A new technique to avoid articular cartilage injury in anterior cruciate ligament reconstruction through far antero-medial portal

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    Orthopaedics & Traumatology: Surgery & Research 100 (2014) 827830

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    echnical note

    new technique to avoid articular cartilage injury in anterior cruciateigament reconstruction through far antero-medial portal

    . Kamei , M. Ochi , M.A. Usman , E.H. Mahmoudepartment of Orthopaedic surgery, Graduate School of Biomedical Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, 7348551 Hiroshima, Japan

    a r t i c l e i n f o

    rticle history:ccepted 17 June 2014

    a b s t r a c t

    Far antero-medial (FAM) portal technique is usually used in our department in anterior cruciate liga-ment (ACL) reconstruction when drilling the femoral tunnel. Although the FAM portal technique carriespotential risks, such as cartilage injury of the lateral femoral condyle, peroneal nerve injury and bloweywords:nterior cruciate ligament reconstructionar antero-medial portal techniqueartilage damage

    out of the lateral femoral condyles posterior wall, these problems were resolved in a cadaveric study,in which 110120knee flexion was recommended when drilling the femoral tunnel. However, thereis a potential risk of injuring the cartilage of the medial femoral condyle especially when drilling thepostero-lateral bundle. A new method is proposed to ensure that the femoral tunnel drilling does notdamage the cartilage of the medial femoral condyle.

    2014 Elsevier Masson SAS. All rights reserved.. Introduction

    The anterior cruciate ligament (ACL) reconstruction techniquemproved with the advancement of an anatomical study andf surgical instruments, enabling reconstruction of an authenticnatomical ACL footprint. Thus, a number of comparatively excel-ent clinical results have been reported, and its basic procedure isstablished with stable results [15]. ACL augmentation procedurereserving ACL remnant was reported for the first time by Adachit al. in 2000 [6], and then, many reports have been publishedhowing good clinical results [710]. In case of ACL remnants, anugmentation procedure is usually performed with the far antero-edial (FAM) portal technique,; the incision of the FAM portal isade as medial as possible, especially in selective PL bundle recon-truction because it is not necessary to create the AM tunnel [7]. Inuch cases, the cartilage injury of the medial femoral condyle isn issue due to the large diameter of the burr. Actually, we expe-ienced a case of the drill potentially injuring the cartilage of theedial femoral condyle. Therefore, Ochi developped a new proce-ural technique with the FAM portal involving overdrilling, whichs performed when insertion of the guide wire may interfere withhe medial femoral condyle, rendering linear access impossible athe time of creating a femoral tunnel. Corresponding author. Tel.: +81 82 57 5233.E-mail address: ochim@hiroshima-u.ac.jp (M. Ochi).

    http://dx.doi.org/10.1016/j.otsr.2014.06.016877-0568/ 2014 Elsevier Masson SAS. All rights reserved.2. Technique

    2.1. Creation of a far antero-medial portal

    Since 2011, computed tomography (CT) at 120of knee flex-ion and reconstructed three dimensional (3D) knee models usingthe volume rendering technique have been taken to investigatethe appropriate insertion point of the FAM portal. At first, theanatomical footprint on the sagittal plane is marked and decidesthe direction of the guide pin so as not to damage the cartilage ofthe medial femoral condyle. Then, the intersection of skin and guidepin is defined as the FAM portal position. Using 3D-CT, the lengthfrom the medial border of the patellar tendon to the FAM position ismeasured, in order to make a FAM portal (Fig. 1a and b). After con-firming that a 23-Gauge Cathelin needle can access the foot print ofthe femoral ACL attachment from the defined FAM position underanterolateral arthroscopic view (Fig. 2a and b), an approximately10 mm longitudinal skin incision is made.

    2.2. Creation of a femoral tunnel

    The passing pin is inserted at the anatomical position of thefemoral ACL attachment, and the tip of the pin is advanced throughthe femoral skin. Then overdrill is performed using the 4.5 mmEndobutton drill with the passing pin as the guide. However, there

    is a risk of malposition of the FAM and the tip of the drill may injurethe cartilage of the femoral medial condyle (Fig. 3.). In such a riskscenario, it is necessary to pull out the terminal of the pin towardsthe center, and advance it up to the position of 510 mm projecting


  • 828 G. Kamei et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 827830

    Fig. 1. a: the anatomical footprint of the PL bundle is marked on the sagittal plane;b: the direction of the guide pin is determined, so as not to damage the cartilage ofthe medial femoral condyle. The intersection of the skin and guide pin is defined asthe far antero-medial portal position (arrowhead). (Dotted line: the length from themedial border of the patellar tendon (arrow) to the FAM position).


