Journal of Sports Science and Medicine
Journal of Sports Science and Medicine
ISSN: 1303 - 2968   
Ios-APP Journal of Sports Science and Medicine
Androit-APP Journal of Sports Science and Medicine
Views
347
Download
145
 
©Journal of Sports Science and Medicine (2021) 20, 237 - 249   DOI: https://doi.org/10.52082/jssm.2021.237

Review article
Comparison of Clinical Outcomes between Anteromedial and Transtibial Techniques of Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis
Ran Li1, Tao Li1, Qiuping Zhang2, Weili Fu1, , Jian Li1
Author Information
1 Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, China
2 Rheumatism Immunology Laboratory, West China Hospital, Sichuan University, China

Weili Fu
✉ Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu, Sichuan 610041, P. R. China
Email: foxwin2008@163.com
Publish Date
Received: 05-12-2020
Accepted: 04-02-2021
Published (online): 08-03-2021
Share this article
 
ABSTRACT

This study compared clinical outcomes obtained after single-bundle anterior cruciate ligament (ACL) reconstruction using the anteromedial (AM) and transtibial (TT) techniques, which comprise the conventional transtibial (cTT) and modified transtibial (mTT) techniques. This study included clinical randomized controlled trials and prospective and retrospective controlled trials with AM and TT techniques from the PubMed and Embase databases and the Cochrane Library. All databases were searched from January 2010 to July 2020. Two independent evaluators verified the quality of the included studies using the Cochrane Collaboration’s risk of bias tool and the Newcastle-Ottawa Scale (NOS). Outcome measures analysed included the Lachman test, pivot-shift test, side-to-side difference (SSD), Lysholm score, Tegner activity scale, International Knee Documentation Committee (IKDC) grade and score. Ten randomized controlled trials (RCTs) and 16 prospective and retrospective controlled trials were included with a total of 2202 patients. There were 1180 patients and 1022 patients in the AM and TT groups, respectively. Compared to the cTT group, superior postoperative results were observed in the AM group based on the negative rate of the Lachman test and the pivot-shift test, IKDC grade and score, Lysholm score, Tegner activity scale and SSD (p < 0.05). However, there was no significant difference between the AM and mTT groups (p > 0.05). Compared to the conventional TT technique, the AM technique exhibited superior clinical outcomes. Nevertheless, the modified TT and AM techniques had comparable results. With neither of the techniques (mTT or AM) producing significantly superior outcomes, surgeons can choose either of them depending on their preferences.

Key words: Anterior cruciate ligament reconstruction, anteromedial, transtibial, modified transtibial, meta-analysis


           Key Points
  • This meta-analysis was conducted based on the latest studies about the cTT, mTT and AM techniques.
  • Compared to the cTT technique, the AM technique showed superior clinical outcomes.
  • The mTT and AM techniques had comparable clinical outcomes.
  • Surgeons can choose the one between the mTT and AM techniques, depending on their preferences.

INTRODUCTION

Anterior cruciate ligament (ACL) tears are among the most common knee injuries, and single-bundle ACL reconstruction has increasingly become the standard method for restoring knee stability and function (Kopf et al., 2010; Duquin et al., 2009). Technology in ACL reconstruction has made great progress over the past few decades (Csintalan et al., 2008). Initially, the conventional transtibial (cTT) technique for drilling the femoral tunnel played an important role in single-bundle ACL reconstruction (Mirzatolooei, 2012), owing to its simplicity in creating tunnels (Robin et al., 2015). However, several studies have shown that the conventional TT technique may lead to ACL reconstruction failure due to the increased obliquity of the femoral tunnel and placement of the graft in a non-anatomic site (Arnold et al., 2001; Heming et al., 2007; Loh et al., 2003; Paessler et al., 2004). Independent drilling techniques, such as the anteromedial (AM) and outside-in (OI) methods, have been advocated for single-bundle ACL reconstruction (Bottoni 2008; Duquin et al., 2009; Chechik et al., 2013; Seo et al., 2013). To restore anatomical insertion of the ACL, AM and OI techniques create an additional incision for a solitary femoral tunnel on the anteromedial and outside-in aspects, which is efficient but challenging. Recently, the modified transtibial (mTT) method has been introduced to the field. Furthermore, some studies have shown that the mTT technique may result in the femoral tunnel being in a similar anatomic position with comparable clinical outcomes to the AM technique (Hussin et al., 2018; Lee et al., 2014; Youm et al., 2014).

Many studies have attempted to compare the cTT and AM techniques for single-bundle ACL reconstruction since 2010. Some of them reported that the AM technique yields superior outcomes. Based on the physical examination and functional outcome measures, two meta-analyses (Chen et al., 2017; Liu et al., 2017) agreed that the AM technique is superior to the cTT technique. However, several recent studies (Cury et al., 2017; Geng and Gai, 2018; Özer et al., 2018) also claimed that the two techniques are not significantly different. However, it is unclear whether the mTT technique yields similar clinical outcomes to those of the AM technique with respect to anatomical reconstruction. Consequently, in this meta-analysis, we reviewed and analysed the latest studies on TT and AM techniques in single-bundle ACL reconstruction to compare postoperative clinical outcomes between the cTT and AM techniques, as well as for mTT and AM techniques.

