 KNEE

Graft-bending angle and femoral tunnel

length after single-bundle anterior cruciate
ligament reconstruction
COMPARISON OF THE TRANSTIBIAL, ANTEROMEDIAL PORTAL
Y. S. Shin, AND OUTSIDE-IN TECHNIQUES
K. H. Ro,
We used immediate post-operative in vivo three-dimensional computed tomography to
J. H. Jeon,
compare graft bending angles and femoral tunnel lengths in 155 patients who had
D. H. Lee
undergone single-bundle reconstruction of the anterior cruciate ligament using the
transtibial (n = 37), anteromedial portal (n = 72) and outside-in (n = 46) techniques.
From Korea
The bending angles in the sagittal and axial planes were significantly greater but the
University Anan
coronal-bending angle was significantly less in the transtibial group than in the
Hospital, Seoul,
anteromedial portal and outside-in groups (p < 0.001 each). The mean length of the femoral
Korea
tunnel in all three planes was significantly greater in the transtibial group than the
anteromedial portal and outside-in groups (p < 0.001 each), but all mean tunnel lengths in
the three groups exceeded 30 mm. The only significant difference was the coronal graft-
bending angle in the anteromedial portal and outside-in groups (23.5° vs 29.8°, p = 0.012).
Compared with the transtibial technique, the anteromedial portal and outside-in
techniques may reduce the graft-bending stress at the opening of the femoral tunnel.
Despite the femoral tunnel length being shorter in the anteromedial portal and outside-in
techniques than in the transtibial technique, a femoral tunnel length of more than 30 mm in
the anteromedial portal and outside-in techniques may be sufficient for the graft to heal.
Cite this article: Bone Joint J 2014;96-B:743–51.

 Y. S. Shin, MD, Orthopaedic
Surgeon
Seonam Hospital, Department
of Orthopaedic Surgery, Seoul,
Korea.
 K. H. Ro, MD, Orthopaedic
Surgeon
 J. H. Jeon, MD, Orthopaedic
Surgeon
 D. H. Lee, MD, Orthopaedic
Surgeon & Professor
Anam Hospital, Department of
Orthopaedic Surgery, Korea
University, College of
Medicine, Seoul, Korea.
Correspondence should be sent
to Dr D. H. Lee; e-mail:
eoak22@empal.com
©2014 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.96B6.
33201 $2.00
Bone Joint J
2014;96-B:743–51.
Received 16 September 2013;
Accepted after revision 26
March 2014
The transtibial (TT) technique has been most
popular method of reconstructing the anterior
cruciate ligament (ACL) for the past 20 years.
However, the intra-articular opening of the
femoral tunnel created by the TT technique
may lie outside the true femoral footprint of
the ACL. This may result in a non-anatomical
femoral tunnel, which is the main cause of con-
ventional ACL reconstruction failure with use
of this technique.1,2 Consequently, the antero-
medial (AM) portal and outside-in (OI) tech-
niques of reconstruction of the ACL were
developed to centre the graft within the femo-
ral insertion of the ACL and to address the
non-anatomical direction of the graft.3,4
Three-dimensional computed tomography
(3D-CT) has been used to evaluate the results of
ACL reconstruction.5,6 Most of these,7-9 how-
ever, have focused on measuring the femoral tun-
nel opening and its direction to show the
superiority of the AM portal and OI techniques
in reproducing the anatomical footprints of the
ACL. Graft-bending angle and femoral tunnel
length may be of greater clinical relevance. The
graft-bending angle may be associated with
reduced graft longevity, due to abrasive wear
from the sharp edge of the bone tunnel opening
when the graft is acutely bent and stretched.10,11
If the femoral tunnel length is too short, this may
reduce graft healing because of an inadequate
length of graft in the tunnel itself.12-14 The AM
portal technique has been shown to result in a
shorter femoral tunnel than the TT tech-
nique,15,16 but comparisons of their graft-bend-
ing angles have yielded conflicting results.
To the best of our knowledge, no in vivo 3D-
CT studies have assessed graft-bending angles
and femoral tunnel lengths of single-bundle
ACL reconstruction using the OI technique.
Moreover, comparisons of bending angles
using the TT and AM portal techniques have
been performed only in cadaveric specimens:
no in vivo studies have used 3D-CT.17,18
We therefore compared the graft-bending
angle and length of femoral tunnel after the use
of these three femoral drilling techniques in sin-
gle-bundle ACL reconstruction, using in vivo
3D-CT analysis. We hypothesised that TT
would result in a less acute graft-bending angle
and a longer femoral tunnel length than the AM
portal and OI techniques and that there would
be no difference between the latter two methods.

