Accessory Anteromedial Portal Research Articles

Deep Deltoid Ligament Reconstruction Utilizing Suture Augmentation via an Arthroscopically- Assisted Approach: A Novel Technique and Case Series

Category: Trauma; Arthroscopy Introduction/Purpose: Deltoid ligament rupture is a common occurrence in the setting of acute ankle fractures. The indications for surgical restoration of the deltoid ligament complex vary considerably throughout the literature. If medial ankle instability exists after ankle fracture fixation, repair or reconstruction of the deltoid ligament complex may be performed, which is traditionally done via an open approach. While the superficial deltoid is easily accessed with an open approach, the deep deltoid ligament is extremely difficult to visualize. We present a novel technique for reconstruction of the deep deltoid ligament complex utilizing suture augmentation via an arthroscopically-assisted approach and present our outcomes. With this method, the deep deltoid ligament disruption is easily visualized and reconstructed in a minimally invasive manner through an accessory anteromedial arthroscopy portal. Methods: This is a technique guide and retrospective case series. Data was obtained via chart review including pre-operative, intraoperative, and post-operative follow ups. Variables such as age, weight, body mass index (BMI), sex, side, history of previous ankle surgery, preoperative ambulatory status, length of hospital stay, as well as disposition were documented. Radiographs were reviewed for evidence of restoration of the medial clear space as well as hardware position and bony union. In addition, a technique guide was developed using expert surgeon experience and opinion while using this novel technique. Results: 7 patients who underwent this novel technique were reviewed with an average follow up time of six months (3-8 months). All patients suffered bimalleolar or trimalleolar equivalent fractures. Patients were indicated for deep deltoid ligament reconstruction if medial ankle instability existed intraoperatively with valgus stress testing under fluoroscopy. Medial clear space decreased from a mean 11mm preoperatively to 3.3mm postoperatively. 6 patients returned to ambulation without brace by three months postoperatively. One patient demonstrated increased medial clear space measured at 6.6mm postoperatively and residual pain on follow up, but was treated conservatively and able to progress to weight bearing as tolerated by 6 months. One patient developed a keloid scar that required a steroid injection. No postoperative infections occurred. Conclusion: Deep deltoid ligament reconstruction utilizing suture augmentation via an arthroscopically-assisted approach should be considered in patients who have residual medial ankle instability after ankle fracture fixation. This novel technique allows visualization of the deep deltoid ligament complex and reconstruction in a minimally invasive manner via an accessory anteromedial arthroscopy portal. Our short term outcomes demonstrate success in restoring ankle function and radiographic parameters of the medial clear space. Further studies are needed to evaluate long term postoperative functional outcomes, stability, and development of post-traumatic arthritis.

The "N+10 Rule" to Avoid Graft-Tunnel Mismatch in Bone-Patellar Tendon-Bone ACL Reconstruction Using Independent Femoral Tunnel Drilling.

Graft-tunnel mismatch (GTM) is a common problem in anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-patellar tendon-bone (BPTB) grafts. Application of the "N+10 rule" in endoscopic ACLR with BPTB grafts will result in acceptable tibial tunnel length (TTL), minimizing GTM. Controlled laboratory study. Endoscopic BPTB ACLR was conducted on the paired knees of 10 cadaveric specimens using 2 independent femoral tunnel drilling techniques-accessory anteromedial portal and flexible reamer. The graft bone blocks were trimmed to 10 × 20 mm, and the intertendinous distance (represented by "N") between the bone blocks was measured. The N+10 rule was used to set the angle of the ACL tibial tunnel guide to the appropriate number of degrees for drilling. The amount of excursion or recession of the tibial bone plug in relation to the anterior tibial cortical aperture was measured in both flexion and extension. A GTM threshold of ±7.5 mm was set based on prior studies. The mean BPTB ACL intertendinous distance was 47.5 ± 5.5 mm. The mean measured intra-articular distance was 27.2 ± 3 mm. Using the N+10 rule, the mean total (flexion plus extension) GTM was 4.3 ± 3.2 mm (GTM in flexion, 4.9 ± 3.6 mm; GTM in extension, 3.8 ± 3.5 mm). In 18 of 20 (90%) cadaveric knees, the mean total GTM fell within the ±7.5-mm threshold. When comparing the actual measured TTL to the calculated TTL, there was a mean difference of 5.4 ± 3.9 mm. When comparing femoral tunnel drilling techniques, the total GTM for the accessory anteromedial portal technique was 2.1 ± 3.7 mm, while the total GTM for the flexible reamer technique was 3.6 ± 5.4 mm (P = .5). The N+10 rule resulted in an acceptable mean GTM in both flexion and extension. The mean difference between the measured versus calculated TTL using the N+10 rule was also acceptable. The N+10 rule is a simple and effective intraoperative strategy for achieving desired TTL regardless of patient-specific factors to avoid excessive GTM in endoscopic BPTB ACLR using independent femoral tunnel drilling.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Lateral Extra-Articular Tenodesis Staple Risks Penetration of Anterior Cruciate Ligament Reconstruction Tunnel