METHODS

Search strategy

PubMed and Embase databases and the Cochrane Library were searched from January 2010 to July 2020. The following terms were searched in the title, abstract, MeSH and keyword fields: (TP OR Transportal OR Transtibial OR TT OR “modified transtibial” OR mTT) AND (AM OR Anteromedial Portal) AND (“Reconstructive Surgical Procedures” OR Arthroscopy OR “Joint instability” OR Reconstructions) AND (“Anterior Cruciate Ligament” OR ACL).

Inclusion criteria and exclusion criteria

Inclusion criteria were as follows: 1) clinical studies comparing AM and TT (or mTT) techniques in ACL reconstruction; 2) patients who underwent primary arthroscopic single-bundle ACL reconstruction; and 3) complete reports on clinical outcomes, including the Lachman test, pivot-shift test, side-to-side difference (SSD), Lysholm score, Tegner activity score, IKDC grade or score.

Exclusion criteria were as follows: 1) comparisons that were not between AM and TT (or mTT) techniques in ACL reconstruction; 2) animal or cadaveric studies; 3) all patients underwent double-bundle ACL reconstruction; 4) absent reports on clinical outcomes; and 5) studies with a low level of evidence.

Literature selection

Two researchers (RL and TL) independently included and excluded studies based on titles, abstracts and full text. After reading the full text, the two researchers selected the studies that met the inclusion criteria. At the end of the selection, disagreements were resolved after discussion between two researchers.

Data extraction

Two researchers (RL and TL) independently checked all suitable studies using the data extraction sheet, and all disagreements were resolved by discussion. The extracted data included author, publication date, study design, patient demographics (sample size, sex and age), follow-up period, graft type, and clinical outcomes. If there were omitted outcomes, they were estimated using a specific method (Hozo et al., 2005) according to relevant original data.

Quality assessment

The same two researchers independently assessed the risk of bias for RCTs using the Cochrane Collaboration’s tool (Higgins et al., 2003). The methodological quality of prospective and retrospective controlled trials was assessed using the Newcastle–Ottawa Assessment Scale (NOS) (Stang, 2010). In the NOS, there are three domains: selection, comparability and outcome. For the selection domain (four items) and outcome domain (three items), every item can be given a maximum of one star. The only item in the comparability domain can be given a maximum of two stars. A study can be awarded nine stars at most. Studies with ≥ 7, 5-6, 3-4, and 0-2 stars were identified as good, fair, poor-fair, and poor quality, respectively. For the Cochrane Collaboration’s tool, there are seven domains: random sequence generation, allocation of concealment, performance bias, detection bias, attrition bias, reporting bias and other bias. The risk of bias was assessed as high, low and unclear.

Statistical analysis

The TT group was divided into cTT and mTT subgroups. The two subgroups were compared to the AM group.

This meta-analysis was conducted using Review Manager version 5.3 software (Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration, 2014), and all extracted data were input and checked by the reviewers. For dichotomous data, odds ratio (OR) and 95% confidence interval (CI) were calculated. For continuous data, the weighted mean difference (WMD) was calculated with the 95% CI. The Chi-square test and inconsistency (I2) were used to estimate statistical heterogeneity. I2 values of 25, 50, and 75% were considered low, medium, and high heterogeneity, respectively. The fixed-effects model was used when I2 < 50%; otherwise, the random-effects model was applied. The Lachman test, pivot-shift test and IKDC grade were analysed as dichotomous variables, while the SSD, Lysholm score, Tegner activity scale and IKDC score were analysed as continuous variables. Publication bias was assessed by the Begg’s test.

RESULTS

Identification of studies

Three hundred sixty-two articles were selected after the initial search. Among these articles, 76 were excluded due to being identified as duplicates using endnote X8, and 255 were removed after review of the titles and abstracts. Five studies were excluded after reviewing the full text, as four studies lacked relevant clinical outcome parameters, and one study was low quality. Finally, 26 articles were included in our meta-analysis. A summary is presented in Figure 1.

Characteristics and quality of studies

The 26 selected articles included ten RCTs, 15 retrospective comparative studies and one prospective comparative study. Among the 26 included articles, 21 compared AM and cTT techniques, and the other five compared AM and mTT techniques. All basic information from the articles is shown in Table 1. These 26 studies included 2202 patients, of whom 1180 (53.6%) underwent the AM technique and 1022 (46.4%) received the TT technique for arthroscopic-assisted ACL reconstruction.

Only one study (Lee et al.,2014) used both single-bundle and double-bundle ACL reconstruction in the AM technique; therefore, the single-bundle data were extracted. One study (Cury et al.,2017) compared the AM, TT and OI techniques, while another study (Sohn et al.,2014) compared the AM, mTT and OI techniques. Likewise, data on the OI technique were excluded in the two studies.

In addition, we assessed the quality of the included studies using the Newcastle-Ottawa Quality Assessment scale (NOS) for nonrandomized trials and the Cochrane Collaboration’s risk of bias tool for RCTs. The assessment results are summarized in Table 2 and Figure 2. All nonrandomized trials scoring ≥6 were of good or fair quality, and all RCTs were at low or unclear risk of bias.

