Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation

Correct placement of the tibial and femoral bone tunnel is prerequisite to a successful anterior cruciate ligament (ACL) reconstruction. This study compares the resulting radiographic femoral bone tunnel position of two commonly used techniques for arthroscopically assisted drilling of the femoral bone tunnel: the transtibial approach or drilling through the anteromedial arthroscopy portal. The resulting bone tunnel position was assessed in postoperative knee radiographs of 70 patients after ACL reconstruction. Three independent observers identified the femoral bone tunnel and determined its position in the lateral and A–P view. Differences in femoral tunnel position between transtibial and anteromedial drilling were evaluated. In the sagittal plane, significantly more femoral bone tunnels were positioned close to the reference value using an anteromedial drilling technique (86%) when compared to transtibial drilling (57%). Drilling through the transtibial tunnel resulted in a significantly more anterior position of the femoral tunnel. In the frontal plane, femoral bone tunnels which were placed through the anteromedial arthroscopy portal displayed a significantly greater angulation towards the lateral condylar cortex (50.92°) when compared to transtibial drilling (58.82°). In conclusion, drilling the femoral tunnel through the anteromedial arthroscopy portal results in a radiographic femoral bone tunnel position which is suggested to allow stabilization of both anterior tibial translation and rotational instability when using a single bundle reconstruction technique. Further studies may evaluate if there are any clinical advantages using the anteromedial portal technique.