To identify the risk of anterior cruciate ligament (ACL) femoral tunnel penetration with the use of a staple for lateral extra-articular tenodesis (LET) graft fixation and to determine whether this varied between 2 different techniques for ACL femoral tunnel drilling. Twenty paired, fresh-frozen, cadaver knees underwent ACL reconstruction with a LET. Left and right knees were randomized to ACL reconstruction with femoral tunnel creation by use of either a rigid guide pin and reamer through the accessory anteromedial portal or by the use of a flexible guide pin and reamer through the anteromedial portal. Immediately after tunnel creation, the LET was performed and fixated with a small Richard's staple. Fluoroscopy was used to obtain a lateral view of the knee to determine staple position, and visualization of the ACL femoral tunnel was performed with the arthroscope to investigate penetration of the staple into the femoral tunnel. The Fisher exact test was conducted to determine whether there was any difference in tunnel penetration between tunnel creation techniques. The staple was noted to penetrate the ACL femoral tunnel in 8 of 20 (40%) extremities. When stratified by tunnel creation technique, the Richards staple violated 5 of 10 (50%) of the tunnels made via the rigid reaming technique compared with 3 of 10 (30%) of those created with a flexible guide pin and reamer (P= .65). A high incidence of femoral tunnel violation is seen with lateral extra-articular tenodesis staple fixation. Level IV, controlled laboratory study. The risk of penetrating the ACL femoral tunnel with a staple for LET graft fixation is not well understood. Yet, the integrity of the femoral tunnel is important for the success of ACL reconstruction. Surgeons can use the information in this study to consider adjustments to operative technique, sequence, or fixation devices used when performing ACL reconstruction with concomitant LET to avoid the potential for disruption of ACL graft fixation.

Acute Deep Deltoid Ligament Reconstruction using a Novel, Arthroscopically-Assisted Technique: Case Report

Category: Arthroscopy; Ankle; Sports; Trauma Introduction/Purpose: The deltoid ligament complex is the main stabilizing structure of the ankle mortise and is often disrupted in rotational ankle injuries. Current treatment involves open techniques for the acute repair of the superficial deltoid layer, however, repair or reconstruction of the deep deltoid ligament (DDL) has proven to be challenging using open techniques. Our described arthroscopically-assisted technique allows for better intra-articular visualization and durable reconstruction of the ruptured DDL with suture and knotless bone anchors. The goal of this new, minimally invasive approach is to facilitate a faster and more reliable recovery and prevent long-term dysfunction and degeneration from medial and rotational ankle instability. We believe it has the potential to provide improved immediate ankle stability and decrease overall surgical morbidity compared to open treatments. Methods: Case of a 48-year-old male with ligamentous-equivalent Massioneuve fracture with medial clear space (MCS) measuring 11 millimeters. Arthroscopy revealed unstable syndesmosis and rupture of the DDL. After syndesmotic fixation, there was persistent MCS widening on stress exam. Arthroscopically-assisted DDL reconstruction was performed using an accessory anteromedial (AAM) portal between the tibialis anterior tendon and posterior tibial tendon. Needle localization identified the sagittal midpoint of the medial wall of the talus, inferior to articular cartilage. Anchor sites at both the medial talar wall and midportion of the distal medial malleolus (insertion and origin of the DDL, respectively) were then drilled via the AAM portal under arthroscopic and fluoroscopic guidance respectively at the isometric point. A suture anchor was placed into the talus and tails were loaded and secured to the medial malleolus with a bioabsorbable anchor. Ankle mortise was stable to stress exam and there were no restraints to physiologic motion. Results: The patient was kept non-weight bearing on his right lower extremity for a total of 6 weeks postoperatively and was seen in the clinic for routine follow-up visits at 2 weeks, 6 weeks, and 3 months post-procedure. Sutures were removed at 2 weeks, without any wound complications, and he was transitioned from splint to a short leg cast. He required only three days of oral narcotic analgesia. Weight-bearing in a controlled ankle motion (CAM) boot and physical therapy were both initiated at 6 weeks post-op. Radiographs at each follow-up visit were without abnormalities. At 3 months post-op, he was graduated from the CAM boot into a lace-up ankle brace, without any complaints of ankle pain or instability. The patient progressed well with full weight-bearing and physical therapy and was seen for a final visit at 5 months post-op with stable MCS. No complications were encountered. Conclusion: Acute DDL rupture is a common occurrence in ankle fractures and can be diagnosed radiographically and by arthroscopy. Known sequelae of untreated DDL disruption include medial instability and late valgus collapse. This case report demonstrates a novel, minimally invasive technique to successfully reconstruct the DDL, which may minimize the surgical morbidity compared to open dissection methods and allow for decreased recovery time postoperatively. This approach may also be utilized for cases of chronic instability. Future work includes larger case series with long-term follow-up and refinement of the technique as instrumentation advances.