Lachman test

Seventeen studies involving 1325 patients compared the cTT and AM techniques. The results suggested that the AM group had a significantly higher rate of postoperative negative Lachman tests than the cTT group (OR = 0.46, 95% CI: 0.35 to 0.60, P < 0.001). The data, analysed in a fixed-effects model, exhibited medium heterogeneity (p = 0.02, I2 = 46%). There were also 144 patients in two studies that compared the AM and mTT techniques with respect to the postoperative Lachman test. Through analysis using a fixed-effects model, no significant difference was found (OR = 1.31, 95% CI: 0.57 to 3.02, p = 0.53), and no heterogeneity was found in either study (p = 0.69, I2 = 0%) (Figure 3).

Pivot-shift test

Nineteen studies with a total of 1632 patients compared the postoperative pivot-shift test between the AM and cTT techniques with medium heterogeneity (p = 0.02, I2 = 44%). The results, analysed by a fixed-effects model, showed that the AM group had a significantly higher rate of postoperative negative pivot-shift test than the cTT group (OR = 0.46, 95% CI: 0.37 to 0.59, p < 0.001). Three studies with a total of 184 patients reported the postoperative pivot-shift test between the AM and mTT techniques. Furthermore, there was no significant difference between the AM and mTT groups analysed in a fixed-effects model (OR = 1.00, 95% CI: 0.47 to 2.14, p = 1.00). Low heterogeneity was found among the three studies (p = 0.34, I2 = 7%) (Figure 4).

IKDC grade

Twelve studies, contributing a total of 955 patients, reported the postoperative IKDC grade between the AM and cTT techniques with medium heterogeneity (p = 0.07, I2 = 41%). The proportion of patients with IKDC grade A was slightly higher in the AM group than in the cTT group after analysis in a fixed-effects model (OR = 0.73, 95% CI: 0.55 to 0.97, p = 0.03). There were 40 patients in one study comparing the postoperative IKDC grades of the AM and mTT techniques. The results were analysed with no significant difference using a fixed-effects model (OR = 0.81, 95% CI: 0.23 to 2.86, p = 0.75) (Figure 5).

IKDC score

Ten studies reported the postoperative IKDC score between the AM and cTT techniques, involving 792 patients. An analysis was performed using a fixed-effects model. The results indicated that there was a significant difference between the AM and cTT groups (WMD = -1.22, 95% CI: -1.92 to -0.52, p < 0.001). The AM group exhibited a better postoperative IKDC score without heterogeneity (p = 0.58, I2 = 0%). In addition, 336 patients in five studies compared the AM and mTT techniques in terms of the postoperative IKDC score. Using the fixed-effects model, the results did not show any significant difference between the AM and mTT groups (WMD = -0.19, 95% CI: -0.55 to 0.18, p = 0.32). Medium heterogeneity was found among these studies (p = 0.20, I2 = 34%) (Figure 6).

Lysholm score

Sixteen studies with 1353 patients compared the postoperative Lysholm score between the AM and cTT techniques. The data, analysed using a fixed-effects model, exhibited medium heterogeneity (p = 0.03, I2 = 45%). The results suggested that the postoperative Lysholm score in the AM group was significantly higher than in the cTT group (WMD = -0.96, 95% CI: -1.38 to -0.55, p < 0.001). The postoperative Lysholm scores of 144 patients in two studies were analysed using a fixed-effects model, with a significant difference observed between the AM and mTT groups (WMD = -0.36, 95% CI: -0.73 to 0.01, p = 0.06). The data showed medium heterogeneity (p = 0.16, I2 = 39%) (Figure 7).

Tegner activity scale

Eight studies involving 626 patients reported the postoperative Tegner activity scale in the AM and cTT techniques. Analysis using a fixed-effects model indicated that there was a significant difference between the AM and cTT groups (WMD = -0.30, 95% CI: -0.49 to -0.12, p = 0.001), and the data showed no heterogeneity (p = 0.57, I2 = 0%). Postoperative Lysholm scores of 276 patients in four studies were analysed using a fixed-effects model, with no significant difference observed between the AM and mTT groups (WMD = -0.03, 95% CI: -0.27 to 0.22, p = 0.83). The data showed no heterogeneity (p = 0.83, I2 = 0%) (Figure 8).

Side-to-side difference

Nine studies reported postoperative SSD between the AM and cTT techniques, involving a total of 876 patients. Medium heterogeneity was identified among the studies (p = 0.19, I2 = 29%). The results indicated that the postoperative SSD in the cTT group was significantly higher than in the AM group (WMD = 0.33, 95% CI: 0.19 to 0.47, p < 0.001). In addition, in the postoperative SSD between the AM and mTT techniques, a study with 92 patients indicated no significant differences between the two groups (WMD = 0.00, 95% CI: -0.57 to 0.57, p = 1.00). The results were analysed using a fixed-effects model. The KT-1000 knee arthrometer was applied to all 10 studies (Figure 9).

