Femoral Tunnel Placement During Anterior Cruciate Ligament Reconstruction An In Vivo Imaging Analysis Comparing Transtibial and 2-Incision Tibial Tunnel-Independent Techniques

Background: Recent studies have questioned the ability of the transtibial technique to place the anterior cruciate ligament graft within the footprint of the anterior cruciate ligament on the femur. There are limited data directly comparing the abilities of transtibial and tibial tunnel-independent techniques to place the graft anatomically at the femoral attachment site of the anterior cruciate ligament in patients. Hypothesis: Because placement with the tibial tunnel-independent technique is unconstrained by the tibial tunnel, it would allow for more anatomic tunnel placement compared with the transtibial technique. Study Design: Cross-sectional study; Level of evidence, 3. Methods: High-resolution, multiplanar magnetic resonance imaging and advanced 3-dimensional modeling techniques were used to measure in vivo femoral tunnel placement in 8 patients with the transtibial technique and 8 patients with a tibial tunnel independent technique. Femoral tunnel placement in 3 dimensions was measured relative to the center of the native anterior cruciate ligament attachment on the intact contralateral knee. Results: The tibial tunnel-independent technique placed the graft closer to the center of the native anterior cruciate ligament attachment compared with the transtibial technique. The transtibial technique placed the tunnel center an average of 9 mm from the center of the anterior cruciate ligament attachment, compared with 3 mm for the tibial tunnel-independent technique. The transtibial technique resulted in a more anterior and superior placement of the tunnel compared with the tibial tunnel independent technique. Conclusion: The tibial tunnel-independent technique allowed for more anatomic femoral tunnel placement compared with the transtibial technique.