American Sports Medicine Institute, Birmingham, Alabama, USA.
Radiology Associates Birmingham, Birmingham, Alabama, USA.
Orthop J Sports Med. 2014 Mar 5;2(3):2325967114525572. doi: 10.1177/2325967114525572. eCollection 2014 Mar.
Advocates of medial portal drilling claim that the transtibial technique results in a more vertical positioning of the graft, which could lead to subsequent failure and/or a residual pivot shift on postoperative examination. However, advocates of transtibial drilling state that with appropriate placement and adequate notchplasty, their technique places the graft in a more anatomically correct position on the wall, negating the resultant potential for pivot shift and early postoperative failure.
Transtibial femoral drilling can adequately reproduce the femoral origin of the anterior cruciate ligament (ACL) and place the graft in an anatomical position equivalent to medial portal drilling.
Controlled laboratory study.
Ten matched-pair cadaveric knees (N = 20) were scanned using computed tomography (CT), and 3-dimensional images of the native ACL origin were reconstructed. The matched pairs were then randomized into transtibial and medial portal groups. The femoral tunnel was drilled in each knee according to group. A bamboo skewer was placed in the femoral tunnel, and the knees underwent a second CT scan. Arthroscopic notchplasty was performed, and the femoral tunnels were redrilled. Radiographs confirmed placement, and the post-notchplasty tunnel was reamed with a 4-mm reamer. The knees underwent a third CT scan. CT scans compared femoral tunnel placement with the native ACL footprint before and after notchplasty.
The post-notchplasty transtibial group revealed an average of 68.3% coverage of the native ACL femoral origin. The medial portal group revealed an average of 60.8% coverage, with 1 instance of perforation of the posterior cortex. There were no instances of perforation in the transtibial group.
Both drilling techniques place the graft in an anatomically correct position.
Transtibial drilling of the femur can adequately place the entry tunnel at the origin of the ACL's native footprint.
提倡经胫骨侧入路钻孔的人认为，胫骨侧入路技术可使移植物更垂直定位，这可能导致术后检查时出现移植物失败和/或残余旋转不稳定。然而，提倡胫骨侧钻孔的人则表示，通过适当的定位和充分的切迹成形术，他们的技术可以使移植物在壁上处于更解剖学上正确的位置，从而消除旋转不稳定和术后早期失败的潜在风险。
胫骨侧股骨钻孔可以充分复制前交叉韧带（ACL）的股骨起点，并将移植物置于与经内侧入路钻孔相同的解剖位置。
对照实验室研究。
对 10 对配对的尸体膝关节（N=20）进行计算机断层扫描（CT）扫描，并重建了 ACL 原始起源的三维图像。然后将配对的膝关节随机分为胫骨侧和内侧入路组。每组膝关节均按分组进行股骨隧道钻孔。将竹筷插入股骨隧道，然后对膝关节进行第二次 CT 扫描。进行关节镜下切迹成形术，并重新钻孔股骨隧道。X 线片确认位置，并用 4mm 扩孔器扩孔。膝关节再次进行 CT 扫描。CT 扫描比较了切迹成形术前、后股骨隧道的位置与 ACL 原始足迹的关系。
经胫骨侧钻孔的术后隧道平均覆盖 ACL 股骨原始起点的 68.3%。内侧入路组平均覆盖 60.8%，有 1 例后皮质穿孔。胫骨侧钻孔组无穿孔病例。
两种钻孔技术均可将移植物置于解剖学上正确的位置。
经胫骨侧钻孔可充分将股骨入口隧道置于 ACL 原始附着点。