Sensitivity analysis

In this meta-analysis, we also performed a series of sensitivity analyses to evaluate the pooled results’ stability. The sensitivity analysis was performed by classifying studies as RCTs or nonrandomized trials based on their comparison between cTT and AM techniques. When RCTs were included, there were significant changes in the Lachman test (OR = 0.52, 95% CI: 0.32 to 0.83, p = 0.006), the pivotshift test (OR = 0.54, 95% CI: 0.38 to 0.77, p < 0.0006), the Lysholm score (WMD = -0.74, 95% CI: -1.22 to -0.27, p = 0.002) and the SSD (WMD = 0.34, 95% CI: 0.19 to 0.50, p < 0.001). Compared to the mTT and AM techniques, there were sufficient data only on the IKDC score and the Lysholm score. Consequently, the sensitivity analysis between the mTT and AM subgroups was performed in two terms, as mentioned above. We also classified the included studies by graft type. When the two studies with allografts were included, the data showed that the AM group was superior to the mTT group in the Lysholm score (WMD = -1.98, 95% CI: -3.71 to -0.25, p = 0.02), but no changes were found in the IKDC score. There was no significant change when the three studies with autografts were included.

Publication bias

To ensure accuracy, the Lachman test and the IKDC score were chosen as indicators in the cTT and mTT subgroups. Publication bias was not observed in either the cTT (p = 0.93) or the mTT subgroups (p = 1.00) using Begg’s test.

DISCUSSION

In our meta-analysis, one of the most important findings is that, compared to the cTT technique, the AM technique is superior in clinical outcome parameters for single-bundle ACL reconstruction, including the negative rate of Lachman test and Pivot-shift test, the proportion with IKDC grade A, the IKDC score, the Lysholm score, Tegner activity scale and SSD. However, no significant difference was found in the abovementioned terms between the AM and mTT techniques in single-bundle ACL reconstruction.

The reason that these differences exist has not been elucidated. This may be because of the biomechanics, especially the position of the femoral tunnel. As with traditional isometric and non-anatomic reconstruction, the cTT technique places the femoral tunnel more superiorly and anteriorly or rather vertically than the native femoral ACL site (Arnold et al., 2001; Dargel et al., 2009; Paessler et al., 2004). As an anatomical reconstruction, the AM technique does more horizontally, where the centre of the femoral tunnel drilled is nearer to the native ACL footprint (Strauss et al., 2011; Osti et al., 2015; Jennings et al., 2017; Venosa et al., 2017). Anatomical ACL reconstruction involves placement of the femoral tunnel at the centre of the original femoral footprint (Xu et al., 2016). Furthermore, the femoral tunnel being in a more anatomical position benefits the knee’s anterior-posterior and rotational stability (Lee et al., 2014; Tasdemir et al., 2015; Kilinc et al., 2016) because of translational and tensioning patterns similar to the native ACL (Zhang et al., 2012; Zavras et al., 2005). In our meta-analysis, this finding is supported by the lower SSD and the greater percentage of the negative rate of the postoperative Lachman test and pivot-shift test in the AM group. The cTT exhibits weak anti-rotation force (Franceschi et al., 2013; Inderhaug et al., 2013) and fails to prevent knee osteoarthritis (Ro et al., 2018), which may directly affect the long-term efficacy of ACL reconstruction. The cTT technique may result in feelings or motions of instability when patients perform daily activities after undergoing ACL reconstruction, which is likely to decrease postoperative functional outcomes (Ro et al., 2018). This seems to result in a worse postoperative Lysholm score, IKDC score, Tegner activity scale and a lower proportion of IKDC grade A in the cTT group.

Although the AM technique has been advocated for anatomic single-bundle ACL reconstruction, there are still some drawbacks. For instance, the AM technique leads to a limited arthroscopic view and a shorter femoral tunnel (Lubowitz, 2009; Bedi et al., 2010). Additionally, it is possible to cause posterior wall blowout and damage the posterior articular cartilage (Nakamura et al., 2009; Koutras et al., 2013; Rahr-Wagner et al., 2013). Thus, several surgeons have suggested several simple technical modification of the conventional TT technique, which may overcome the limitations of the AM technique. Youm et al. (2014) created the femoral tunnel by positioning the tibia in internal rotation and varus alignment. Lee et al. (2014) attempted this technique when an anterior drawer force, a varus force and an external rotation force were applied to the tibia. Other surgeons claimed that the external rotation of the femoral guide or a far medial entry into the tibia could achieve an extra few degrees of obliquity in the femoral tunnel (Sohn et al., 2014; Hussin et al., 2018; Pande et al., 2017; Golish et al., 2007). Some studies have shown that the mTT technique has better clinical outcomes and stability (Salinas et al., 2017), while some have indicated that both techniques have similar clinical outcomes (Pande et al., 2017; Youm et al., 2014; Hussin et al., 2018). Our meta-analysis supports the idea that the mTT and AM techniques have comparable clinical outcomes. Given this, surgeons can choose the one with which they are more familiar.

The mTT technique was optimized based on the cTT technique to achieve anatomical reconstruction. Anatomically placing tibial and femoral tunnels has obtained a consensus in the literature for providing the preferred results (Alentorn-Geli et al., 2010; Kopf et al., 2010; Arnold et al., 2001). Comparison between the AM and mTT techniques is of greater clinical significance. Furthermore, there are deficient data comparing the cTT and mTT techniques. Consequently, we did not compare the cTT and mTT techniques.

