Advantages and Disadvantages of Transtibial, Anteromedial Portal, and Outside-In Femoral Tunnel Drilling in Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review.
OBJECTIVE
Controversy exists regarding the best method for creating the knee anterior cruciate ligament (ACL) femoral tunnel or socket. The purpose of this study was to systematically review the risks, benefits, advantages, and disadvantages of the endoscopic transtibial (TT) technique, anteromedial portal technique, outside-in technique, and outside-in retrograde drilling technique for creating the ACL femoral tunnel.


METHODS
A PubMed search of English-language studies published between January 1, 2000, and February 17, 2014, was performed using the following keywords: "anterior cruciate ligament" AND "femoral tunnel." Included were studies reporting risks, benefits, advantages, and/or disadvantages of any ACL femoral technique. In addition, references of included articles were reviewed to identify potential studies missed in the original search.


RESULTS
A total of 27 articles were identified through the search. TT technique advantages include familiarity and proven long-term outcomes; disadvantages include the risk of nonanatomic placement because of constrained (TT) drilling. Anteromedial portal technique advantages include unconstrained anatomic placement; disadvantages include technical challenges, short tunnels or sockets, and posterior-wall blowout. Outside-in technique advantages include unconstrained anatomic placement; disadvantages include the need for 2 incisions. Retrograde drilling technique advantages include unconstrained anatomic placement, as well as all-epiphyseal drilling in skeletally immature patients; disadvantages include the need for fluoroscopy for all-epiphyseal drilling.


CONCLUSIONS
There is no one, single, established "gold-standard" technique for creation of the ACL femoral socket. Four accepted techniques show diverse and subjective advantages, disadvantages, risks, and benefits.


METHODS
Level V, systematic review of Level II through V evidence.
Taos Orthopaedic Institute, Taos, New Mexico, U.S.A.
Brett N
BN
Robin
Taos Orthopaedic Institute, Taos, New Mexico, U.S.A.
Sunil S
SS
Jani
Taos Orthopaedic Institute, Taos, New Mexico, U.S.A.
Sean C
SC
Marvil
Taos Orthopaedic Institute, Taos, New Mexico, U.S.A.
John B
JB
Reid
Taos Orthopaedic Institute, Taos, New Mexico, U.S.A.
Carl K
CK
Schillhammer
Taos Orthopaedic Institute, Taos, New Mexico, U.S.A.. Electronic address: jlubowitz@kitcarson.net.
James H
JH
Lubowitz
D000328:Adult; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D059549:Anterior Cruciate Ligament Reconstruction / Q000009:adverse effects / Q000379:methods*; D001182:Arthroscopy / Q000379:methods; D004838:Epiphyses / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D005269:Femur / Q000601:surgery; D005471:Fluoroscopy; D006801:Humans; D007718:Knee Injuries / Q000601:surgery; D008297:Male; D018570:Risk Assessment; D013977:Tibia / Q000601:surgery