VOL. 96-B, No. 6, JUNE 2014 743

744 Y. S. SHIN, K. H. RO, J. H. JEON, D. H. LEE
Table I. Demographic and clinical characteristics of patients included in this study
Data
Parameter Transtibial
Number of male/female patients 32:5
Mean age in years (range) 35 (19 to 60)
Mean height in cm (range) 173 (153 to 183)
Mean weight in kg (range) 75 (46.9 to 104)
Mean body mass index in kg/m2 (range) 25.2 (19.8 to 35.4)
Patients and Methods
Between 2010 and 2012, we prospectively collected data
from 118 patients who were about to undergo reconstruc-
tion of the ACL with autologous hamstring tendon, using
either the AM portal (72 patients) or OI technique
(46 patients). For comparison, we retrospectively evaluated
the immediate post-operative 3D-CTs of 37 patients who
had undergone reconstruction of the ACL with autologous
hamstring tendon between April 2008 and December 2010,
using the TT technique. These 37 patients had a similar
body mass index (BMI), age and height as the patients in
the AM portal and OI groups. Patients were excluded if
they had combined collateral or posterior cruciate ligament
injuries, or were undergoing revision ACL reconstruction.
In our hospital, the TT technique was used for ACL
reconstruction until December 2010, after which the AM
portal technique was introduced due to growing concern
about positioning of the femoral tunnel opening with the
TT technique. When the FlipCutter (Arthrex, Naples, Flor-
ida) became available to us in October 2011, we changed to
the OI technique. However, if patients did not want two
incisions, the AM portal technique was used. The mean
ages of the TT, AM portal and OI groups were 35 years
(19 to 60), 30 years (15 to 53) and 32 years (16 to 60),
respectively. The pre-operative demographic data of the
three groups were similar (Table I). All operations were car-
ried out by a single surgeon (DHL). The study was
approved by the Ethics Committee of our hospital (Korea
University Anam Hospital). All patients who underwent
reconstruction of the ACL using the AM portal and OI
techniques provided written informed consent for the oper-
ation and an immediate post-operative CT scan. Patients
who had previously undergone ACL reconstruction using
the TT technique consented by telephone to enrolment in
the study. In order to avoid the possible effects of tunnel
widening after autograft reconstruction, which usually
(75%) occurs three to six months post operatively,19 all
patients underwent post-operative 3D-CT within three
days of their surgery.
In general, the operation started with arthroscopic
debridement of the joint and harvesting of the ipsilateral
hamstring tendon. Transtibial ACL reconstruction was car-
ried out using conventional anterolateral (AL) and antero-
Anteromedial portal Outside-in p-value
49:23 37:9 0.171
30 (15 to 53) 32 (16 to 60) 0.094
170 (151 to 184) 171 (149 to 184) 0.281
74 (48 to 130) 69 (43 to 85) 0.063
25.4 (18.4 to 40.1) 23.7 (17.5 to 30.4) 0.237
medial (AM) portals. The extra-articular landmark of the
tibial tunnel was always 1 cm above the insertion of the pes
anserinus and 1.5 cm medial to the tibial tubercle to allow
for oblique orientation (approximately 50°) of the tibial
guide. The intra-articular point of the tibial guide was
placed at the centre of the native tibial footprint of the
ACL. After insertion of the guide pin, a tibial tunnel was
created using a cannulated reamer of the same diameter as
the graft. A 5 mm to 7 mm femoral offset guide was
inserted through the tibial tunnel and placed in the over-
the-top position by flexing the knee to 90°. The guide pin
was directed between the 10.30 and 11 o’clock positions
for the right knee and between the 1 o’clock and 1.30 posi-
tions for the left knee. An appropriately-sized cannulated
reamer was next passed through the tibial tunnel and over
the guide pin to create the femoral tunnel. The hamstring
tendon graft was fixed on the femoral side with Rigidfix