Furthermore, Chen et al. (2015) concluded that they did not observe a significant difference in functional outcomes, but in stability, after comparing the AM and cTT techniques. This study only included three RCTs and one study in double-bundle ACL reconstruction, with a total of 10 included studies, which lacked the Tegner activity scale and SSD. Liu et al. (2017) reported that the AM technique was superior to the cTT technique based on both physical examination and scoring system results. Similarly, this study analysed only nine studies from 2010 to 2014, involving six retrospective comparative studies, lacking randomization and blinding. Chen et al. (2017) reported that the AM technique performed better in terms of postoperative stability and functional outcomes compared to the cTT technique in single-bundle ACL reconstruction. However, only five studies were included, incurring limitations of small sample size and relevant data. In contrast, there were 10 RCTs in the 26 included studies in our meta-analysis, with a rich set of data. Second, only studies comparing single-bundle ACL reconstruction were included. Finally, we added analysis of an mTT subgroup compared to the AM group to explore whether the AM or mTT techniques presented better clinical outcomes.

There are some limitations in our meta-analysis. First, retrospective studies lacked randomization and blinding, although we had already excluded low-quality studies. Second, the graft types, follow-up period and surgical performance were varied, possibly affecting the heterogeneity. Although we cannot neglect the influence of the graft type on the results, we only included the soft tissue graft instead of artificial ligaments, which reduced the heterogeneity to the greatest extent. The third limitation refers to the time to return to sports and rate of re-rupture, which were also recorded, but there were insufficient data from the included studies to be pooled for meta-analysis, and the data were measured using different methods. Finally, considering the small sample size, the comparison between the AM and mTT techniques needs more data to support credible long-term conclusions.

CONCLUSION

Compared to the conventional TT technique, the AM technique exhibited superior clinical outcomes. Nevertheless, the modified TT and AM techniques presented comparable results. With neither of the techniques (mTT and AM) producing significantly superior outcomes, surgeons can choose either of them, depending on their preferences.

ACKNOWLEDGEMENTS

Ran Li and Tao Li contributed equally to this work. The experiments comply with the current laws of the country in which they were performed. The authors have no conflict of interest to declare. The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author who was an organizer of the study.

AUTHOR BIOGRAPHY

Journal of Sports Science and Medicine Ran Li
Employment: Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University.
Degree: MD
Research interests: Sports medicine and rehabilitation.
E-mail: Liranscu@126.com
 

Journal of Sports Science and Medicine Tao Li
Employment: Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University.
Degree: MD
Research interests: Sports medicine.
E-mail: jockertao@126.com
 

Journal of Sports Science and Medicine Qiuping Zhang
Employment: Rheumatism Immunology Laboratory, West China Hospital, Sichuan University.
Degree: MD
Research interests: Rheumatism and Immunity.
E-mail: 1988zhangqiufeng@163.com
 

Journal of Sports Science and Medicine Weili Fu
Employment: Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University.
Degree: MD
Research interests: Sports medicine.
E-mail: foxwin2008@163.com
 

Journal of Sports Science and Medicine Jian Li
Employment: Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University.
Degree: MD
Research interests: Sports medicine (Repair and reconstruction of knee).
E-mail: LiJianhuaxi@126.com
 
