What did the study look at?
Anterior cruciate ligament (ACL) reconstruction replaces the torn ligament with a graft (transplanted tissue). There are two main techniques: the transtibial technique, in which the thigh bone tunnel is drilled through the shin bone tunnel, and the anteromedial portal technique, in which it is drilled through a separate front-inner entry point. The transtibial technique has been criticised for being unable to create an anatomic thigh bone tunnel, because its position depends on the shin bone tunnel. The article presents the authors' method for performing it anatomically.
How was it done?
This is not a patient study but a video-supported surgical technique note. The main steps described are:
- The patient lies on their back, with the operated knee hanging over the end of the table by about 6 inches.
- A 2-3 mm bone trim of the inner wall of the thigh bone notch (notchplasty) is performed to improve the view.
- The authors' preferred graft in most cases is the patellar tendon graft with a bone block at each end (bone-tendon-bone).
- The shin bone tunnel is drilled with the knee bent at 90 degrees, using a guide set at about 52-55 degrees aimed at the front-inner part of the ligament's attachment.
- The thigh bone tunnel is aimed at about the 10 o'clock position in a right knee and 2 o'clock in a left knee by passing a 7 mm offset guide through the shin tunnel and rotating it outwards; a half-fluted reamer is used to protect the shin tunnel.
- The graft is rotated so that its marked bone surface faces forwards and upwards, and is fixed with metal screws.
What did it find?
The article does not report measured patient outcomes; it contains technical recommendations and a comparison of the advantages and disadvantages of the two methods. According to the authors, the transtibial technique allows easy graft passage and has known long-term outcomes, but carries a risk of non-anatomic and vertical graft placement. The anteromedial technique requires deep knee flexion and can result in a short thigh bone tunnel or a back-wall blow-out. The authors report that earlier literature generally shows no clinical outcome difference between the two techniques.
A rehabilitation protocol is also described, with return to sport allowed at 6 to 8 months at the authors' discretion.
The authors' conclusion
The authors argue that, with proper technique, an anatomic ACL reconstruction can also be achieved with the transtibial method. As the literature comparing the two techniques is equivocal, they suggest choosing the technique according to the surgeon's comfort and preference, and being proficient in both to allow adjustments during surgery.
Reference
Manderle BJ, Beletsky A, Gorodischer T, Chahla J, Cancienne JM, Vadhera AS, Trasolini N, Williams BT, Gürsoy S, Bach BR, Verma NN. (2021). Transtibial Anterior Cruciate Ligament Reconstruction: Tips for a Successful Anatomic Reconstruction. Arthroscopy Techniques, 10(12), e2783–e2788. Licence: CC BY-NC-ND 4.0.
DOI: 10.1016/j.eats.2021.08.025
Free full text: PMC8719302
This article summarises a published scientific paper for general information; it does not replace an examination or a personal medical assessment. Please consult your doctor about your symptoms.