    Fig. 2. a and b: a 23-Gauge Cathelin needle is inserted towards the anatomical foot-print of the anterior cruciate ligament (ACL) from the edge of the inferior medialportion of the patellar tendon not to injure the cartilage of the medial femoral

    condyle and injury to the attachment of the lateral collateral lig-rom the femoral attachment (Fig. 4). The skin incision is shiftednward utilizing the extensible property of the skin, insert the drillnto the joint with its tip outward, then gradually turn the direc-ion inward, and advance carefully, so as not to interfere with theartilage of the medial femoral condyle. After interdigitating the tipf the drill with the terminal of the pin (Fig. 5), the drill is alignedgainst the pin, and the pin is pushed back into the drill hollowole until the bone tunnel is created. After confirming that the pins placed sufficiently deeply into the drill hollow hole, a femoralunnel is created with overdrilling. In order to pull the drill outrom the articular joint cavity, the pin is pulled back, the drill tips then moving freely, and pulled out slowly turning the directionf the drill tip outward not to injure the cartilage of the medialondyle. By performing the same procedures repeatedly, it is pos-

    ible to create tunnels for the AM and PL bundles in double-bundleeconstruction.condyle and confirm the incision site.

    3. Discussion

    Three ACL reconstruction femoral drilling methods include: farantero-medial portal technique, transtibial technique and outside-in technique [11]. Each procedure has been reported to have somedisadvantages [1215]. The transtibial technique is technicallydemanding when creating the femoral tunnel, especially in double-bundle ACL reconstruction because the position of the femoraltunnel is dependent on the position and angle of the tibial tun-nel [13]. The outside-in technique is a more invasive procedurebecause it is necessary to make an additional incision on the lateralside of the distal end of the femur. The FAM portal technique car-ries the potential risks of injuring the cartilage of the lateral femoralcondyle of causing blowout of the posterior wall, of damaging theattachment of the lateral collateral ligament and of damaging theperoneal nerve. However, the mechanism of risks of the FAM por-tal technique has been solved and it is now possible to create thefemoral tunnel safely [14,15]. Nakamura et al. and Zantop et al.recommend a high knee flexion position of more than 110to pre-vent peroneal nerve injury, cartilage damage of the lateral femoralament [14,16]. Nakamae et al. recommend a knee flexion angle ofbetween 110 and 120 to avoid damage of the lateral collateral

  • G. Kamei et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 827830 829

    Fig. 3. a: insertion of the K-wire at the anatomical position and then overdrillingwft



    Fig. 4. Having pulled the terminal of the pin toward the center, advance it up tothe position 510 mm projecting from the femoral attachment; a: skeletal model;b: arthroscopic view.


    ith K-wire as the guide. There is a risk of damaging the cartilage of the medialemoral condyle; b: the cartilage damage of the medial femoral condyle caused byhe drill from the FAM portal.

    igament and cartilage injury of the lateral femoral condyle whenrilling the PL tunnel [15].For the above reasons, the FAM portal technique is used in our

    epartment when creating the femoral tunnel. The FAM portal isade as far away as possible from the medial border of the patellar

    endon, in order to prevent the risks associated with the FAM por-

    al technique, but there is a possibility of injury to the cartilage ofhe medial femoral condyle, especially with narrow intercondy-ar notch cases and in creating the PL bundle. There have beeno reports that indicate the risks of cartilage injury of the medial

    ig. 5. Insertion of the drill into the joint with its tip outward. It is then gradually turned inemoral condyle; a: skeletal model; b,c: arthroscopic view.femoral condyle when drilling the femoral tunnel. As mentionedabove, we experienced a case where the drill would have injuredthe cartilage of the medial femoral condyle. Therefore, Ochi devel-oped new method to make the femoral tunnel, so as not to injurethe cartilage of the medial femoral condyle. It is vital not to injurecartilage when inserting a 2.4-mm guide pin, but the passing pinmight pass through at the exactly the intersection with cartilagewhen drilling the femoral tunnel at the anatomical position. Thismethod will be useful in such cases as there is a high risk to injurethe cartilage in overdrilling.ward, and advanced carefully, so as not to interfere with the cartilage of the medial

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    30 G. Kamei et al. / Orthopaedics & Traumato

    isclosure of interest

    The authors declare that they have no conflicts of interest con-erning this article.


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