Department of Orthopedics, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA.
Sports Medicine Center, OrthoCarolina, Charlotte, North Carolina, USA.
Am J Sports Med. 2020 Nov;48(13):3200-3207. doi: 10.1177/0363546520956645. Epub 2020 Oct 5.
The anteromedial (AM) portal and transtibial (TT) approaches are 2 common anterior cruciate ligament (ACL) femoral tunnel drilling techniques, each with unique benefits and disadvantages. A hybrid TT (HTT) technique using medial portal guidance of a flexible TT guide wire has recently been described that may combine the strengths of both the AM portal and the TT approaches.
The HTT technique will achieve anatomic femoral tunnel apertures similar to the AM portal technique, with improved femoral tunnel length and orientation.
Randomized controlled trial; Level of evidence, 2.
A total of 30 consecutive patients with primary ACL tears were randomized to undergo the TT, AM portal, or HTT technique for femoral tunnel positioning at the time of reconstruction. All patients underwent 3-dimensional computed tomography of the operative knee at 6 weeks postoperatively. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as graft bending angles in the sagittal and coronal planes, were measured.
Tibial tunnel lengths and aperture positions were identical between the 3 groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regard to both height ( = .629) and depth ( = .582). By contrast, compared with the AM portal and HTT techniques, femoral apertures created with the TT technique were significantly higher ( < .001 and < .001, respectively) and shallower ( = .014 and = .022, respectively) in the notch. The mean femoral tunnel length varied significantly between the groups, measuring 35.2, 41.6, and 54.1 mm for the AM portal, HTT, and TT groups, respectively ( < .001). Last, there was no difference between the mean coronal ( = .190) and sagittal ( = .358) graft bending angles between the TT and HTT groups. By contrast, compared with the TT and HTT techniques, femoral tunnels created with the AM portal technique were significantly more angulated in the coronal plane (17.7° [ < .001] and 12.5° [ = .006], respectively) and sagittal plane (13.5° [ < .001] and 10.5° [ = .013], respectively).
This prospective randomized controlled trial found that the HTT technique achieved femoral aperture positions equally as anatomic as the AM portal technique but produced longer, less angulated femoral tunnels, which may help reduce graft strain and mismatch. As such, this hybrid approach may represent a beneficial combination of both the TT and the AM portal techniques.
NCT02795247 (ClinicalTrials.gov identifier).
前内侧（AM）入路和经胫骨（TT）入路是两种常见的前交叉韧带（ACL）股骨隧道钻取技术，每种技术都有其独特的优点和缺点。最近描述了一种使用内侧入路引导柔性 TT 导丝的混合 TT（HTT）技术，该技术可能结合了 AM 入路和 TT 入路的优势。
HTT 技术将获得与 AM 入路技术相似的解剖学股骨隧道开口，同时改善股骨隧道长度和方向。
随机对照试验；证据水平，2 级。
总共 30 例初次 ACL 撕裂患者在重建时随机分为 TT、AM 入路或 HTT 技术进行股骨隧道定位。所有患者术后 6 周均行膝关节三维 CT 检查。测量股骨和胫骨隧道开口位置和隧道长度，以及矢状面和冠状面的移植物弯曲角度。
3 组的胫骨隧道长度和开口位置相同。AM 入路和 HTT 技术在高度（=.629）和深度（=.582）方面均获得相同的股骨开口位置。相比之下，与 AM 入路和 HTT 技术相比，TT 技术形成的股骨开口在切迹处明显更高（<.001 和 <.001）且更浅（=.014 和 =.022）。各组间股骨隧道长度差异显著，AM 入路、HTT 和 TT 组分别为 35.2、41.6 和 54.1mm（<.001）。最后，TT 和 HTT 组间的冠状位（=.190）和矢状位（=.358）移植物弯曲角度无差异。相比之下，与 TT 和 HTT 技术相比，AM 入路技术形成的股骨隧道在冠状面（17.7°[<.001]和 12.5°[=.006]）和矢状面（13.5°[<.001]和 10.5°[=.013]）的角度更大。
本前瞻性随机对照试验发现，HTT 技术获得的股骨开口位置与 AM 入路技术同样具有解剖学意义，但产生了更长、角度更小的股骨隧道，这可能有助于减少移植物的应变和不匹配。因此，这种混合方法可能代表了 TT 和 AM 入路技术的有益结合。
NCT02795247（ClinicalTrials.gov 标识符）。
