[Anatomical double-bundle anterior cruciate ligament reconstruction - transtibial versus anteromedial reaming of femoral tunnels].

PURPOSE OF THE STUDY: The aim of the study was to compare two options of how to get the correct anatomical position of both femoral tunnels, using the transtibial or the anteromedial portal technique, during anatomical double-bundle anterior cruciate ligament (ACL) reconstruction.

MATERIAL AND METHODS: A total of 36 patients, 29 men and seven women, underwent double-bundle ACL reconstruction between October 2009 and December 2010. Their average age was 26.5 years. The average interval between ACL injury and reconstruction was 7.4 months. A diagnostic arthroscopy for the treatment of cartilage and meniscal lesions was performed in 21 patients and one-stage ACL reconstruction with diagnostic arthroscopy was carried out in the remaining 15 patients. In all 36 patients, the position of the tip of the guide wire in relation to the anatomical insertion sites of both the anteromedial (AM) and posterolateral (PL) bundles was assessed intra-operatively. Three guide wire positions were found: the tip was in the centre of the native insertion site, the tip was within the insertion site but not in its centre, and the tip was outside the insertion site.

RESULTS: Using the transtibial technique through the AM tunnels, the tip of the guide wire was centred within the femoral AM insertion site only in one patient (2.8%), out of the centre but within the AM insertion site in four patients (11.1%) and outside the insertion site in the remaining 31 patients (86.1%). With this technique, the position of the femoral PL tunnels was outside the native PL insertion site in all 36 patients. With the transtibial technique using the PL tunnels, the tip of the guide wire was centred within the femoral AM native insertion in 11 patients (30.5%), out of the centre but still within the AM insertion site in 16 (44.5%) and outside the AM insertion site in nine patients (25%). Aiming for the femoral PL tunnel resulted in the tip of the guide wire being outside the native femoral PL insertion site in all cases. Using the technique of guide wire insertion through an accessory AM portal it was possible to achieve the centres of both the AM and PL native anatomical insertion sites in all 36 patients (100%).

DISCUSSION: We agree with the many authors who recommend the reaming of PL femoral tunnels through an accessory AM portal because the transtibial technique does not allow for the placement of their precise native anatomical positions. Our intraoperative findings showed that the transtibial technique was effective to get the correct anatomical position of AM femoral tunnels just in 30.5% of the patients. In view of the fact that the same results can be achieved with the AM transportal technique in 100% of the patients, we prefer this technique in accordance with the majority of other authors.

CONCLUSIONS: In anatomical double-bundle ACL reconstruction, the native anatomical position of PL tunnels was achieved in all patients and the native AM tunnels in most of them using the accessory AM portal technique. The transtibial technique proved to be unsatisfactory.