Jennings Jonathan K, Leas Daniel P, Fleischli James E, D'Alessandro Donald F, Peindl Richard D, Piasecki Dana P
Southern Bone & Joint Specialists, Dothan, Alabama, USA.
Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.
Orthop J Sports Med. 2017 Aug 7;5(8):2325967117719857. doi: 10.1177/2325967117719857. eCollection 2017 Aug.
Improved biomechanical and clinical outcomes are seen when the femoral tunnels of the anterior cruciate ligament (ACL) are placed in the center of the femoral insertion. The transtibial (TT) technique has been shown to be less capable of this than an anteromedial (AM) portal approach but is more familiar to surgeons and less technically challenging. A hybrid transtibial (HTT) technique using medial portal guidance of a transtibial guide wire without knee hyperflexion may offer anatomic tunnel placement while maintaining the relative ease of a TT technique.
To evaluate the anatomic and biomechanical performance of the HTT technique compared with TT and AM approaches.
Controlled laboratory study.
Thirty-six paired, fresh-frozen human knees were used. Twenty-four knees (12 pairs) underwent all 3 techniques (TT, AM, HTT) for femoral tunnel placement, with direct measurement of femoral insertional overlap and femoral tunnel length. The remaining 12 knees (6 pairs) underwent completed reconstructions to evaluate graft anisometry and tunnel orientation, with each technique performed in 4 specimens and tested using motion sensors with a quad-load induced model. Graft length changes and graft/femoral tunnel angle were measured at varying degrees of flexion.
Percentage overlap of the femoral insertion averaged 37.0% ± 28.6% for TT, 93.9% ± 5.6% for HTT, and 79.7% ± 7.7% for AM, with HTT significantly greater than both TT ( = .007) and AM ( = .001) approaches. Graft length change during knee flexion (anisometry) was 30.1% for HTT, 12.8% for AM, and 8.5% for TT. When compared with the TT approach, HTT constructs exhibited comparable graft-femoral tunnel angulation (TT, 150° ± 3° vs HTT, 142° ± 2.3°; < .001) and length (TT, 42.6 ± 2.8 mm vs HTT, 38.5 ± 2.0 mm; = .12), while AM portal tunnels were significantly shorter (31.6 ± 1.6 mm; = .001) and more angulated (121° ± 6.5°; < .001).
The HTT technique avoids hyperflexion and maintains femoral tunnel orientation and length, similar to the TT technique, but simultaneously achieves anatomic graft positioning.
The HTT technique offers an anatomic alternative to an AM portal approach while maintaining the technical advantages of a traditional TT reconstruction.
当将前交叉韧带（ACL）的股骨隧道置于股骨止点中心时，可观察到生物力学和临床效果得到改善。经胫骨（TT）技术在这方面的能力已被证明不如前内侧（AM）入路，但外科医生对其更为熟悉，技术难度也更低。一种使用经胫骨导丝在内侧入路引导且无需膝关节极度屈曲的混合经胫骨（HTT）技术，可能在保持TT技术相对简便性的同时实现隧道的解剖学定位。
评估HTT技术与TT和AM入路相比的解剖学和生物力学性能。
对照实验室研究。
使用36对新鲜冷冻的人膝关节。24个膝关节（12对）接受了所有3种股骨隧道置入技术（TT、AM、HTT），并直接测量股骨止点重叠和股骨隧道长度。其余12个膝关节（6对）进行了完整的重建，以评估移植物各向异性和隧道方向，每种技术在4个标本中进行，并使用四负荷诱导模型的运动传感器进行测试。在不同屈曲角度下测量移植物长度变化和移植物/股骨隧道角度。
TT技术的股骨止点重叠百分比平均为37.0%±28.6%，HTT技术为93.9%±5.6%，AM技术为79.7%±7.7%，HTT技术显著高于TT技术（P =.007）和AM技术（P =.001）。膝关节屈曲期间移植物长度变化（各向异性），HTT技术为30.1%，AM技术为12.8%，TT技术为8.5%。与TT入路相比，HTT结构的移植物 - 股骨隧道角度（TT，150°±3° vs HTT，142°±2.3°；P <.001）和长度（TT，42.6±2.8 mm vs HTT，38.5±2.0 mm；P =.12）相当，而AM入路隧道明显更短（31.6±1.6 mm；P =.001）且角度更大（121°±6.5°；P <.001）。
HTT技术避免了极度屈曲，并保持了股骨隧道方向和长度，与TT技术相似，但同时实现了解剖学上的移植物定位。
HTT技术在保持传统TT重建技术优势的同时，为AM入路提供了一种解剖学替代方法。
