Anterior cruciate ligament reconstruction: Can optimal graft placement be achieved with a free-hand drilled transtibial technique?

Abstract

Objective: Anterior cruciate ligament (ACL) injuries are common among athletes and active individuals participating in sports. ACL reconstruction using the single-bundle technique can be performed through transtibial or anteromedial portals. The transtibial technique carries the theoretical risk of vertical placement of the femoral tunnel in the intercondylar notch. The aim of this study is to assess the efficacy of a free-hand drilled-transtibial technique in achieving optimal graft positioning. Materials and Methods: We analyzed a retrospective series of post-operative knee radiographs in 52 consecutive patients who underwent a single-bundle ACL reconstruction by a single surgeon using this transtibial method, from June 2009 to January 2010. Tunnel positioning was radiographically assessed by an independent single observer, who was not involved in the management of patients. The graft inclination angle, the coronal and the sagittal femoral and tibial tunnel placements were evaluated. Results: Post-operative radiographs of 40 patients (40 knees) were retrospectively evaluated for femoral and tibial tunnel positioning. In the coronal plane, the mean graft inclination angle was 21°, the femoral tunnel was positioned at a mean of 43% lateral to the lateral femoral condyle and the tibial tunnel at a mean of 46% lateral to the medial border of the medial tibial plateau. In the sagittal plane, the femoral tunnel was placed at 84% posteriorly across Blumensaat's line and the tibial tunnel at a mean of 43% along the length of the tibial plateau. The results were consistent with optimal tunnel positioning according to anatomic and clinical studies. Conclusion: The transtibial technique described in this series can achieve optimal tunnel positioning for single-bundle ACL reconstruction.