 
REFERENCES
Journal of Sports Science and Medicine Alentorn-Geli E., Samitier G., Alvarez P., Steinbacher G., Cugat R. (2010) Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up. International Orthopaedics 34, 747-754.  Crossref
Journal of Sports Science and Medicine Arnold M. P., Kooloos J., van Kampen A. (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surgery, Sports Traumatology, Arthroscopy 9, 194-199.  Crossref
Journal of Sports Science and Medicine Azboy I., Demirtaş A., Gem M., Kıran S., Alemdar C., Bulut M. (2014) A comparison of the anteromedial and transtibial drilling technique in ACL reconstruction after a short-term follow-up. Archives of Orthopaedic and Trauma Surgery 134, 963-969.  Crossref
Journal of Sports Science and Medicine Özer M., Özer H., Selek H., Baltacı G., Harput G., Taşkesen A., Çetinkaya M. (2018) Radiological and functional comparison of single-bundle anterior cruciate ligament reconstruction: transtibial versus anteromedial technique. Turkish Journal of Medical Sciences 48, 455-461.  Crossref
Journal of Sports Science and Medicine Bedi A., Raphael B., Maderazo A., Pavlov H., Williams R. J. (2010) Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 26, 342-350.  Crossref
Journal of Sports Science and Medicine Bohn M. B., Sørensen H., Petersen M. K., Søballe K., Lind M. (2015) Rotational laxity after anatomical ACL reconstruction measured by 3-D motion analysis: a prospective randomized clinical trial comparing anatomic and nonanatomic ACL reconstruction techniques. Knee Surgery, Sports Traumatology, Arthroscopy 23, 3473-3481.  Crossref
Journal of Sports Science and Medicine Bottoni C. R. (2008) Anterior cruciate ligament femoral tunnel creation by use of anteromedial portal. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 24, 1319.  Crossref
Journal of Sports Science and Medicine Chechik O., Amar E., Khashan M., Lador R., Eyal G., Gold A. (2013) An international survey on anterior cruciate ligament reconstruction practices. International Orthopaedics 37, 201-206.  Crossref
Journal of Sports Science and Medicine Chen H., Tie K., Qi Y., Li B., Chen B., Chen L. (2017) Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials. Journal of Orthopaedic Surgery and Research 12, 167.  Crossref
Journal of Sports Science and Medicine Chen Y., Chua K. H., Singh A., Tan J. H., Chen X., Tan S. H., Tai B. C., Lingaraj K. (2015) Outcome of Single-Bundle Hamstring Anterior Cruciate Ligament Reconstruction Using the Anteromedial Versus the Transtibial Technique: A Systematic Review and Meta-analysis. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 31, 1784-1794.  Crossref
Journal of Sports Science and Medicine Csintalan R. P., Inacio M. C., Funahashi T. T. (2008) Incidence rate of anterior cruciate ligament reconstructions. The Permanente Journal 12, 17-21.  Crossref
Journal of Sports Science and Medicine Cury R., Sprey J., Bragatto A., Mansano M. V., Moscovici H. F., Guglielmetti L. (2017) Comparative evaluation of the results of three techniques in the reconstruction of the anterior cruciate ligament, with a minimum follow-up of two years. Revista Brasileira de Ortopedia 52, 319-324.  Crossref
Journal of Sports Science and Medicine Dargel J., Schmidt-Wiethoff R., Fischer S., Mader K., Koebke J., Schneider T. (2009) Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surgery, Sports Traumatology, Arthroscopy 17, 220-227.  Crossref
Journal of Sports Science and Medicine de Abreu-e-Silva G. M., Baumfeld D. S., Bueno E. L., Pfeilsticker R. M., de Andrade M. A., Nunes T. A. (2014) Clinical and three-dimensional computed tomographic comparison between ACL transportal versus ACL transtibial single-bundle reconstructions with hamstrings. The Knee 21, 1203-1209.  Crossref
Journal of Sports Science and Medicine Duquin T. R., Wind W. M., Fineberg M. S., Smolinski R. J., Buyea C. M. (2009) Current trends in anterior cruciate ligament reconstruction. The Journal of Knee Surgery 22, 7-12.  Crossref
Journal of Sports Science and Medicine Franceschi F., Papalia R., Rizzello G., Del Buono A., Maffulli N., Denaro V. (2013) Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 29, 1330-1337.  Crossref
Journal of Sports Science and Medicine Geng Y., Gai P. (2018) Comparison of 2 femoral tunnel drilling techniques in anterior cruciate ligament reconstruction. A prospective randomized comparative study. BioMed Central Musculoskeletal Disorders 19, 454.  Crossref
Journal of Sports Science and Medicine Golish S. R., Baumfeld J. A., Schoderbek R. J., Miller M. D. (2007) The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: a cadaveric study. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 23, 1187-1192.  Crossref
Journal of Sports Science and Medicine Guglielmetti L. G., Cury R., de Oliveira V. M., de Camargo O. P., Severino N. R., Fucs P. M. (2014) Anterior cruciate ligament reconstruction: a new cortical suspension device for femoral fixation with transtibial and transportal techniques. Journal of Orthopaedic Surgery and Research 9, 110.  Crossref
Journal of Sports Science and Medicine Heming J. F., Rand J., Steiner M. E. (2007) Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. The American Journal of Sports Medicine 35, 1708-1715.  Crossref
Journal of Sports Science and Medicine Higgins J. P., Thompson S. G., Deeks J. J., Altman D. G. (2003) Measuring inconsistency in meta-analyses. British Medical Journal (Clinical research ed.) 327, 557-560.  Crossref
Journal of Sports Science and Medicine Hozo S. P., Djulbegovic B., Hozo I. (2005) Estimating the mean and variance from the median, range, and the size of a sample. BioMed Central Medical Research Methodology 5, 13.  Crossref
