Purpose
The purpose of this study was to investigate and optimize anterior cruciate ligament
(ACL) femoral outside-in drilling technique with a goal of anatomic restoration of
the footprint morphologic length, width, area, and angular orientation.
Methods
Ex vivo, computer navigation was used to create virtual 3-dimensional maps of femoral
bone tunnels for ACL drill guide pin insertion paths on small, medium, and large models
of averaged femora considering various pin insertion angles to the femur. We then
determined which pin insertion angle resulted in an ACL femoral footprint optimally
matching normal human anatomic length, width, area, and angular orientation of the
footprint long axis.
Results
During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of
60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin
entrance angle of 20° to the transepicondylar axis, results in the closest approximation
of the gold standard of normal anatomic morphology of the human knee ACL femoral footprint
length, width, area, and angular orientation.
Conclusions
During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of
60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin
entrance angle of 20° to the transepicondylar axis, results in optimal reconstruction
of the normal human anatomic ACL femoral footprint length, width, area, and angular
orientation.
Clinical Relevance
We describe arthroscopic landmarks for anatomic ACL femoral socket creation that may
be considered by practicing arthroscopic surgeons in the operating room, without open
dissection or fluoroscopy and unaffected by type of drill guide or variations in the
thickness of the femoral soft-tissue envelope.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to ArthroscopyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The ability of 3 different approaches to restore the anatomic anteromedial bundle femoral insertion site during anatomic anterior cruciate ligament reconstruction.Arthroscopy. 2011; 27: 200-206
- Anterior cruciate ligament femoral tunnel length: Cadaveric analysis comparing anteromedial portal versus outside-in technique.Arthroscopy. 2010; 26: 1357-1362
- Anteromedial portal technique for the anterior cruciate ligament femoral socket: Pitfalls and solutions.Arthroscopy. 2009; 25: 95-101
- Femoral tunnel position in anterior cruciate ligament reconstruction using three techniques. A cadaver study.Arthroscopy. 1999; 15: 750-756
- Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: A cadaveric study of femoral tunnel length and obliquity.Arthroscopy. 2010; 26: 342-350
- A comparison of 2 drilling techniques on the femoral tunnel for anterior cruciate ligament reconstruction.Arthroscopy. 2011; 27: 372-379
- Single versus two-incision arthroscopic anterior cruciate ligament reconstruction.Arthroscopy. 1996; 12: 462-469
- My technique in femoral tunnel preparation: The “Retro-Drill” technique.Tech Orthop. 2005; 20: 224-227
- Development and application of an inside-to-out drill bit for anterior cruciate ligament reconstruction.Arthroscopy. 2005; 21: 1012
- All-inside anterior cruciate ligament graft-link technique: Second-generation, no-incision anterior cruciate ligament reconstruction.Arthroscopy. 2011; 27: 717-727
- No tunnel 2-socket technique: All-inside anterior cruciate ligament double-bundle retroconstruction.Arthroscopy. 2008; 24: 1184-1189
- No-tunnel anterior cruciate ligament reconstruction: The transtibial all-inside technique.Arthroscopy. 2006; 22: 900.e1-900.e11
- Reconstruction technique affects femoral tunnel placement in ACL reconstruction.Clin Orthop Relat Res. 2008; 466: 1467-1674
- Femoral tunnel placement during anterior cruciate ligament reconstruction: An in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel–independent techniques.Am J Sports Med. 2009; 37: 1904-1911
- Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: A radiographic evaluation.Knee Surg Sports Traumatol Arthrosc. 2009; 17: 220-227
- Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: A cadaver study.Knee Surg Sports Traumatol Arthrosc. 2001; 9: 194-199
- Transitioning to anatomic anterior cruciate ligament graft placement.J Knee Surg. 2009; 22: 155-160
- The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: A cadaveric study.Arthroscopy. 2007; 23: 1187-1192
- Double-bundle anterior cruciate ligament reconstruction: A cadaveric study on the posterolateral tunnel position and safety of the lateral structures.Arthroscopy. 2008; 24: 436-440
- Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 459-464
- Effect of knee flexion angle on tunnel length and articular cartilage damage during anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: e31
- Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel.Arthroscopy. 2008; 24: 113-115
- Potential risks of femoral tunnel drilling through the far anteromedial portal: A cadaveric study.Arthroscopy. 2009; 25: 481-487
- Anterior cruciate ligament femoral footprint anatomy: Systematic review of the 21st century literature.Arthroscopy. 2012; 28: 872-881
- Medial portal drilling: Effects on the femoral tunnel aperture morphology during anterior cruciate ligament reconstruction.J Bone Joint Surg Am. 2011; 93: 2063-2071
- The femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: A radiographic evaluation.Knee Surg Sports Traumatol Arthrosc. 2010; 18: 52-55
- Anterior cruciate ligament reconstruction: Endoscopic versus two-incision technique.Arthroscopy. 1994; 10: 502-512
- Clinical and radiographic results of ACL reconstruction: A 5- to 7-year followup study of outside-in versus inside-out reconstruction techniques.Knee Surg Sports Traumatol Arthrosc. 2001; 9: 77-85
- Anatomic anterior cruciate ligament reconstruction: The two incision technique.Knee Surg Sports Traumatol Arthrosc. 2006; 14: 510-516
- Femoral and tibial tunnel position using a transtibial drilled anterior cruciate ligament reconstruction technique.J Knee Surg. 2008; 21: 246-249
- Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography.J Bone Joint Surg Am. 2010; 92: 1427-1431
- Independent drilling outperforms conventional transtibial drilling in anterior cruciate ligament reconstruction.Am J Sports Med. 2009; 37: 1912-1919
- Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions.Am J Sports Med. 2010; 38: 1987-1996
- Arthroscopy, anatomy, and translational research.Arthroscopy. 2007; 23: 233-234
Article info
Publication history
Published online: January 18, 2013
Accepted:
October 7,
2012
Received:
September 24,
2011
Footnotes
The authors report the following potential conflict of interest or source of funding in relation to this article: Arthrex. Consulting (J.H.L., S.A.), employee (J.K.), and education and research support (J.H.L., S.A., B.R.W., A.A-H.).
Identification
Copyright
© 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
