Review of evolution of tunnel position in anterior cruciate ligament reconstruction

Table 3 Clinical studies summary

Ref.	Year	Study type	Study size	Graft type	Femoral tunnel positioning	Tibial tunnel positioning	Follow-up time	Outcome measures	Results
Adebe et al[57]	2011	Retrospective cohort	22 patients	Hamstring and (BPTB)	Anatomic vs non-anatomic	-	6-36 mo	Tibial translation and rotation	Anatomic tunnel more stable in terms of anterior and medial translation and internal rotation
Alentorn-Geli et al[65]	2010	Cross-sectional comparative	47 patients	BPTB	Transtibial vs anteromedial portal techniques	-	2-5 yr	IKDC score; knee stability; ROM; one-leg hop test; mid-quadriceps circumference; VAS for satisfaction with surgery; Lysholm score; Tegner score; SF-12	From AMP technique, significantly lower recovery time from surgery to walking without crutches, return to normal life, return to jogging, training and play. Significantly better knee stability values but no difference in other functional scores surgery
Avadhani et al[69]	2010	Prospective cohort	41 patients	BPTB	-	AP position of tunnel	Minimum 2 yr	IKDC score; modified lysholm score	Placing the tibial tunnel in the anterior 25% of the tibial plateau was associated with poor knee outcomes
Behrend et al[59]	2006	Retrospective cohort	50 patients	BPTB	Position assessed using quadrant method of bernard and hertel	Position assessed using criteria of staubli and rauschning	Mean 19 mo	IKDC score	More anterior the femoral canal, highly significant correlation with poorer IKDC score. Position of the tibial tunnel had no statistically significant effect on IKDC score
Duffee et al[61]	2013[6]	Prospective cohort	436 patients	Hamstring and BPTB	Transtibial vs anteromedial portal techniques	-	6 yr	KOOS	No difference between the techniques in terms of predicting functional outcome with KOOS
Fernandes et al[60]	2014	Prospective cohort	86 patients	Hamstring and BPTB	Anteromedial footprint (anatomic) and high anteromedial position	-	6 and 12 mo	IKDC score; tegner score; lysholm scale; return to sports	Femoral tunnel positions at AM footprint and high AM position associated with earlier return to sports on previous Tegner score level and better functional outcomes at 12 mo
Franceschi et al[62]	2013	Retrospective cohort	94 patients	Hamstring	Transtibial vs anteromedial portal techniques	-	Minimum 5 yr	IKDC score; Lysholm scale; KT-1000 arthrometer; Lachman test; Pivot shift test; radiographic assessment	No difference between the two techniques in terms of functional scores (lysholm and IKDC) though the anteromedial portal technique provided better rotational and anterior translational stability
Hatayama et al[68]	2013	Prospective cohort	60 patients	Hamstring	-	AP position of tibial tunnel	2 yr	Pivot shift test; stress radiographs; 2nd look arthroscopy	Anterior placement of the tibial tunnel inside the footprint led to better anterior knee stability
Hosseini et al[58]	2012	Retrospective cohort	26 patients	Hamstring, BPTB and allograft	Non-anatomic	Non-anatomic	-	Patients undergoing revision ACL surgery: MRI based 3D modelling	Both the tibial and femoral tunnel positions in the failed ACLR were non-anatomic compared to native ACL values
Jepsen et al[55]	2007	Prospective randomised trial	60 patients	Hamstring	High (1 o’clock) vs Low (2 o’clock) positions	-	1 yr	Laxity; IKDC Evaluation and Examination forms; radiograph assessment	No significant difference in the laxity at 25 degrees and 70 degrees or scores on the IKDC examination form. Significant difference in the scores on the IKDC evaluation form
Koutras et al[64]	2013	Prospective cohort	51 patients	Hamstring	Transtibial vs anteromedial portal techniques	-	3 and 6 mo	Lysholm score; isokinetic tests; functional tests	AMP technique had significantly better suggesting a quicker return to function and performance
Noh et al[52]	2013	Prospective randomised trial	61 patients	Allograft	Transtibial vs anteromedial portal techniques	-	Mean 30.2 mo	Lachman test; pivot shift test; IKDC score; lysholm score; tegner activity scale; radiograph and MRI assessment	AMP technique resulted in a more posterior femoral tunnel position than the TT technique and knees with this technique were more stable with a higher lysholm score
Ohsawa et al[67]	2012	Retrospective cohort	121 patients	Hamstring	-	Posterior tibial landmark vs anterior tibia landmark	Minimum 2 yr	3D CT; 2nd look arthroscopy + EUA; Lachman, pivot shift and side-side stability tests; lysholm score	Pivot shift and side to side stability tests and knee flexion were significantly better in the anterior landmark group
Park et al[54]	2010	Cross-sectional	70 patients	Allograft	High (1 o’clock) vs low (2 o’clock) positions	-	Intraoperative	Intraoperative anterior and rotational knee stability at differing degrees of flexion	The low femoral tunnel group showed significantly better intraoperative internal rotational stability at 0° and 30° of flexion
Rahr-Wagner et al[63]	2013	Prospective cohort	9239 patients	-	Transtibial vs anteromedial technique	-	4 yr	Need for revision; pivot-shift and instrumented objective test	Increased risk of revision ACL surgery when using the AM technique compared with the TT technique
Sadoghi et al[56]	2011	Prospective cohort	53 knees	Hamstring and BPTB	Anatomic vs non-anatomic	Anatomic vs non-anatomic	1 yr	3D CT; Tegner score;WOMAC score; IKDC score; KT-1000 arthrometer measurements; pivot-shift test	Significantly superior clinical outcome in anatomic ACL reconstructions in terms of higher clinical scores (tegner and IKDC), higher anterior posterior stability, and less pivot shift
Seon et al[53]	2011	Prospective cohort	58 patients	Allograft	High (1 o’clock) vs low (2 o’clock) positions	-	Minimum 2 yr	Lysholm; Tegner; Clinical and radiographic stability	Low tunnel group had significantly better internal rotational stability at 0 and 30 degrees of knee flexion
Seo et al[66]	2013	Retrospective cohort	89 patients	Allograft	Transtibial vs“outside in” techniques	-	Minimum 1 yr	3D CT; pivot-shift; lachman; IKDC; lysholm; tegner; ROM	A more anatomical femoral tunnel with better knee joint rotational stability on pivot shift test
Taketomi et al[51]	2013	Case series	34 patients	Hamstring	Anatomic	-	2 yr	Lysholm score; IKDC score; KT-2000 arthrometer; lachman test; reverse pivot-shift test	Excellent short-term using the anatomic femoral tunnel objectively, subjectively and in terms of knee stability

ACL: Anterior cruciate ligament; AM: Anteromedial; TT: Transtibial; KOOS: Knee injury and osteoarthritis outcomes score; ACLR: Anterior cruciate ligament reconstruction; SF-12: Short form 12; VAS: Visual analogue scale; AP: Anter posterior; TT: Transtibial; AMP: Antero medial portal; ROM: Range of movements.