Five-Stranded Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

Background: Hamstring tendon (HT) autograft for anterior cruciate ligament (ACL) reconstruction has shown equivalent graft failure rates to bone-patellar-tendon-bone (BTB) with decreased prevalence of anterior knee pain. It should be noted that young athletes, particularly females athletes, may have increased graft failure rates with HT versus BTB. Additionally, HT graft diameters <8 mm have shown worse patient-reported outcomes and higher graft failure rates. Five-strand HT autograft offers a method to increase graft size without utilization of allograft tissue or synthetic material. Indications: This presentation describes the technique for 5-strand HT autograft reconstruction of the ACL. Tips and tricks on graft prep, tunnel placement, tunnel depth, and avoiding pitfalls in surgery are provided. Technique Description: Gracilis and semitendinosus tendon harvest is performed through an L-shaped flap of sartorial fascia. If the 4-strand configuration is <8 mm, the semitendinosus is tripled for a 5-strand configuration. Graft is attached to a 15-mm fixed-length button construct for femoral fixation. The tibial tunnel is typically drilled with the guide through the accessory anteromedial portal. Independent femoral tunnel drilling is then performed via the accessory anteromedial tunnel with the knee in hyperflexion, using an offset guide to aid in tunnel placement. Femoral tunnel is initially reamed to depth of 25 mm and then drilled through the far cortex with a 4.5-mm drill to allow for suspensory fixation. Total length to the lateral cortex is measured and reaming of the tunnel is performed to achieve a 5- to 7-mm difference between total tunnel length to the lateral cortex and reamed tunnel length, assuring room for the button to flip on the femoral cortex. Tibial fixation is achieved by interference fixation versus tying the free suture limbs over a post with a washer. Results: Recent studies show the HT autograft to have similar re-rupture rates for ACL reconstruction compared with other autograft options. Additionally, this option has low donor-site morbidity and has demonstrated significant less anterior knee pain and kneeling pain postoperatively. Discussion/Conclusion: ACL reconstruction with 5-strand HT autograft has shown to be an effective method to increase the graft diameter with low rates of donor-site morbidity.

Poster 255: Lateral Extra-Articular Tenodesis Staple Risks Penetration of ACL Reconstruction Tunnel

Objectives:The purpose of this study was to identify the risk of ACL femoral tunnel penetration by a small Richards staple used for Lateral Extra-Articular Tenodesis (LET) fixation and to determine whether or not the risk varies between two techniques for ACL femoral tunnel creation.Methods:20 paired fresh frozen cadaver knees underwent ACL reconstruction with a LET using the modified Lemaire technique (Getgood et al. AJSM, Jan 2020). Left and right knees were randomized to ACL reconstruction with femoral tunnel creation by either the accessory anteromedial portal (AMP) technique or the flexible guide pin and reamer method. The femoral tunnels in the accessory AMP technique arm were created using a 7mm offset guide. Both arms used a 10mm reamer and were reamed to a depth of 25mm. After tunnel creation and prior to passing the ACL graft, the LET was performed. This was completed by harvesting an 8cm long and 10mm wide central portion of the IT band which was left attached to its distal insertion on Gerdy’s tubercle. This was routed underneath the LCL and fixed with a small Richards staple on the lateral metaphyseal flare proximal and posterior to the LCL insertion. The staple was angled anteriorly and distally. Fluoroscopy was used to obtain a lateral view of the knee to ensure appropriate position of the staple (Figure 1). Finally, tunneloscopy was performed from the anteromedial portal to investigate penetration of the staple into the femoral tunnel (Figure 2). A Fisher’s exact test was conducted to determine if there was any difference in tunnel penetration between tunnel creation techniques.Results:The staple was noted to penetrate the ACL femoral tunnel in 8/20 (40%) extremities. When stratified by tunnel creation technique, the Richards staple violated 5/10 (50%) of the tunnels made via the accessory AMP technique compared to 3/10 (30%) of those created with a flexible guide pin and reamer (p = 0.65).Conclusions:Staple fixation of a LET carries significant risk of penetrating the ACL tunnel that does not vary by the technique of femoral tunnel creation. This raises concerns over the potential effect of the staple on ACL graft fixation and the ACL graft itself.

