Background: The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint. Furthermore, suspensory fixation of soft tissue grafts has become popularized because of complications associated with cross-pin fixation. Concerns regarding the use of both have recently arisen.
Purpose: To raise awareness of the increased risk of graft failure when using the anteromedial portal technique with suspensory femoral fixation during ACL reconstruction.
Study design: Cohort study; Level of evidence, 3.
Methods: From November 1998 to August 2012, a total of 465 primary ACL reconstructions were performed using quadrupled hamstring autograft tendons, with drilling of the femoral tunnel performed via the transtibial portal. Graft fixation on the femur was achieved with cross-pin fixation, while interference screw fixation was used on the tibia. From September 2012 to October 2013, there were 69 reconstructions performed through an anteromedial portal. While there was no change in graft choice, a change was made to using suspensory femoral fixation. No other surgical or postoperative rehabilitation changes were made.
Results: During the 14-year period in which ACL reconstructions were performed via the transtibial portal and with cross-pin fixation, 2 graft failures (0.4% failure rate) were reported. After switching to the anteromedial portal with suspensory fixation, 7 graft failures (10.1% failure rate) were reported over a 13-month period. These were 5 male and 2 female patients, with a mean age of 18.8 years-all elite athletes. The same surgical technique was used in all patients, and all patients had at least an 8 mm-diameter graft. Patients were cleared to return to sport at an average of 8.4 months postoperatively, after completing functional performance tests. Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition. The final patient sustained a rerupture 10 months after being cleared to play.
Conclusion: Compared with the transtibial technique with cross-pin graft fixation, there is an increased risk of graft failure when performing autologous hamstring ACL reconstructions using the anteromedial portal technique with cortical suspensory fixation.
Keywords: anterior cruciate ligament; anteromedial; cross-pin fixation; graft failure; suspensory fixation; transtibial.
Conflict of interest statement
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
Technical Note: Anterior Cruciate Ligament Reconstruction in the Presence of an Intramedullary Femoral Nail Using Anteromedial DrillingM Lacey et al. World J Orthop 8 (5), 379-384. PMID 28567341.This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.
Anterior Cruciate Ligament Graft Isometry Is Affected by the Orientation of the Femoral TunnelGM Ebersole et al. J Knee Surg 29 (3), 260-6. PMID 26190786.Transtibial and AM portal suspensory fixation and apical fixation demonstrate similar changes in length and tension throughout knee range of motion. The all-epiphyseal tu …
No-tunnel Anterior Cruciate Ligament Reconstruction: The Transtibial All-Inside TechniqueJH Lubowitz. Arthroscopy 22 (8), 900.e1-11. PMID 16904591.The purpose of this technical note is to describe the transtibial all-inside anterior cruciate ligament (ACL) reconstruction technique. This technique combines the advant …
Anteromedial Portal Double-Bundle Anterior Cruciate Ligament Reconstruction Yields Similar Outcomes to Non-AMP Femoral Drilling Double-Bundle Techniques: A Systematic Review of Comparative StudiesT Tejpal et al. Orthop J Sports Med 7 (12), 2325967119888140. PMID 31853457. - ReviewDB AMP ACLR results in significantly improved functional outcome scores postoperatively. AMP techniques yield similar functional outcomes to OI ACLR. No direct comparison …
New Trends in Anterior Cruciate Ligament Reconstruction: A Systematic Review of National Surveys of the Last 5 YearsA Grassi et al. Joints 6 (3), 177-187. PMID 30582107. - ReviewThe purpose of this study was to analyze national surveys of orthopaedic surgeons on anterior cruciate ligament (ACL) reconstruction to determine their preferences relate …
Cited by 1 PubMed Central articles
Femoral-tibial Fixation Affects Risk of Revision and Reoperation After Anterior Cruciate Ligament Reconstruction Using Hamstring AutograftLM Spragg et al. Knee Surg Sports Traumatol Arthrosc 27 (11), 3518-3526. PMID 30824978.ACLR using HS autograft appears to have the lowest risk of aseptic revision when crosspin or interference fixation is used on the femoral side and is coupled with an inte …
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