Journal of Sports Science and Medicine Hussein M., van Eck C. F., Cretnik A., Dinevski D., Fu F. H. (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. The American Journal of Sports Medicine 40, 512-520.  Crossref
Journal of Sports Science and Medicine Hussin E. A., Aldaheri A., Alharbi H., Farouk H. A. (2018) Modified transtibial versus anteromedial portal techniques for anterior cruciate ligament reconstruction, a comparative study. Open Access Journal of Sports Medicine 9, 199-213.  Crossref
Journal of Sports Science and Medicine Inderhaug E., Strand T., Fischer-Bredenbeck C., Solheim E. (2013) Long-term results after reconstruction of the ACL with hamstrings autograft and transtibial femoral drilling. Knee Surgery, Sports Traumatology, Arthroscopy 21, 2004-2010.  Crossref
Journal of Sports Science and Medicine Jennings J. K., Leas D. P., Fleischli J. E., D'Alessandro D. F., Peindl R. D., Piasecki D. P. (2017) Transtibial Versus Anteromedial Portal ACL Reconstruction: Is a Hybrid Approach the Best?. Orthopaedic Journal of Sports Medicine 5, 2325967117719857.  Crossref
Journal of Sports Science and Medicine Kilinc B. E., Kara A., Oc Y., Celik H., Camur S., Bilgin E., Erten Y. T., Sahinkaya T., Eren O. T. (2016) Transtibial vs anatomical single bundle technique for anterior cruciate ligament reconstruction: A Retrospective Cohort Study. International Journal of Surgery 29, 62-69.  Crossref
Journal of Sports Science and Medicine Kim M. K., Lee B. C., Park J. H. (2011) Anatomic single bundle anterior cruciate ligament reconstruction by the two anteromedial portal method: the comparison of transportal and transtibial techniques. Knee Surgery & Related Research 23, 213-219.  Crossref
Journal of Sports Science and Medicine Kopf S., Forsythe B., Wong A. K., Tashman S., Anderst W., Irrgang J. J., Fu F. H. (2010) Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. The Journal of Bone and Joint Surgery 92, 1427-1431.  Crossref
Journal of Sports Science and Medicine Koutras G., Papadopoulos P., Terzidis I.P., Gigis I., Pappas E. (2013) Short-term functional and clinical outcomes after acl reconstruction with hamstrings autograft: transtibial versus anteromedial portal technique. Knee Surgery, Sports Traumatology, Arthroscopy 21, 1904-1909.  Crossref
Journal of Sports Science and Medicine Lee J. K., Lee S., Seong S. C., Lee M. C. (2014) Anatomic single-bundle ACL reconstruction is possible with use of the modified transtibial technique: a comparison with the anteromedial transportal technique. The Journal of Bone and Joint Surgery 96, 664-672.  Crossref
Journal of Sports Science and Medicine Liu A., Sun M., Ma C., Chen Y., Xue X., Guo P., Shi Z., Yan S. (2017) Clinical outcomes of transtibial versus anteromedial drilling techniques to prepare the femoral tunnel during anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy 25, 2751-2759.  Crossref
Journal of Sports Science and Medicine Loh J. C., Fukuda Y., Tsuda E., Steadman R. J., Fu F. H., Woo S. L. (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 2002 Richard O'Connor Award paper. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 19, 297-304.  Crossref
Journal of Sports Science and Medicine Lubowitz J. H. (2009) Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 25, 95-101.  Crossref
Journal of Sports Science and Medicine MacDonald P., Kim C., McRae S., Leiter J., Khan R., Whelan D. (2018) No clinical differences between anteromedial portal and transtibial technique for femoral tunnel positioning in anterior cruciate ligament reconstruction: a prospective randomized, controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy 26, 1335-1342.  Crossref
Journal of Sports Science and Medicine Metso L., Nyrhinen K. M., Bister V., Sandelin J., Harilainen A. (2020) Comparison of clinical results of anteromedial and transtibial femoral tunnel drilling in ACL reconstruction. BioMed Central Musculoskeletal Disorders 21, 341.  Crossref
Journal of Sports Science and Medicine Mirzatolooei F. (2012) Comparison of short term clinical outcomes between transtibial and transportal TransFix® femoral fixation in hamstring ACL reconstruction. Acta Orthopaedica et Traumatologica Turcica 46, 361-366.  Crossref
Journal of Sports Science and Medicine Nakamura M., Deie M., Shibuya H., Nakamae A., Adachi N., Aoyama H., Ochi M. (2009) Potential risks of femoral tunnel drilling through the far anteromedial portal: a cadaveric study. Arthroscopy: the journal of arthroscopic & related surgery 25, 481-487.  Crossref
Journal of Sports Science and Medicine Noh J. H., Roh Y. H., Yang B. G., Yi S. R., Lee S. Y. (2013) Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: transtibial technique versus anteromedial portal technique. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 29, 882-890.  Crossref
Journal of Sports Science and Medicine Osti M., Krawinkel A., Ostermann M., Hoffelner T., Benedetto K. P. (2015) Femoral and tibial graft tunnel parameters after transtibial, anteromedial portal, and outside-in single-bundle anterior cruciate ligament reconstruction. The American Journal of Sports Medicine 43, 2250-2258.  Crossref
Journal of Sports Science and Medicine Paessler H., Rossis J., Mastrokalos D., Kotsovolos I. (2004) Anteromedial versus transtibial technique for correct femoral tunnel placement during arthroscopic ACL reconstruction with hamstrings: an in vivo study. Journal of Bone and Joint Surgery 86, 234.
Journal of Sports Science and Medicine Pande H., Prabahkara A., Singh C. M., Pande A., Mathew V., Bm N. (2017) A 3DCT scan based assessment of femoral tunnel placement in arthroscopic ACL reconstruction by modified transtibial and anteromedial portal technique and its relation with the functional outcome: A retrospective comparative study. Journal of Arthroscopy and Joint Surgery 4, 72-78.  Crossref
