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Editorial Commentary: Anatomic Femoral Tunnel Drilling: Does It Really Matter?
Editorial Commentary: Anatomic Femoral Tunnel Drilling: Does It Really Matter?
Abstract: An anatomic anteromedial portal and outside-in technique for creating the anterior cruciate ligament femoral tunnel may improve rotational stability but shows no published differences in clinical outcomes.
See related article on page 142
I
t has been drilled into us that an anteromedial (AM) femoral tunnel surgical technique provides an anatomic and more oblique but shorter tunnel, resulting in more knee stability and potentially achieving better rotational control, which may result in a better functional outcome.1,2 Drs. Lee, Kim, Ahn, and Bin from the Republic of Korea have performed a metaanalysis including 14 recent publications.3 The results are no real surprise and confirm previous studies.4,5 Anteromedial and outside-in femoral tunnel drilling results in a more oblique and shorter femoral tunnel in the coronal plane compared with transtibial drilling. No significant differences in the sagittal plane were observed. However, the study by Lee et al. also highlights one of the more common problems with metaanalysis. Heterogeneity of the included studies may result in bias and limit the generalizability of the findings. Here, the included studies ranged from cadaveric research to observational studies using a multitude of surgical techniques and evaluation methods. Despite these limitations, the results are fairly clear and unambiguous. Transtibial femoral tunnel drilling results in a more vertical and longer tunnel in the coronal plane but not in the sagittal plane. No further work needed. What about the clinical implications? It appears that these differences in tunnel placement make no difference for clinical outcomes.1,6,7 In a recent systematic review, Chalmers et al.1 showed that AM and transtibial drilling techniques result in similar clinical outcomes. Mulcahey et al.8 showed comparable outcomes using KT-1000 (MEDmetric, San Diego, CA) measures
Crown Copyright Ó 2016 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America. All rights reserved. 0749-8063/15991/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.10.016
and International Knee Documentation Committee and Lysholm scores. Rahr-Wagner et al.9 analyzed data from the Danish Knee Ligament Reconstruction Register and reported a higher risk of revision surgery (relative risk, 2.04) with AM tunnel drillingda concerning fact. The jury is still out on whether femoral tunnel position has any impact on clinical outcome as long as the tunnel has been placed in an acceptable location. Many variables influence outcome, and future studies certainly need to address the relation between tunnel position and clinical outcome. Erik Hohmann, M.D., Ph.D., F.R.C.S.(Tr&Orth) Associate Editor
References 1. Chalmers PN, Mall NA, Cole BJ, Verma NN, BushJoseph CA, Bach BR Jr. Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: A systematic review. Arthroscopy 2013;29: 1235-1242. 2. Alentorn-Geli E, Samitier G, Alvarez P, Steinbacher G, Cugat R. Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: A blinded crosssectional study at two- to five-year follow up. Int Orthop 2010;34:747-754. 3. Lee DH, Kim HJ, Ahn HS, Bin SI. Comparison of femoral tunnel length and obliquity between transtibial, anteromedial portal, and outside-in surgical techniques in single-bundle anterior cruciate ligament reconstruction: A meta-analysis. Arthroscopy 2016;32: 142-150. 4. Gavrilidis J, Motsis EK, Pakos EE, Georgoulis AD, Mitsionis G, Xenatakis TA. Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: A cadaveric study. Knee 2008;15:364-367. 5. Musahl V, Plakseychuk A, VanScyoc A, et al. Varying femoral tunnels between the anatomical footprint and
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 32, No 1 (January), 2016: pp 151-152
151
152
EDITORIAL COMMENTARY
isometric positions: Effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med 2005;33:712-718. 6. Noh JH, Roh YH, Yang BG, Yi SR, Lee SY. Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: Transtibial technique versus anteromedial portal technique. Arthroscopy 2013;29:882-890. 7. Franceschi F, Papalia R, Rizzello G, Del Buono A, Maffui N, Denaro V. Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction:
Any clinical relevance? A retrospective comparative study. Arthroscopy 2013;29:1330-1337. 8. Mulcahey MK, David TS, Epstein DM, Alaia MJ, Montgomery KD. Transtibial versus anteromedial portal anterior cruciate ligament reconstruction using soft-tissue graft and expandable fixation. Arthroscopy 2014;30:1461-1467. 9. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC. Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: Results from the Danish Knee Ligament Reconstruction Register. Arthroscopy 2013;29:98-105.
Have you ever thought of reviewing for Arthroscopy? Be part of our peer-review process. It’s rewarding, enlightening, and a great service to your profession. It’s also an important commitment of time and effort. Do you have what it takes to volunteer? Think about it. Visit http://ees.elsevier.com/arth/ and click on the links found in the Reviewer Information box.
