5, pp. 600-613. DOI:10.1177/03635465010290051301

12. Kiapour A.M., Murray M.M. Basic science of anterior cruciate ligament injury and repair. Bone Joint Res., 2014, vol. 3, no. 2, pp. 20-31. DOI:10.1302/2046-3758.32.2000241

13. Kim S.J., Jung K.A., Song D.H. Arthroscopic double-bundle anterior cruciate ligament reconstruction using autogenous quadriceps tendon. Arthroscopy, 2006, vol. 22, no. 7, pp. 797.e1-797.e5. DOI:10.1016/j.arthro.2005.09.027

14. Kyung B.S., Kim J.G., Chang M., Jang K.M., Lee S.S., Ahn J.H., Wang J.H. Anatomic double-bundle reconstruction techniques result in graft obliquities that closely mimic the native anterior cruciate ligament anatomy. Am. J. Sports Med., 2013, vol. 41, no. 6, pp. 1302-1309. DOI:10.1177/0363546513484692

15. Robin B.N., Jani S.S., Marvil S.C., Reid J.B., Schillhammer C.K., Lubowitz J.H. Advantages and Disadvantages of Transtibial, Anteromedial Portal, and Outside-In Femoral Tunnel Drilling in Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy, 2015, vol. 31, no. 7, pp. 1412-1417. DOI:10.1016/j.arthro.2015.01.018

16. Roos E.M., Roos H.P., Ekdahl C., Lohmander L.S. Knee injury and Osteoarthritis Outcome Score (KOOS) – validation of a Swedish version. Scand. J. Med. Sci. Sports, 1998, vol. 8, no. 6, pp. 439-448. DOI:10.1111/j.1600-0838.1998.tb00465.x

17. Kilinc B.E., Kara A., Oc Y., Celik H., Camur S., Bilgin E., Erten Y.T., Sahinkaya T., Eren O.T. Transtibial vs anatomical single bundle technique for anterior cruciate ligament reconstruction: A Retrospective Cohort Study. Int. J. Surg., 2016, vol. 29, pp. 62-69. DOI: 10.1016/j.ijsu.2016.03.025.

18. Stäubli H.U., Rauschning W. Tibial attachment area of the anterior cruciate ligament in the extended knee position. Anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo. Knee Surg. Sports Traumatol. Arthrosc., 1994, vol. 2, no. 3, pp. 138-146. DOI:10.1007/BF01467915

19. Tegner Y., Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin. Orthop. Relat. Res., 1985, no. 198, pp. 43-49.

20. Zayats V.V., Dulaev A.K., Dydykin A.V., Ulianchenko I.N., Kolomoitsev A.V., Kovtun A.V. Analiz effektivnosti tekhnologii artroskopicheskoi plastiki perednei krestoobraznoi sviazki kolennogo sustava [Analysis of efficacy of the technologies of arthroscopic plasty of the anterior cruciate ligament of the knee]. Vestnik Khirurgii imeni I.I. Grekova [Grekov's Bulletin of Surgery], 2017, vol. 176, no. 2, pp. 77-82. (in Russian) DOI: 10.24884/0042-4625-2017-176-2-77-82

21. Wang H., Fleischli J.E., Hutchinson I.D., Zheng N.N. Knee moment and shear force are correlated with femoral tunnel orientation after single-bundle anterior cruciate ligament reconstruction. Am. J. Sports Med., 2014, vol. 42, no. 10, pp. 2377-2385. DOI: 10.1177/0363546514541232

22. Youm Y.S., Cho S.D., Lee S.H., Youn C.H. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Am. J. Sports Med., 2014, vol. 42, no. 12, pp. 2941-2947. DOI:10.1177/0363546514551922

23. Zhang L., Jiang B., Sun J., Ma J., Zhang S., Liu X. [A comparative study of arthroscopic anterior cruciate ligament reconstruction via transtibial and transportal techniques]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi, 2019, vol. 33, no. 9, pp. 1077-1082. (in Chinese). DOI: 10.7507/1002-1892.201904124

24. Minguell J., Nuñez J.H., Reverte-Vinaixa M.M., Sallent A., Gargallo-Margarit A., Castellet E. Femoral tunnel position in chronic anterior cruciate ligament rupture reconstruction: randomized controlled trial comparing anatomic, biomechanical and clinical outcomes. Eur. J. Orthop. Surg. Traumatol., 2019, vol. 29, no. 7, pp. 1501-1509. DOI: 10.1007/s00590-019-02455-x

25. Chen H., Tie K., Qi Y., Li B., Chen B., Chen L. Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials. J. Orthop. Surg. Res., 2017, vol. 12, no. 1, pp. 167. DOI: 10.1186/s13018-017-0671-3

26. Zayats V.V. Tekhnologii anatomicheskoi rekonstruktsii perednei krestoobraznoi sviazki kolennogo sustava: vozmozhnosti i preimushchestva [Technologies of anatomic reconstruction of the knee anterior cruciate ligament: chances and benefits]. Uchenye Zapiski Sankt-Peterburgskogo Gosudarstvennogo Meditsinskogo Universiteta imeni akademika I.P. Pavlova [Scientific Notes of the State Pavlov St. Petersburg Medical University], 2018, vol. 25, no. 1, pp. 28-34. (in Russian). DOI: 10.24884/1607-4181-2018-25-1-28-34

27. Golan E.J., Meredith S.J., Nakamura T., Rothrauff B.B., Fu F.H. Anatomic reconstruction of anterior cruciate ligament: concept, indication and its efficacy. AOJ (Annals of Joints), 2019, vol. 4, pp. 9. DOI: 10.21037/aoj.2018.12.11

28. Özer M., Özer H., Selek H., Baltacı G., Harput G., Taşkesen A., Çetinkaya M. Radiological and functional comparison of singlebundle anterior cruciate ligament reconstruction: transtibial versus anteromedial technique. Turk. J. Med. Sci., 2018, vol. 48, no. 3, pp. 455-461. DOI: 10.3906/sag-1702-119

29. MacDonald P., Kim C., McRae S., Leiter J., Khan R., Whelan D. No clinical differences between anteromedial portal and transtibial technique for femoral tunnel positioning in anterior cruciate ligament reconstruction: a prospective randomized, controlled trial. Knee Surg. Sports Traumatol. Arthrosc., 2018, vol. 26, no. 5, pp. 1335-1342. DOI: 10.1007/s00167-017-4664-x

30. Taşdemir Z., Gülabi D., Sağlam F., Tokgöz Özal S., Elmalı N. Does the anteromedial portal provide clinical superiority compared to the transtibial portal in anterior cruciate ligament reconstruction in nonprofessional athletes in short-term follow-up? Acta Orthop. Traumatol. Turc., 2015, vol. 49, no. 5, pp. 483-491. DOI: 10.3944/AOTT.2015.15.0016

31. Zbrojkiewicz D., Vertullo C., Grayson J.E. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000- 2015. Med. J. Aust., 2018, vol. 208, no. 8, pp. 354-358. DOI: 10.5694/mja17.00974

32. So S.Y., Suh D.W., Lee S.S., Jung E.Y., Ye D.H., Ryu D., Kwon K.B., Wang J.H. Revision Anterior Cruciate Ligament Reconstruction After Primary Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Case Series of 40 Patients. Arthroscopy, 2020, vol. 36, no. 2, pp. 546-555. DOI: 10.1016/j.arthro.2019.08.038