Poster 256: The "N+10 Rule" to Avoid Graft Tunnel Mismatch in Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Using Independent Femoral Tunnel Drilling

Objectives: To determine the amount of tibial graft tunnel mismatch during application of the “N+10” rule in arthroscopic assisted anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) graft using independent femoral tunnel drilling.To compare actual (measured) tibial tunnel length and desired (calculated) tibial tunnel length when using the “N+10” rule for independent femoral tunnel drilling. Methods:Twenty paired knees from 10 fresh frozen cadaveric specimens (5 female and 5 male specimens) underwent arthroscopic assisted bone-patellar tendon-bone ACL reconstruction using independent femoral tunnel drilling with either a hyperflexion accessory anteromedial portal (n=10) or flexible reamer technique (n=10). The prepared patellar tendon graft bone blocks were trimmed to 10 x 20mm for all specimens and the intertendinous distance (N) between the bone blocks was measured. The “N+10 Rule” was used to set the angle of the ACL tibial tunnel guide to the appropriate degree setting for drilling. The amount of excursion or recession of the tibial bone plug in relation to the anterior tibial cortical aperture was measured in both flexion and extension. A +/-6mm threshold was used to assess this strategy based on prior biomechanical aperture fixation studies. As a secondary outcome, the intraarticular distance (IAD) and the actual tibial tunnel length (TTL) were measured and compared to the planned TTL based on the equation: IAD + TTL = N + 20 (size of bone plug in millimeters)Results:The average BTB ACL intertendinous distance (N) was 47.5mm (SD =5.5mm). The average measured IAD was 27.2mm (SD=3.0mm). Using the “N+10 Rule”, the average mismatch of the tibial tunnel was 4.9mm (SD=3.6mm) and 3.8mm (SD=3.5mm) in flexion and extension, respectively. Both values fall within the +/- 6mm threshold. When comparing the actual measured tibial tunnel length (TTL) to the desired TTL, there was an average difference of 5.4mm (SD=3.9mm)Conclusions:The “N+10” rule resulted in an acceptable average mismatch in both flexion and extension using the threshold of +/- 6mm for 20 cadaveric knees. Measured actual TTL compared to the desired calculated TTL were acceptable 61% of the time using the same threshold. The “N+10” is a simple and effective intraoperative strategy for achieving desired tibial tunnel length to avoid excessive graft tunnel mismatch.Figure 1:Derived formula for calculating ideal tibial tunnel length (TTL) using intraarticular distance (IAD), and the known values of the intertendinous distance (N) and lengths of the bone blocks (20mm).Figure 2:Intraoperative photo of BTB ACL graft measuring intertendinous distance between the bone plugs (N=55mm). Following the "N+10" ruleFigure 3:Intraoperative photo of tibial ACL guide measurement of tibial tunnel length at 50mm with guide set to 65 degrees.Figure 4:Intraoperative photo of the ACL tibial tunnel guide positioned on the anatomic tibial footprint set to 65 degrees (N=55mm). Using this setting for the guide, the tibial tunnel measured 50mm as seen in the zoomed in photo, as per the formula.

Flexible Versus Rigid Reaming Systems for Independent Femoral Tunnel Reaming During ACL Reconstruction: Minimum 2-Year Clinical Outcomes.

Background:Radiographic and cadaveric studies have suggested that anatomic anterior cruciate ligament reconstruction (ACLR) femoral tunnel drilling with the use of a flexible reaming system through an anteromedial portal (AM-FR) may result in a different graft and femoral tunnel position compared with using a rigid reamer through an accessory anteromedial portal with hyperflexion (AAM-RR). No prior studies have directly compared clinical outcomes between the use of these 2 techniques for femoral tunnel creation during ACLR.Purpose:To compare revision rates at a minimum of 2 years postoperatively for patients who underwent ACLR with AM-FR versus AAM-RR. The secondary objectives were to compare functional testing and patient-reported outcomes between the cohorts.Study Design:Cohort study; Level of evidence, 3.Methods:Included were consecutive patients at a single academic institution between 2013 and 2018 who underwent primary ACLR without additional ligamentous reconstruction. Patients were separated into 2 groups based on the type of anatomic femoral tunnel drilling: AM-FR or AAM-RR. Graft failure, determined by revision ACLR, was assessed with a minimum 2 years of postoperative follow-up. The authors also compared patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) and functional performance testing performed at 6 months postoperatively.Results:A total of 284 (AAM-RR, 232; AM-FR, 52) patients were included. The mean follow-up time was 3.7 ± 1.5 years, with a minimum 2-year follow-up rate of 90%. There was no significant difference in the rate of revision ACLR between the AAM-RR and AM-FR groups (10.8% vs 9.6%, respectively; P = .806). At 6 months postoperatively, there were no significant between-group differences in peak knee extension strength, peak knee flexion strength, limb symmetry indices, or hop testing, as well as no significant differences in IKDC (AAM-RR, 81.1; AM-FR, 78.9; P = .269) or KOOS (AAM-RR, 89.0; AM-FR, 86.7; P = .104).Conclusion:In this limited study, independent femoral tunnel drilling for ACLR using rigid or flexible reaming systems resulted in comparable rates of revision ACLR at a minimum of 2 years postoperatively, with no significant differences in strength assessments or patient-reported outcomes at 6 months postoperatively.

