Femoral Tunnel Apertures on the Lateral Cortex in Anterior Cruciate Ligament Reconstruction: An Analysis of Cortical Button Fixation

Purpose If the aperture of the oval-shaped femoral tunnel on the lateral cortex becomes bigger than half the size of the cortical button, the risk of fixation failure increases. This study investigated the effect of the location of the entry point and diameter of the femoral tunnel on the length of the major axis of the tunnel aperture in anterior cruciate ligament (ACL) reconstruction using an outside-in technique. Methods Simulation of femoral tunnel drilling was performed on computed tomography (CT)-based 3-dimensional (3D) bone models obtained from 40 participants. The tunnel connected the center of the ACL footprint and various points on the lateral femoral surface. The diameter of the tunnel was set at 4.2 mm, 5.2 mm, or 6 mm, depending on the commercially available outside-in surgical systems (Arthrex, Naples, FL and Smith & Nephew, Andover, MA). The length of the major axis of the oval-shaped aperture on the lateral femoral surface was measured. Results When the tunnel was introduced at 2 cm from the lateral epicondyle in a 45° anteroproximal direction, the major axis was lengthened to 130.7% ± 9.0% ( P Conclusions The risk of fixation failure of a cortical button increases if the entry point for drilling is 2 cm or further from the lateral epicondyle and the tunnel diameter is more than 5 mm. Clinical Relevance This study indicates the potential risk of cortical button fixation failure caused by an oval tunnel aperture on the lateral femoral surface in ACL reconstruction using the outside-in technique.