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The three techniques for femoral tunnel placement in anterior cruciate ligament reconstruction: transtibial, anteromedial portal, and outside-in techniques
Arthrosc Orthop Sports Med 2015;2:77-85
Published online July 1, 2015;  https://doi.org/10.14517/aosm14021
© 2015 Arthroscopy and Orthopedic Sports Medicine.

Nam-Ki Kim, Jong-Min Kim

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Correspondence to: Jong-Min Kim, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea. Tel: +82-2-3010-3897, Fax: +82-2-488-7877, E-mail: jmkim@amc.seoul.kr
Received December 23, 2014; Revised March 11, 2015; Accepted March 11, 2015.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
A femoral tunnel can be created using the transtibial (TT), anteromedial (AM) portal, or outside-in technique. TT technique has a tendency to produce a femoral tunnel in non-anatomic location and a graft may be placed too anteriorly and vertically. Postoperative complications including graft failure and rotational instability have been reported following TT technique. Modified TT techniques were developed for more horizontal and oblique femoral tunnel. Although, modified TT techniques create the femoral tunnel closer to the anterior cruciate ligament (ACL) footprint than the conventional TT technique, they result in shorter tibial tunnel and widening of the intra-articular aperture of tibial tunnel. ACL reconstruction techniques have been transformed into anatomical and tibial tunnel-independent techniques. The AM portal technique uses an accessory AM portal to drill the femoral tunnel separately. It allows more accurate placement of the femoral tunnel guide. However, the AM portal technique has complications such as short femoral socket, posterior wall blowout of the femoral socket. The outside-in technique allows more freedom with positioning of the femoral tunnel and can be performed in retrograde fashion. It is especially useful in revision ACL reconstruction for skeletally immature patients and for those with less than 130˚ of limited range of flexion.
Keywords : Anterior cruciate ligament; Reconstruction; Transtibial technique; Anteromedial portal technique; Outside-in technique
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