The relationship of lateral anatomic structures to exiting guide pins during femoral tunnel preparation utilizing an accessory medial portal

Anatomic reconstruction of the anterior cruciate ligament through an accessory medial portal has become increasingly popular. The purpose of this study is to describe the relationship of guide pin exit points to the lateral anatomic structures when preparing the anterior cruciate ligament femoral tunnel through an accessory medial portal. We utilized seven fresh frozen cadaveric knees. Utilizing an anteromedial approach, a guide wire was placed into the center of each bundle's footprint. Each guide wire was advanced through the lateral femoral cortex. The guide pins were passed at 90, 110, and 130A degrees of knee flexion. The distances from each guide pin to the closest relevant structures on the lateral side of the knee were measured. At 90A degrees the posterolateral bundle guide pin was closest to the lateral condyle articular cartilage (mean 5.4 +/- A 2.2 mm) and gastrocnemius tendon (mean 5.7 +/- A 2.1 mm). At 110A degrees the posterolateral bundle pin was closest to the gastrocnemius tendon (mean 4.5 +/- A 3.4 mm). At 130A degrees the posterolateral bundle pin was closest to the gastrocnemius tendon (mean 7.2 +/- A 5.5 mm) and lateral collateral ligament (mean 6.8 +/- A 2.1 mm). At 90A degrees the anteromedial bundle guide pin was closest to the articular cartilage (mean 2.0 +/- A 2.0 mm). At 110A degrees the anteromedial bundle pin was closest to the articular cartilage (mean 7.4 +/- A 3.5 mm) and gastrocnemius tendon (mean 12.3 +/- A 3.1 mm). At 130A degrees the AM bundle pin was closest to the gastrocnemius tendon (mean 8.2 +/- A 3.2 mm) and LCL (mean 15.1 +/- A 2.9 mm). Neither guide pin (anteromedial or posterolateral bundle) put the peroneal nerve at risk at any knee flexion angle. At low knee flexion angles the anteromedial and posterolateral bundle guide pins closely approximated multiple lateral structures when using an accessory medial arthroscopic portal. Utilizing higher flexion angles increases the margin of error when preparing both femoral tunnels. During preparation of the anterior cruciate ligament femoral tunnel through an accessory anteromedial portal the tunnels should be drilled in at least 110A degrees of knee flexion in order to move guide pin exit points away from important lateral knee structures.