MRI and functional assessment of triportal technique in arthroscopic anatomical single-bundle anterior cruciate ligament reconstruction

BACKGROUND: Arthroscopic anterior cruciate ligament (ACL) reconstruction surgery is routinely performed using two standard portals; however imprecise portal placement leads to the most common surgical error that is associated with the imprecise placement, which is the non anatomical positioning anatomical positioning of the femoral tunnel because of improper visualization of the posterior aspect of the medial surface of lateral femoral condyle, due to inadequate visualization of the attachment area over the femur using the standard two portals. To decrease the incidence of this error, various other portals have been descried to improve the visualization. We propose the routine use of an accessory medial portal, in addition to the standard anterolateral and anteromedial portals, to enhance the visualization of the lateral wall and to improve the anatomic accuracy. The arthroscope can also be moved interchangeably throughout the portals during the procedure for improved viewing during specific steps. The routine use of this portal was assessed both clinically and radiologically in our study at the end of 1 year by functional scoring and magnetic resonance imaging (MRI) scan, wherein the accuracy of the femoral attachment and healing of the graft were checked. OBJECTIVES: To assess the functional and radiological results of the routine use of triportal technique in anatomical ACL reconstruction. MATERIALS AND METHODS: We conducted a prospective study on 20 patients who were assessed preoperatively and postoperatively at the end of 12 months using the International Knee Documentation Committee and Lysholm score, and the stability was checked with Lachman and pivot shift test. An MRI of the postoperative knee was performed after 12 months to assess the position of the graft, graft integrity, and healing. RESULTS: All the patients at the end of the study had an exceptional functional and clinical outcome,which was correlated on MRI showing a near-accurate placement of the femoral tunnel with acceptable inclination. All our patients showed excellent anteroposterior and rotational stability when assessed by IKDC and Lysholm score at the end of 1-year follow-up. CONCLUSION: This study shows that the routine use of the accessory anteromedial portal gives a good functional outcome with the near-accurate placement of femoral tunnel, which corresponds to the MRI findings obtained in our study.

Use of an Accessory Anteromedial Portal to Facilitate Repair of Mid-Body Radial Tears of the Lateral Meniscus in Children and Adolescents

Meniscal tears in adolescent patients are commonly treated with repair to preserve meniscal tissue and prevent future degenerative changes. Historically, meniscal tears best suited for repair are acute vertical tears in patients aged <40 years with a normal mechanical axis, >1 cm and <4 cm in size, within the red–red zone, and concurrent with anterior cruciate ligament reconstruction. However, with continued advancements in technology and the development of new techniques, the possibilities and indications for meniscal repair have broadened. This paper presents the use of an accessory medial portal to facilitate the repair of radial tears of the mid-body of the lateral meniscus. Previous techniques described include all-inside, outside-in, and inside-out repairs, but these techniques can be challenging to achieve optimal simultaneous meniscus reduction, visualization, and suture trajectory. In this Technical Note, we describe the use of an inside-out technique, with emphasis on an accessory anteromedial portal to improve visualization and suture trajectory.

Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Background:Recent studies have suggested that femoral tunnel drilling during anterior cruciate ligament (ACL) reconstruction (ACLR) with the use of a flexible reaming system through a standard anteromedial portal (AM-FR) may result in a different tunnel geometry compared with a rigid reamer through an accessory anteromedial portal with hyperflexion (AM-RR).Purpose:To summarize radiologic, anatomic, and clinical outcomes from available studies that directly compared the use of AM-FR versus AM-RR for independent femoral tunnel creation during ACLR.Study Design:Systematic review; Level of evidence, 4.Methods:A literature search was performed using the MEDLINE (PubMed) and Web of Science databases to identify all studies that directly compared radiologic, anatomic, and clinical outcomes between the use of AM-FR and AM-RR. The literature search, data recording, and methodological quality assessment was performed by 2 independent reviewers. The outcomes analyzed included resultant ACL graft positioning and graft bending angle; femoral tunnel positioning, aperture morphology, length, and widening; posterior wall breakage; and distance from various posterolateral knee structures.Results:A total of 13 studies met the eligibility criteria for inclusion. There was no difference in femoral tunnel aperture location between techniques. There were conflicting findings among studies regarding which technique resulted in a more acute graft bending angle. One study reported greater femoral tunnel widening upon follow-up with the use of AM-FR. AM-FR produced longer and more anteverted femoral tunnels than did AM-RR. The difference in tunnel length was significant and more prominent in lesser degrees of knee flexion. With AM-FR, femoral tunnels were farther from the lateral collateral ligament and peroneal nerve, and 1 of 5 studies had fewer reports of posterior wall breakage. There has been no literature comparing the clinical or functional outcomes of these techniques.Conclusion:Although no clinical studies exist comparing AM-FR and AM-RR for femoral tunnel creation during ACLR, both systems allow for reproducible positioning of an anatomic femoral tunnel aperture. The use of AM-FR results in longer and more anteverted femoral tunnels than using AM-RR, with exit points on the lateral femur that are different but safe. Surgeons should be aware of the technical differences with each method; however, further study is needed to identify any clinically important difference that results.

Usage of Accessory Anteromedial Portal for Anatomical Placement of Femoral Tunnel in Transportal Anterior Cruciate Ligament Reconstruction: A Prospective Study.

Background and objectiveThe anterior cruciate ligament (ACL) has an essential role in preserving the function and stability of the knee joint. It acts primarily to prevent anterior tibial translation. Arthroscopic ACL reconstruction using quadrupled hamstring graft is the widely practiced modality for treating ACL injuries nowadays. The objective of this study was to assess the functional outcomes of ACL reconstruction using the transportal approach for a femoral tunnel through an accessory anteromedial portal (AAM).Materials and methodsThis prospective study included 35 patients who met the inclusion criteria. All patients underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft via transportal technique for femoral canal reaming through AAM. Patients were assessed for the functional outcome for a year using the Tegner-Lysholm knee scoring system.ResultsThe analysis of the studied cases revealed that the mean age of the patients was around 27 years. Males were affected more than females. The left side (77.14%) was affected more than the right side (22.86%); 54.28% of patients had a history of road traffic accidents (RTAs). Preoperatively, 19 (54.28%) patients had poor and 16 (45.72%) patients had fair Tegner-Lysholm scores. After one year of follow-up, 29 (82.85%) of the patients had an excellent score as per the Tegner-Lysholm scoring system. Three patients had knee pain and thigh muscle wasting (2-3 cm), and two of them also had a sense of giving away during follow-up.ConclusionAnatomical reattachment of tendon graft for ACL reconstruction at femoral and tibial footprints is indispensable for good functional outcome and knee kinematics, and the usage of the AAM provides good visualization of femoral footprint and ease to surgeons during ACL reconstruction for making a near-accurate femoral tunnel and thereby achieving better outcomes.

Modified transtibial versus anteromedial portal techniques for anterior cruciate ligament reconstruction, a comparative study.

PurposeThis study compared the accessory anteromedial portal (AAMP) and the modified transtibial technique (MTTT)” for single-bundle anterior cruciate ligament (ACL) reconstruction.Patients and methodsSixty active adult patients with ACL tear were randomly assigned into two equal groups who were treated surgically. One group was operated on using AAMP and the other group through MTTT. Both the groups had the same postoperative course and were followed for 1 year after surgery. The follow-up included Lysholm and International Knee Documentation Committee (IKDC) subjective knee evaluation forms, IKDC objective knee examination form, and radiological evaluation. Results were evaluated and compared with each other.ResultsThere was no significant difference in subjective effects or clinical examination between the two groups. Regarding radiological angles, the AAMP had more oblique graft orientation in the coronal plane than the MTTT, but both were found to be more slanted than native ACL. Also, the MTTT had succeeded to place the graft and tunnel more obliquity than the traditional non-anatomic TTT and better than the anatomic ranges despite having the graft inclination of the AAMP higher than the MTTT. The complaints from the patients and subjective scoring were found to be positively related to graft stability. Patients with healthier preoperative subjective state had a smoother postoperative period and better outcome.ConclusionThis study offers simple modifications to the transtibial technique to allow near anatomic ACL reconstruction with similar results comparable to the AAMP and with fewer complications.

No neurovascular damage after creation of an accessory anteromedial portal for arthroscopic reduction and fixation of coronoid fractures.