Journal of Sports Science and Medicine Rahr-Wagner L., Thillemann T. M., Pedersen A. B., Lind M. C. (2013) Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 29, 98-105.  Crossref
Journal of Sports Science and Medicine Rezazadeh S., Ettehadi H., Vosoughi A. R. (2016) Outcome of arthroscopic single-bundle anterior cruciate ligament reconstruction: anteromedial portal technique versus transtibial drilling technique. Musculoskeletal Surgery 100, 37-41.  Crossref
Journal of Sports Science and Medicine Ro K. H., Kim H. J., Lee D. H. (2018) The transportal technique shows better clinical results than the transtibial techniques for single-bundle anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy 26, 2371-2380.  Crossref
Journal of Sports Science and Medicine Robin B. N., Jani S. S., Marvil S. C., Reid J. B., Schillhammer C. K., Lubowitz J. H. (2015) Advantages and Disadvantages of Transtibial, Anteromedial Portal, and Outside-In Femoral Tunnel Drilling in Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 31, 1412-1417.  Crossref
Journal of Sports Science and Medicine Salinas E. A., Etcheto H. R., Blanchod C. C., Escobar G., Zordan J., Autorino C. M. (2017) Modified Transtibial versus Anteromedial Portal Technique in Single Bundle ACL Reconstruction: Tomographic Comparision Femoral Tunnel Location. Orthopaedic Journal of Sports Medicine 5, 2325967117S00025.  Crossref
Journal of Sports Science and Medicine Seo S. S., Kim C. W., Kim J. G., Jin S. Y. (2013) Clinical results comparing transtibial technique and outside in technique in single bundle anterior cruciate ligament reconstruction. Knee Surgery & Related Research 25, 133-140.  Crossref
Journal of Sports Science and Medicine Sohn O. J., Lee D. C., Park K. H., Ahn H. S. (2014) Comparison of the Modified Transtibial Technique, Anteromedial Portal Technique and Outside-in Technique in ACL Reconstruction. Knee Surgery & Related Research 26, 241-248.  Crossref
Journal of Sports Science and Medicine Stang A. (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. European Journal of Epidemiology 25, 603-605.  Crossref
Journal of Sports Science and Medicine Strauss E. J., Barker J. U., McGill K., Cole B. J., Bach B. R., Verma N. N. (2011) Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction?. The American Journal of Sports Medicine 39, 1263-1269.  Crossref
Journal of Sports Science and Medicine Sukur E., Akman Y. E., Senel A., Unkar E. A., Topcu H. N., Ozturkmen A. Y. (2016) Comparing Transtibial and Anteromedial Drilling Techniques for Single-bundle Anterior Cruciate Ligament Reconstruction. The Open Orthopaedics Journal 10, 481-489.  Crossref
Journal of Sports Science and Medicine Tasdemir Z., Gulabi D., Ozal S. T., Saglam F., Nurzat Elmalı (2015) Is there any clinical superiority of the anteromedial portal compared to the transtibial in anterior cruciate ligament reconstruction in non-professional athlete patients in short term follow-ups?. Acta Orthopaedica Et Traumatologica Turcica 49, 483-491.  Crossref
Journal of Sports Science and Medicine Venosa M., Delcogliano M., Padua R., Alviti F., Delcogliano A. (2017) Femoral Tunnel Positioning in Anterior Cruciate Ligament Reconstruction: Anteromedial Portal versus Transtibial Technique-A Randomized Clinical Trial. Joints 5, 34-38.  Crossref
Journal of Sports Science and Medicine Wei Z., Li F., Peng W., Wei B., Qiu L., Wei C. (2014) Comparative Study on Arthroscopic Anterior Cruciate Ligament Reconstruction with Transtibial Technique and through Anteromedial Approach. Chinese Journal of Reparative and Reconstructive Surgery 28, 339-344.
Journal of Sports Science and Medicine Xu H., Zhang C., Zhang Q., Du T., Ding M., Wang Y., Fu S. C., Hopkins C., Yung S. H. (2016) A Systematic Review of Anterior Cruciate Ligament Femoral Footprint Location Evaluated by Quadrant Method for Single-Bundle and Double-Bundle Anatomic Reconstruction. Arthroscopy: the Journal Of Arthroscopic & Related Surgery 32, 1724-1734.  Crossref
Journal of Sports Science and Medicine Youm Y. S., Cho S. D., Lee S. H., Youn C. H. (2014) Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. The American Journal of Sports Medicine 42, 2941-2947.  Crossref
Journal of Sports Science and Medicine Zavras T. D., Race A., Amis A. A. (2005) The effect of femoral attachment location on anterior cruciate ligament reconstruction: graft tension patterns and restoration of normal anterior-posterior laxity patterns. Knee Surgery, Sports Traumatology, Arthroscopy 13, 92-100.  Crossref
Journal of Sports Science and Medicine Zehir S., Sahin E., Songür M., Kalem M. (2016) Conventional trans-tibial versus anatomic medial portal technique for femoral tunnel preparation in anterior cruciate ligament reconstruction; comparison of clinical outcomes. Nigerian Journal of Clinical Practice 19, 475-479.  Crossref
Journal of Sports Science and Medicine Zhang Q., Zhang S., Li R., Liu Y., Cao X. (2012) Comparison of two methods of femoral tunnel preparation in single-bundle anterior cruciate ligament reconstruction: a prospective randomized study. Acta Cirurgica Brasileira 27, 572-576.  Crossref
 
 
 
Home Issues About Authors
Contact Current Editorial board Authors instructions
Email alerts In Press Mission For Reviewers
Archive Scope
Supplements Statistics
Most Read Articles
  Most Cited Articles
 
  
 
JSSM | Copyright 2001-2020 | All rights reserved. | LEGAL NOTICES | Publisher

It is forbidden the total or partial reproduction of this web site and the published materials, the treatment of its database, any kind of transition and for any means, either electronic, mechanic or other methods, without the previous written permission of the JSSM.

This work is licensed under a Creative Commons License Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.