Abstract: An anatomic anteromedial portal and outside-in technique for creating the anterior cruciate ligament femoral tunnel may improve rotational stability but shows no published differences in clinical outcomes.
See related article on page 142
I
t has been drilled into us that an anteromedial (AM) femoral tunnel surgical technique provides an anatomic and more oblique but shorter tunnel, resulting in more knee stability and potentially achieving better rotational control, which may result in a better functional outcome.1,2 Drs. Lee, Kim, Ahn, and Bin from the Republic of Korea have performed a metaanalysis including 14 recent publications.3 The results are no real surprise and confirm previous studies.4,5 Anteromedial and outside-in femoral tunnel drilling results in a more oblique and shorter femoral tunnel in the coronal plane compared with transtibial drilling. No significant differences in the sagittal plane were observed. However, the study by Lee et al. also highlights one of the more common problems with metaanalysis. Heterogeneity of the included studies may result in bias and limit the generalizability of the findings. Here, the included studies ranged from cadaveric research to observational studies using a multitude of surgical techniques and evaluation methods. Despite these limitations, the results are fairly clear and unambiguous. Transtibial femoral tunnel drilling results in a more vertical and longer tunnel in the coronal plane but not in the sagittal plane. No further work needed. What about the clinical implications? It appears that these differences in tunnel placement make no difference for clinical outcomes.1,6,7 In a recent systematic review, Chalmers et al.1 showed that AM and transtibial drilling techniques result in similar clinical outcomes. Mulcahey et al.8 showed comparable outcomes using KT-1000 (MEDmetric, San Diego, CA) measures
Crown Copyright Ó 2016 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America. All rights reserved. 0749-8063/15991/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.10.016
and International Knee Documentation Committee and Lysholm scores. Rahr-Wagner et al.9 analyzed data from the Danish Knee Ligament Reconstruction Register and reported a higher risk of revision surgery (relative risk, 2.04) with AM tunnel drillingda concerning fact. The jury is still out on whether femoral tunnel position has any impact on clinical outcome as long as the tunnel has been placed in an acceptable location. Many variables influence outcome, and future studies certainly need to address the relation between tunnel position and clinical outcome. Erik Hohmann, M.D., Ph.D., F.R.C.S.(Tr&Orth) Associate Editor
References 1. Chalmers PN, Mall NA, Cole BJ, Verma NN, BushJoseph CA, Bach BR Jr. Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: A systematic review. Arthroscopy 2013;29: 1235-1242. 2. Alentorn-Geli E, Samitier G, Alvarez P, Steinbacher G, Cugat R. Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: A blinded crosssectional study at two- to five-year follow up. Int Orthop 2010;34:747-754. 3. Lee DH, Kim HJ, Ahn HS, Bin SI. Comparison of femoral tunnel length and obliquity between transtibial, anteromedial portal, and outside-in surgical techniques in single-bundle anterior cruciate ligament reconstruction: A meta-analysis. Arthroscopy 2016;32: 142-150. 4. Gavrilidis J, Motsis EK, Pakos EE, Georgoulis AD, Mitsionis G, Xenatakis TA. Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: A cadaveric study. Knee 2008;15:364-367. 5. Musahl V, Plakseychuk A, VanScyoc A, et al. Varying femoral tunnels between the anatomical footprint and
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 32, No 1 (January), 2016: pp 151-152
151
152
EDITORIAL COMMENTARY
isometric positions: Effect on kinematics of the anterior cruciate ligament-reconstructed knee. Am J Sports Med 2005;33:712-718. 6. Noh JH, Roh YH, Yang BG, Yi SR, Lee SY. Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: Transtibial technique versus anteromedial portal technique. Arthroscopy 2013;29:882-890. 7. Franceschi F, Papalia R, Rizzello G, Del Buono A, Maffui N, Denaro V. Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction:
Any clinical relevance? A retrospective comparative study. Arthroscopy 2013;29:1330-1337. 8. Mulcahey MK, David TS, Epstein DM, Alaia MJ, Montgomery KD. Transtibial versus anteromedial portal anterior cruciate ligament reconstruction using soft-tissue graft and expandable fixation. Arthroscopy 2014;30:1461-1467. 9. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC. Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: Results from the Danish Knee Ligament Reconstruction Register. Arthroscopy 2013;29:98-105.
Have you ever thought of reviewing for Arthroscopy? Be part of our peer-review process. It’s rewarding, enlightening, and a great service to your profession. It’s also an important commitment of time and effort. Do you have what it takes to volunteer? Think about it. Visit http://ees.elsevier.com/arth/ and click on the links found in the Reviewer Information box.