(DePuy Mitek, Raynham, Massachusetts) and with a bio-
degradable interference screw on the tibial side. The
strength of the reconstruction was increased by the addition
of the post-tie fixation.
ACL reconstruction by the AM portal technique
required additional, high and low anteromedial portals.
The femoral footprint was marked using a radiofrequency
device by viewing the target point through the high antero-
medial portal. The Bullseye femoral guide (Linvatec, Key
Largo, Florida) was inserted through the low anteromedial
portal and efforts were made to place the tip of the guide
pin, inserted through the femoral aiming guide, at the cen-
tre of the previously marked footprint. The femoral tunnel
was created by reaming over the guide pin with the knee in
approximately 120° of flexion, as measured with a gonio-
meter: this was maintained by a surgical assistant. After
creating the femoral tunnel, the tibial tunnel was drilled
with a reamer of the same size as the graft. The hamstring
tendon graft was fixed with an extracortical endobutton
(Smith & Nephew Endoscopy, Andover, Massachusetts) on
the femoral side. Fixation on this tibial side was by the
same method as that for the TT technique.
Placement of the portal and fixation of the graft were iden-
tical to those of the AM portal technique. After marking the
centre of the femoral footprint of the ACL with a radiofre-
quency device, a FlipCutter guide (Arthrex, Naples, Florida)
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 GRAFT-BENDING ANGLE AND FEMORAL TUNNEL LENGTH AFTER SINGLE-BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
was set at 105° and inserted through the anterolateral
portal, with its tip positioned as close as possible to the cen-
tre of the footprint of the ACL. A skin incision of approxi-
mately 2 cm was made at the point at which the drill sleeve
of the FlipCutter came into contact with the skin. After
choosing a cutter to match the diameter of the graft, it was
drilled into the joint. The blade was then turned 90º into
the cutting position with a probe and locked by turning the
blue hub. Retrograde drilling was performed to a planned
depth of between 25 mm to 30 mm. The tibial tunnel was
drilled as described above.
Dimensional Computed Tomography (CT) using Curved Pla-
nar Reformation (CPR). All measurements were performed
using the ruler tool contained in the Picture Archiving and
Communication System (PACS) software (PI View STAR,
version 5025, Infinitt, Seoul, Korea). 3D surface models
were produced using 64-slice multi-detector computed
tomography (MDCT; Brilliance 64, Phillips, Cleveland,
Ohio). In order to compare the configuration of the tunnels
created by the TT, AM portal, and OI techniques, the centre
of the femoral tunnel was determined by 3D-CT visualisa-
tion of the medial wall of the lateral femoral condyle. The
data from the PACS software were imported into Rapidia
imaging software (Version 2.8).
Two-dimensional (2D) CPR images were created on a
clinical workstation from axial data with a slice thickness
of 1 mm and a slice interval of 1 mm. The area of interest
was calculated automatically by the PACS using region-of-
interest tools and freehand manual tracings (mouse and
pointer). The CPR method began by stacking axial sections,
including a volume of interest, to generate an imaging vol-
ume. A reformatting algorithm was applied to the rotated
imaging volume. For a composite sagittal CPR image, a
coronal section was selected as the reference plane, and a
single-voxel-thick plane was extruded through the entire
data set along the defined curved line. Finally, the curved
plane along the course of the ACL graft was flattened and
displayed as a 2D composite sagittal plane. All CPR-associ-
ated procedures were performed by an experienced muscu-
loskeletal radiologist who oversaw the imaging component
of the project.
The graft-bending angles (coronal and sagittal) were
