Anatomic femoral tunnel placement is difficult by the transtibial technique: comparison of three different femoral tunnel drilling techniques in double-bundle anterior cruciate ligament reconstructions

Knee Surg Sports Traumatol Arthrosc. 2020 Feb;28(2):584-593. doi: 10.1007/s00167-019-05740-8. Epub 2019 Oct 14.


Purpose: To compare the position and direction of femoral and tibial tunnels for both the anteromedial bundle (AMB) and posterolateral bundle (PLB) among three different femoral tunnel drilling techniques, transtibial (TT), transportal (TP), and outside-in (OI) techniques, in anatomic double-bundle ACL reconstruction to clarify advantages and disadvantages of each technique.

Methods: One-hundred and thirty-nine patients underwent primary ACL reconstruction with an autologous semitendinosus tendon in our institution between 2014 and 2016. Thirteen patients were excluded according to the exclusion criteria. Of the 126 patients, 98 patients agreed to be included in this study. Patients were then randomized into three groups according to the femoral tunnel drilling technique; the TT, TP, and OI groups. Femoral and tibial tunnel angles and positions were measured using three-dimensional computed tomography.

Results: Of patients who agreed to be included in this study, eight patients (seven in TT and one in OI) were excluded since the femoral tunnel could not be created at the intended position. Eighty-six patients (29 in TT, 29 in TP, and 28 in OI) were included for the analyses. Tunnel angles, as well as tunnel lengths, had significant differences among different techniques depending on each technique's characteristics. In terms of tunnel position, femoral tunnel positions of both the AMB and PLB in the TT group were significantly higher than those in the TP group (AMB: p = 0.003, PLB: p = 0.001), and the PLB tunnel position in the TP group had significantly smaller vaciance than that in the TT group (p = 0.004) and OI group (0.002).

Conclusions: The femoral tunnel positions created by the TT technique were significantly higher, with larger variance, than the TP technique in double-bundle ACL reconstruction, although the positions seemed to be within anatomical footprint. In addition, there were several cases in which femoral tunnels could not be created at the intended position by the TT technique.

Level of evidence: I.

Keywords: Anterior cruciate ligament; Outside-in technique; Randomized controlled trial; Transportal technique; Transtibial technique; Tunnel position.

Publication types

  • Comparative Study

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament Injuries / diagnostic imaging
  • Anterior Cruciate Ligament Injuries / surgery*
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Female
  • Femur / diagnostic imaging
  • Femur / surgery*
  • Hamstring Tendons / transplantation
  • Humans
  • Male
  • Middle Aged
  • Tibia / diagnostic imaging
  • Tibia / surgery
  • Tomography, X-Ray Computed
  • Young Adult