Comparison of three approaches for femoral tunnel during double-bundle anterior cruciate ligament reconstruction: A case controlled study

Abstract Background It is still controversial whether which femoral tunnel creation technique is best during anterior cruciate ligament reconstruction (ACLR). We aimed to clarify the features of three different techniques based on the femoral tunnel position created with the same tunnel-creating concept and the measurement data. Methods The femoral tunnel of double-bundle (DB) ACLR was created using the behind-remnant approach in a remnant preserved manner following the policy of our institute. The trans-tibial approach (TT) was applied for all primary ACL injured cases until December 2012. The trans-portal approach (TP) was applied from January to September 2013, and the outside-in approach (OI) was indicated from October 2013 to March 2014. We compared the femoral tunnel aperture positions with the postoperative three-dimensional computed tomography (3D-CT). Additionally, the femoral tunnel length and the septum distance of each anteromedial (AM) and posterolateral (PL) tunnel were analyzed. Results The AM tunnel aperture position of TT was significantly higher and shallower than that of TP in knee flexion position. The femoral tunnel length of TP was significantly shorter than that of TT and OI. The septum between each tunnel of OI trended wider than that of TT and TP. Conclusions The AM tunnel aperture position of TT runs the risk of a high and shallow position. TP runs the risk of insufficiently short tunnel length. It is important to apply each method flexibly to each case because no single best approach was found.