title: Graft position in arthroscopic anterior cruciate ligament reconstruction: anteromedial versus transtibial technique.
abstract: BACKGROUND
  When treating anterior cruciate ligament (ACL) injuries, the position of the ACL graft plays a key role in regaining postoperative knee function and physiologic kinematics. In this study, we aimed to compare graft angle, graft position in tibial tunnel, and tibial and femoral tunnel positions in patients operated with anteromedial (AM) and transtibial (TT) methods to those of contralateral healthy knees.
  
  
  METHODS
  Forty-eight patients who underwent arthroscopic ACL reconstruction with ipsilateral hamstring tendon autograft were included. Of these, 23 and 25 were treated by AM and TT techniques, respectively. MRI was performed at 18.4 and 19.7 months postoperatively in AM and TT groups. Graft angles, graft positions in the tibial tunnel and alignment of tibial and femoral tunnels were noted and compared in these two groups. The sagittal graft insertion tibia midpoint distance (SGON) has been used for evaluation of graft position in tunnel.
  
  
  RESULTS
  Sagittal ACL graft angles in operated and healthy knees of AM patients were 57.78° and 46.80° (p < 0.01). With respect to TT patients, ACL graft angle was 58.87° and 70.04° on sagittal and frontal planes in operated knees versus 47.38° and 61.82° in healthy knees (p < 0.001). ACL graft angle was significantly different between the groups on both sagittal and frontal planes (p < 0.001). Sagittal graft insertion tibia midpoint distance ratio was 0.51 and 0.48 % in the operated and healthy knees of AM group (p < 0.001) and 0.51 and 0.48 % in TT group (p < 0.001). Sagittal tibial tunnel midpoint distance ratio did not differ from sagittal graft insertion tibia midpoint distance of healthy knees in either group. Femoral tunnel clock position was better in AM [right knee 10:19 o'clock-face position (310° ± 4°); left knee 1:40 (50° ± 3°)] compared with TT group [right knee 10:48 (324° ± 5°); left knee 1:04 (32° ± 4°)]. With respect to the sagittal plane, the anterior-posterior position of femoral tunnel was better in AM patients. Lysholm scores and range of motion of operated knees in the AM and TT groups showed no significant difference (p > 0.05).
  
  
  CONCLUSIONS
  Precise reconstruction on sagittal plane cannot be obtained with either AM or TT technique. However, AM technique is superior to TT technique in terms of anatomical graft positioning. Posterior-placed grafts in tibial tunnel prevent ACL reconstruction, although tibial tunnel is drilled on sagittal plane.
authors.affiliation: Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey. olcayguler77@gmail.com.
authors.forename: Olcay
authors.identifier: http://orcid.org/0000-0002-0022-0439
authors.initials: O
authors.lastname: Guler
authors.affiliation: Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey.
authors.forename: Mahir
authors.initials: M
authors.lastname: Mahırogulları
authors.affiliation: Orthopedics and Traumatology Department, Kanuni Sultan Suleyman Training Hospital, Istanbul, Turkey.
authors.forename: Serhat
authors.initials: S
authors.lastname: Mutlu
authors.affiliation: Orthopedics and Traumatology Department, Nisa Hospital, Istanbul, Turkey.
authors.forename: Mehmet H
authors.initials: MH
authors.lastname: Cercı
authors.affiliation: Orthopedics and Traumatology Department, Medipol University, Medical Faculty, Atatürk Bulvarı No: 27 Unkapanı, Fatih, 34083, Istanbul, Turkey.
authors.forename: Ali
authors.initials: A
authors.lastname: Seker
authors.affiliation: Orthopedics and Traumatology Department, Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey.
authors.forename: Selami
authors.initials: S
authors.lastname: Cakmak
mesh_terms: D000328:Adult; D016118:Anterior Cruciate Ligament / Q000000981:diagnostic imaging / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries / Q000175:diagnosis / Q000601:surgery*; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D001182:Arthroscopy / Q000379:methods*; D005260:Female; D000070632:Hamstring Tendons / Q000637:transplantation*; D006801:Humans; D007719:Knee Joint / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D012372:ROC Curve; D016059:Range of Motion, Articular; D014182:Transplantation, Autologous
keywords: Anterior cruciate ligament reconstruction; Anteromedial technique; Lysholm scoring; Single-bundle ACL reconstruction; Tibial tunnel