Arthroscopic reduction and internal fixation for coronoid process fractures has been proposed to overcome limitations of open approaches. Currently, arthroscopy is most frequently used to assist insertion of a retrograde guide wire for a retrograde cannulated screw. The present anatomical study presents an innovative arthroscopic technique to introduce an antegrade guide wire from an accessory anteromedial portal and evaluates its safety and reproducibility. Six fresh-frozen cadaver specimens were obtained and prepared to mimic an arthroscopic setting. The coronoid process was localized and a 0.9mm Kirschner wire was introduced from an accessory anteromedial portal, located 2cm proximal to the standard anteromedial portal. At the end of the procedure, a lateral radiograph was taken to verify the Kirschner wire position and open dissection was conducted to evaluate possible damage to neurovascular structures. The Kirschner wire was drilled without complications in the coronoid process of all six specimens. Damage of the brachial artery, the median nerve, and the ulnar nerve did not occur in any specimen. A corridor between the brachialis muscle, the median intermuscular septum, and the pronator teres could be identified as suitable for the wire passage. This study presents a safe and reproducible technique combining the possibility to introduce a guide wire from the anteromedial part of the coronoid, under direct visual control, with a completely arthroscopic approach. This wire can guide the introduction of a retrograde cannulated screw from the dorsolateral ulna to the tip of the coronoid. This new arthroscopic approach permits to obtain improved visual control over coronoid process fixation, without endangering neurovascular structures.

Transportal Anterior Cruciate Ligament Reconstruction with Quadrupled Hamstring Tendon Graft: A Prospective Outcome Study.

Background:Anterior cruciate ligament (ACL) reconstruction has been one of the most commonly performed procedures throughout the world. Unsatisfactory outcome with conventional ACL reconstruction has been attributed to nonanatomic graft placement. Researchers have advised placing the graft in the native footprint of ACL to avoid nonanatomic graft placement. The goal of this study was to analyze the outcome of anatomic single bundle ACL reconstruction using transportal technique.Materials and Methods:This was a prospective outcome study conducted on 85 consecutive patients of ACL reconstruction of which 62 patients met inclusion and exclusion criteria and were analyzed for final results. All the patients underwent ACL reconstruction by quadrupled hamstring tendon graft using transportal technique and the accessory anteromedial (AAM) portal for femoral tunnel creation. The graft was fixed with endobutton on femoral side and bioabsorbable screw on the tibial side. Patients were evaluated for range of motion, International Knee Documentation Committee (IKDC) score, and Lysholm scores at a minimum followup period of 2 years. The mean pre- and postoperative scores were compared using Wilcoxon signed-rank test.Results:The mean Lysholm and IKDC scores improved significantly (P < 0.0001) from preoperative value. According to IKDC score, 90.3% (n = 56) were either normal or near normal at final followup. According to Lysholm score, 75.8% of patients had excellent and 13.3% had good results. Preoperatively, pivot shift was present in 85.5% (n = 53) of patients which reduced to 4.8% (n = 3) postoperatively. Infection and knee stiffness occurred in two patients, and femoral tunnel blowout and graft re-rupture occurred in one patient each.Conclusion:Anatomic ACL reconstruction by AAM portal is a reproducible technique which gives good clinical outcome at short-term followup.

Influence of the different anteromedial portal on femoral tunnel orientation during anatomic ACL reconstruction

ObjectiveThe purpose of this study was to evaluate the effect of femoral tunnel orientation, drilled through the accessory anteromedial (AAM) portal or the high AM portal in anatomic anterior cruciate ligament (ACL) reconstruction. MethodsIn 16 cadaver knees, using o'clock method, centers of the ACL femoral footprint were drilled with an 8-mm reamer via an AAM portal (eight knees) or a high AM portal (eight knees). Computed tomography (CT) scans were taken of each knee. Three-dimensional (3D) models were constructed to identify the femoral tunnel orientation and to create femoral tunnel virtual cylinders for measuring tunnel angles and length. ResultsIn two of the 16 specimens, we observed a posterior femoral cortex blowout (PFCB) when drilling through a high AM portal. When drilled through the high AM portal, the femoral tunnel length was significantly shorter than when using an AAM portal (30.3 ± 3.8 mm and 38.2 ± 3.1 mm, p < 0.001). The femoral tunnel length was significantly shorter in the group with PFCB compared to the group with no PFCB (25.9 ± 0.6 mm and 35.5 ± 4.5 mm, p = 0.011). The axial obliquity of the high AM portal was significantly higher than that of the AAM portal (52.2 ± 5.9° and 43.0 ± 2.3°, p = 0.003). ConclusionsIn anatomic ACL reconstruction, a mal-positioned AM portal can cause abnormal tunnel orientation, which may lead to mechanical failure during ACL reconstruction. Therefore, it is important to select accurate AM portal positioning, and possibly using an AAM portal by measuring an accurate position when drilling a femoral tunnel in anatomic ACL reconstruction.

Functional and computed tomography correlation of femoral and tibial tunnels in single-bundle anterior cruciate ligament reconstruction: Use of accessory anteromedial portal.