defined as the angles between the line connecting the cen-
tres of the extra- and intra-articular apertures of the femo-
ral tunnel and the line connecting the centres of the intra-
articular apertures of the femoral and tibial tunnels, which
was usually consistent with the direction of the visible
intraarticular graft (Figs. 1 and 1b). The axial line was
drawn from the centre of the intra-articular openings of the
femoral tunnel on axial CT cutting. The posterior condylar
tangential line connected the medial and lateral posterior
surfaces of the condyles. The angle subtended by these two
lines was defined as the axial bending angle (Fig. 1c). Out
of consideration for the driving course of the graft, which
runs from the intra-articular opening of the tibial tunnel to
the extra-articular opening of the femoral tunnel, through
VOL. 96-B, No. 6, JUNE 2014
745
the intra-articular opening of the femoral tunnel, we
defined an increased angle as a more acute bending angle in
all three planes. The femoral tunnel lengths (coronal, sagit-
tal, and axial) were defined as the distances between the
intra-articular and extra-articular openings of the femoral
tunnel in each plane (Fig. 2).
The graft-bending angle and length of the femoral tunnel
were measured on 3D-CT after reconstruction of the ACL
by two independent orthopaedic surgeons experienced in
placement of the femoral tunnel. These measurements were
repeated two weeks later. The measurement used for anal-
ysis was the mean of the two measurements.
Statistical analysis. At an α level of 0.05 and a power of
0.8, we performed a post hoc power analysis to detect a
mean difference of 8º for each bending angle and 7 mm for
length of the femur tunnel. We assumed that the common
standard deviations of bending angle and femur tunnel
length were 9.9% and 5.2%, as calculated from our pilot
study of 11 and eight patients per group. We found that the
total sample sizes for bending angle and tunnel length were
135 and 115 patients, respectively. This study included
155 patients, with adequate power, to detect significant dif-
ferences in graft-bending angle (0.816) and femoral tunnel
length (0.853) for each measured view (coronal, sagittal,
and axial) within the three groups.
All statistical analyses were performed using IBM SPSS
Statistics version 20 software (IBM, Armonk, New York).
A p-value of < 0.05 was considered statistically significant.
All data are presented as means and standard deviations
(SD). The intra-observer and inter-observer reliabilities of
each measurement were determined by calculating the
intraclass correlation coefficient (ICC) and the standard
error of measurement. Single measured ICC was used to
determine the intra-observer reliability of measurements
obtained on two occasions by each observer. The mean
measured ICC was used to evaluate inter-observer reliabil-
ity by comparing the mean of two measurements of each
variable. The demographic characteristics of the three
groups were compared using analysis of variances
(ANOVA) for continuous variables and Fisher’s exact tests
for categorical variables. Multivariate analysis of variance
(MANOVA) was used to compare graft-bending angle and
femoral tunnel length between the three groups, with uni-
variate homogeneity of variance using Levene’s test being
non-significant (p > 0.05) for these variables. Any statisti-
cally significant differences among the three groups were
assessed using post hoc Tukey tests to determine which two
of the three groups differed significantly.
Results
The inter-observer and intra-observer reliabilities for graft-
bending angle (0.746 to 0.908) and femoral tunnel length
(0.802 to 0.907) in each view (coronal, sagittal, and axial)
were satisfactory.
Table II shows the mean graft-bending angle and femoral
tunnel length in each plane for the three groups. One way
746 Y. S. SHIN, K. H. RO, J. H. JEON, D. H. LEE

