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Vertical placement of the femoral tunnel can result in rotational instability and impingement against the PCL
3%
49/1506
Anterior placement of the femoral tunnel can result in elongation of the graft
8%
113/1506
Tibial tunnel placement should be placed posterior to a line extending from Blumenstaat's line when the knee is in full extension
11%
159/1506
Transtibial drilling through a tibia tunnel that is too far anterior can result in a vertical (12:00) graft
22%
330/1506
Transtibial drilling through a tibia tunnel that is too far anterior can result in an oblique (10:30 or 1:30 position) graft
56%
837/1506
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Tunnel placement is the most critical aspect of ACL reconstruction. The most common error in an ACL reconstruction is to place either the tibial or femoral tunnel too anteriorly, leading to graft impingement and failure. If the femoral tunnel is drilled through the tibia tunnel (transtibial drilling), it is important to understand that the direction of the tibial tunnel influences femoral tunnel placement. A tibia tunnel placed too far anteriorly can lead to a vertical (12:00) graft orientation relative to the intercondylar notch. This problem can also be potentially be avoided by drilling the femoral tunnel through a medial portal. Pinczewski et al reviewed radiographs of 200 ACL reconstructed patients over 7 years. There was an 11% rate of graft failure and they found if the tibial tunnel was placed >50% posteriorly along the length of the anterior tibial plateau, the incidence of rupture was 17% (11 of 66) vs 7% (8 of 115) if the graft was placed <50% posteriorly. They conclude that optimal results at seven years after operation are associated with the radiolographic orientation of the tunnels. Illustration A is a summary of the results described by Pinczewski et al. Taking 0% as the anterior and 100% as the posterior extent, the femoral tunnel was a mean of 86% along Blumensaat’s line and the tibial tunnel was 48% along the tibial plateau. Taking 0% as the medial and 100% as the lateral extent, the tibial tunnel was 46% across the tibial plateau and the mean inclination of the graft in the coronal plane was 19°. Illustration B reinforces the concept described in Option #3 and demonstrates an ideal tibial tunnel placement, whereby it is placed posterior to a line extending from Blumenstaats line when the knee is in full extension.
1.8
(102)
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