Background:An accessory anteromedial portal (AAMP) has been shown to be effective in placing an anatomically ideal femoral tunnel. It is well known that this is due to the independent femoral drilling which is possible with the AAMP. However very little is known regarding the significance of this reconstruction technique in influencing the functional outcomes of anatomic anterior cruciate ligament reconstruction (ACLR). This study documents the influence of tibial and femoral tunnel positions on functional outcomes of anatomic ACLR using the AAMP.Materials and Methods:41 patients who underwent anatomic ACLR between 2011 and 2013 were included in this prospective cohort study. The primary outcome involved the documentation of femoral and tibial tunnel positions with volume rendering imaging using a three-dimensional computed tomography (3D-CT) done at the end of 1 year. The tunnel position evaluations from the CT images were performed by an independent observer specializing in radiodiagnosis. Functional outcome measures included preoperative and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores (subjective) documented by an independent investigator who was not involved with the surgical procedure, at the end of 1 year.Results:The minimum followup was 1 year. All patients achieved good clinical and functional outcomes postoperatively with no reported complications. Tunnel position evaluations with 3D-CT revealed the average tibial tunnel distance to be 15.5 mm (standard deviation [SD] =2.52) from the anterior border of the tibial plateau and the average femoral tunnel distance to be 14.33 mm (SD = 2.6) from the inferior margin of the medial surface of lateral femoral condyle and 13.72 mm (SD = 2.8) from the posterior margin of the medial surface of lateral femoral condyle. The average tunnel diameters were found to be 7.9 mm (SD = 0.72) for the tibial tunnels and 8.6 mm (SD = 1.07) for the femoral tunnels. Statistically significant correlation between the tibial tunnel distance and the IKDC scores with anterior placement of tibial tunnel were found; however, no such statistical relationship were found between the femoral tunnel positions and the functional outcome measures.Conclusion:AAMP gives an ideal approach to drill the femoral tunnel independently. However, the influence of this tunnel placement on long term functional outcomes of ACLR needs to be assessed on larger cohort of patients.

Anterior Cruciate Ligament Reconstruction With Bone–Patellar Tendon–Bone Autograft and a Medial Parapatellar Portal

Anterior cruciate ligament (ACL) reconstruction is one of the most extensively studied surgical procedures in orthopaedics. The importance of this ligament for knee function and stability has been widely studied. For athletes who participate in activities involving cutting, twisting, and running, surgical reconstruction of the ACL has become the standard of care. However, there is much debate regarding the techniques involved in ACL reconstruction, including graft choice, technique of drilling the femoral tunnel, and single- versus double-bundle reconstruction. In recent studies, ACL femoral tunnel drilling via a medial parapatellar or accessory anteromedial portal provides a more anatomic graft placement than transtibial femoral drilling. Long-term outcomes of these techniques have not been widely studied. This article details our technique for ACL reconstruction with bone–patellar tendon–bone autograft and a medial parapatellar portal.

A prospective evaluation of the anterior horn of the lateral meniscus as a landmark for tibial tunnel placement in anterior cruciate ligament (ACL) reconstruction

BackgroundThe goal of this study was to prospectively evaluate the accuracy and consistency of the anterior horn of the lateral meniscus as a landmark in achieving the desired tibial tunnel location during primary anterior cruciate ligament (ACL) reconstruction. MethodsOne hundred consecutive adult patients undergoing primary ACL reconstruction were enrolled in the study. One sports-fellowship trained surgeon performed all ACL reconstructions using independent tunnel drilling with an accessory anteromedial portal for the femoral tunnel. All guide pins for the tibial tunnel were placed using a 55-degree guide using the posterior border of the anterior horn of the lateral meniscus as a landmark. Following pin placement, a true lateral fluoroscopic image was obtained. These were digitally analyzed to measure the location of the pin along the length of the tibial plateau. ResultsThe average anteroposterior (A–P) distance achieved using the posterior border of the anterior horn of the lateral meniscus as a landmark for tibial tunnel placement was 37.0%±5.2% (mean±standard deviation) [range 26.4%–49.2%]. 66% of tibial tunnels were located between 30.0% and 39.9% of the A–P tibial distance. Only 18% of tibial tunnels localized between 40.0% and 44.9%, the area of the anatomic footprint described by Staubli and Rauschning [9] 16% of patients were significant outliers, with tunnels localizing to 25.0%–29.9% (6 patients) or 45.0%–49.9% (10 patients). ConclusionsUse of the posterior border of the anterior horn of the lateral meniscus as a landmark for tibial tunnel placement during anatomic ACL reconstruction yields an inconsistent tunnel location. Level of EvidenceII, Prospective study.