1. First author: Teodor Grigora Coauthor: Alexandru Robul Coordinator(s): Lecturer Russu Octav Marius, Medical Doctor Roman Ciprian Oliviu University of Medicine and Pharmacy Târgu Mure SYSTEMATIC REVIEW OVER TRANSTIBIAL VERSUS ANTEROMEDIAL TUNNEL IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

2. INTRODUCTION:

3.  Increasing evidence has shown that anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) better restores normal knee kinematics and functionality than nonanatomic ACLR. INTRODUCTION:

4.  The purpose of this study was to systematically review the risks, benefits, advantages and disadvantages of the artroscopic transtibial (TT) technique and anteromedial (AM) portal technique for creating the ACL femoral tunnel. INTRODUCTION:

5.  A PubMed search of English - language studies published between January 2010, and February 2015, was performed using the following keywords: “anterior cruciate ligament” or “ACL”, “transtibial” and “anteromedial”. MATERIAL AND METHODS:

6.  Included were studies reporting risks, benefits, advantages, and/or disadvantages of the two ACL femoral techniques. MATERIAL AND METHODS:

7.  The PubMed search produced 89 articles. RESULTS:

8.  After application of our inclusion and exclusion criteria and additional search of article references, 8 articles were included and systematically reviewed. RESULTS:

9. 8 articles were included and systematically reviewed 4 clinical studies 3 post- operative 3D CT studies 1 controlled laboratory study RESULTS:

10.  Two clinical studies showed better Lysholm score and IKDC score with the AM technique as compared to the TT technique. RESULTS:

11.  Other two clinical studies showed comparable KT-1000 measurements for both AM and TT femoral drilling techniques. RESULTS:

12.  Three post-operative 3D CT studies showed that the AM technique positions the ACL tunnel closer to the native ACL footprint in both femur and tibia. RESULTS:

13.  A controlled laboratory study revealed significant relationships between femoral tunnel orientation and postoperative knee joint flexion moment. RESULTS:

14.  Thus the AM technique provides better restoration of these knee kinetic parameters compared with the TT technique. RESULTS:

16. DISCUSSIONS: In this systematic review of clinical, post-operative 3D CT and controlled laboratory studies directly comparing AM and TT techniques for ACLR in the literature, the favourite is the former.

17. DISCUSSIONS: Out of the selected eight studies, six indicate a better Lysholm and IKDC score, better tunnel position and kinetic parameters. However, two studies have not been able to demonstrate any difference between the effectiveness of the TT versus the AM technique.

18. DISCUSSIONS: “The TT technique has been used for years with good clinical outcomes [...] But in our experience, we have found that an anatomic femoral socket cannot be prepared with a TT technique [...] to achieve the desired position on the femur.” “[...] the AM technique correlates with greater stability of the knee after ACL reconstruction.” Asheesh Bedi, MD, Orthopaedic Surgeon at Ann Arbor, MI states in an interview regarding the effectiveness of the AM technique:

19.  ACL reconstruction using a single-bundle TT can achieve good or excellent results, but anatomic ACL reconstruction is essential to the restoration of normal knee kinematics and achieving successful results after surgery. CONCLUSION:

20. Abreu-e-Silva GM, Baumfeld DS, Bueno EL, Pfeilsticker RM, Andrade MA, Nunes TA. Clinical and three- dimensional computed tomographic comparison between ACL transportal versus ACLtranstibial single-bundle reconstructions with hamstrings. PMID: 25257780 Inderhaug E, Larsen A, Strand T, Waaler PA, Solheim E. The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomicACL reconstruction. PMID: 25274095 Song EK, Kim SK, Lim HA, Seon JK. Comparisons of tunnel-graft angle and tunnel length and position between transtibial and transportal techniques in anterior cruciate ligament reconstruction. PMID: 25120231 Tashiro Y, Okazaki K, Uemura M, Toyoda K, Osaki K, Matsubara H, Hashizume M, Iwamoto Y. Comparison of transtibial and transportal techniques in drilling femoral tunnels during anterior cruciate ligamentreconstruction using 3D-CAD models. PMID: 24744615, PMCID: PMC3983023 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. PMID: 25124481 REFERENCES:

21. Wang H, Fleischli JE, Hutchinson ID, Zheng NN. Knee moment and shear force are correlated with femoral tunnel orientation after single-bundle anterior cruciate ligament reconstruction. PMID: 25062662 Wei Z, Li F, Peng W, Wei B, Qiu L, Wei C. Comparative study on arthroscopic anterior cruciate ligament reconstruction with transtibial technique and through anteromedial approach. PMID: 24844016 Azboy I, Demirtaş A, Gem M, Kıran S, Alemdar C, Bulut M. A comparison of the anteromedial and transtibial drilling technique in ACL reconstruction after a short-term follow-up. PMID: 24770982 Robin BN, Jani SS, Marvil SC, Reid JB, Schillhammer CK, Lubowitz JH. Advantages and Disadvantages of Transtibial, Anteromedial Portal, andOutside-In Femoral Tunnel Drilling in Single- Bundle Anterior CruciateLigament Reconstruction: A Systematic Review. PMID: 25749530 Hwang MD, Piefer JW, Lubowitz JH. Anterior cruciate ligament tibial footprint anatomy: systematic review of the21st century literature. PMID: 22301359 REFERENCES: