CarlLee Tyler, Ries Zach, Duchman Kyle, Gao Yubo, Wolf Brian, Amendola Annunziato, Hettrich Carolyn, Bollier Matthew
University of Iowa Hospitals and ClinicsDepartment of Orthopaedic Surgery and Rehabilitation.
Iowa Orthop J. 2017;37:117-122.
Anteromedial (AM) and outside-in (OI) are two commonly used techniques for drilling the femoral tunnel during anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare clinical and radiographic outcomes of patients undergoing primary ACLR using either AM or OI femoral drilling with minimum two year follow-up.
Overall, 138 prospectively enrolled patients undergoing primary ACLR underwent AM or OI femoral drilling. Patients were categorized by femoral drilling technique and were evaluated pre-operatively as well as at six weeks and two years post-operatively. Outcomes scores were collected at each visit using SF-36 PCS and MCS components, KOOS, and the Knee Activity Rating Scale. Complications, including graft failure, stiffness requiring manipulation under anesthesia, and revision surgery were also collected.
Overall, 47 (34.1%) patients underwent AM femoral drilling and 91 (65.9%) patients underwent OI femoral drilling. Univariate analysis revealed no difference in pre-operative outcomes with the exception of the AM group having higher KOOS Knee Pain (p=0.023) and WOMAC Pain (p=0.036) scores. Postoperatively, OI femoral tunnels had a higher radiographic coronal angle (68.8°±8.6° vs 51.4°±11.3°; p<0.001) and knee extension (1.2°±2.7 vs 2.9°±4.0°; p=0.010). There were no differences in knee flexion, complications, or graft failure. Postoperatively, the AM group had higher KOOS ADL and WOMAC Functional (85 vs. 79 ,p=0.030) scores at the six week mark, although these differences did not meet the minimal clinically importance difference1. Graft failure at two years were similar in the AM and OI groups (8.5% vs. 6.6%, p=0.735). Multivariate analysis showed no clinical outcome differences between AM and OI techniques.
ACL reconstruction using the AM technique yielded lower radiographic coronal tunnel angle and slightly decreased knee extension. The theoretical risk of graft failure secondary to higher coronal angle of the graft as it passes around a sharper femoral tunnel aperture was not observed. Additionally, differences in pre-operative KOOS Knee pain existed but these differences were not significant postoperatively. We conclude no clinically relevant differences by two years in patients undergoing primary ACL reconstruction using either AM or OI femoral drilling techniques. Level of Evidence: Level II Prospective Comparative Study.
在前交叉韧带重建（ACLR）手术中，前内侧（AM）和由外向内（OI）是两种常用的股骨隧道钻孔技术。本研究的目的是比较采用AM或OI股骨钻孔技术进行初次ACLR且至少随访两年的患者的临床和影像学结果。
总体而言，138例接受初次ACLR的前瞻性入组患者接受了AM或OI股骨钻孔。患者根据股骨钻孔技术进行分类，并在术前以及术后六周和两年进行评估。每次随访时使用SF - 36生理健康评分（PCS）和心理健康评分（MCS）、膝关节损伤和骨关节炎疗效评分（KOOS）以及膝关节活动评分量表收集结果评分。还收集了并发症，包括移植物失败、需要在麻醉下进行手法治疗的僵硬以及翻修手术。
总体而言，47例（34.1%）患者接受了AM股骨钻孔，91例（65.9%）患者接受了OI股骨钻孔。单因素分析显示术前结果无差异，但AM组的KOOS膝关节疼痛（p = 0.023）和Western Ontario和McMaster大学骨关节炎指数（WOMAC）疼痛评分（p = 0.036）较高。术后，OI股骨隧道的影像学冠状角更高（68.8°±8.6°对51.4°±11.3°；p < 0.001），膝关节伸展度更大（1.2°±2.7对2.9°±4.0°；p = 0.010）。膝关节屈曲、并发症或移植物失败方面无差异。术后六周时，AM组的KOOS日常生活活动（ADL）和WOMAC功能评分更高（85对79，p = 0.030），尽管这些差异未达到最小临床重要差异。AM组和OI组两年时的移植物失败率相似（8.5%对6.6%，p = 0.735）。多因素分析显示AM和OI技术在临床结果上无差异。
采用AM技术进行ACL重建可使影像学冠状隧道角更低，膝关节伸展度略有降低。未观察到因移植物在更尖锐的股骨隧道孔径周围通过时冠状角较高而导致移植物失败的理论风险。此外，术前KOOS膝关节疼痛存在差异，但术后这些差异不显著。我们得出结论，在采用AM或OI股骨钻孔技术进行初次ACL重建的患者中，两年时无临床相关差异。证据级别：II级前瞻性比较研究。