Fig. 1a

Fig. 1b

Fig. 1c

a) Coronal, b) Sagittal and c) axial CT images of graft-bending angles after reconstruction of the anterior cruciate ligament using the transtibial
(TT) (left), anteromedial portal (AM) (middle) and outside-in OI (right) techniques. Figures 1a and b – The lines connecting the centres of the extra-
and intra-articular openings of the femoral tunnel and those connecting the centres of the intra-articular openings of the femoral and tibial tunnels
were used to measure the coronal and sagittal graft-bending angles. Figure 1c – The angle subtended by the axial line from the centre of the intra-
articular apertures of the femoral tunnel on axial CT, and the posterior condylar, line connecting the medial and lateral posterior surfaces of the
condyles was defined as the axial bending angle. The transtibial technique resulted in greater bending angles in the sagittal and axial planes, but
a smaller bending angle in the coronal plane than the anteromedial portal and outside-in techniques.

MANOVA showed significant differences in mean graft-
bending angle and mean femoral tunnel length between the
three groups in all three CT planes of measurement
(p < 0.001 each). Exploratory analyses to verify this differ-
ence between pairs of groups using the Tukey test showed
that the bending angles in the sagittal and axial planes were
significantly greater in the TT than in the AM portal and OI
groups (p < 0.001 each), whereas the coronal bending angle
was significantly smaller in the TT group than in the other
two groups (p < 0.001 each). Bending angles in the sagittal

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 GRAFT-BENDING ANGLE AND FEMORAL TUNNEL LENGTH AFTER SINGLE-BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION 747

Fig. 2a

Fig. 2b

Fig. 2c

a) Coronal, b) sagittal and c) axial CT images of femoral tunnel length after reconstruction of the anterior cruciate ligament using the transti-
bial (TT) (left), anteromedial portal (AM) (middle), and outside-in (OI) (right) techniques. The length of the femoral tunnel was defined as the
distance between the intra- and extra-articular openings of the femoral tunnel in each plane. Lengths were significantly longer using the tran-
stibial than the anteromedial portal and outside-in techniques.

and axial planes were similar in the AM portal and OI
groups (p > 0.999 each), but coronal bending angle was
significantly greater in the OI than in the AM portal group
(p = 0.012, Table III). These findings indicate that the
driving course of the graft in the TT group described a less
acute curve in the coronal plane, but more acute curves in
the sagittal and axial planes, than did the other two
groups. In contrast, the graft driving courses of the AM
portal and OI techniques were similar, except for that in
the coronal plane.

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748 Y. S. SHIN, K. H. RO, J. H. JEON, D. H. LEE

Table II. Mean bending angles and femoral tunnel lengths in the three planes (BA, bending angle; FTL, femoral tunnel length)

Transtibial technique Anteromedial portal technique Outside-In technique p-value*

Mean,SD (range) Mean, SD (range) Mean, SD (range)

Coronal BA 12.91, SD 6.67 (10.63 to 18.03)
Sagittal BA 65.67, SD 11.09 (46.87 to 86.69)
Axial BA 60.03, SD 8.25 (57.28 to 62.78)
Coronal FTL 44.83, SD 5.05 (43.15 to 46.51)
Sagittal FTL 45.06, SD 5.26 (43.31 to 46.81)
Axial FTL 43.96, SD 4.91 (42.32 to 45.59)
* by one-way analysis of variance (ANOVA)
23.50, SD 9.02 (21.38 to 25.62)
49.47, SD 11.98 (22.46 to 77.07)
35.04, SD 9.37 (32.83 to 37.24)
34.15, SD 4.84 (33.01 to 35.28)
34.36, SD 4.85 (33.22 to 35.50)
33.96, SD 4.96 (32.79 to 35.12)
29.75, SD 11.15 (26.44 to 33.06) < 0.001
50.84, SD 10.67 (24.16 to 76.69) < 0.001
34.12, SD 8.84 (31.50 to 36.75) < 0.001
33.21, SD 4.20 (31.96 to 34.45) < 0.001
33.37, SD 4.36 (32.07 to 34.66) < 0.001
33.27 SD 4.63 (31.90 to 34.65), < 0.001

Table III. Differences between graft-bending angles (coronal, sagittal, axial)

95% Confidence Interval

Measure view Technique* Mean difference Standard error Lower Upper p value

{
TT vs AM portal -10.59 1.87 -15.12 -6.70 < 0.001
Coronal TT vs OI -16.84 2.04 -21.78 -11.90 < 0.001
AM portal vs OI -6.25 1.74 -10.47 -2.03 0.012

{
TT vs AM portal 16.20 2.31 10.62 21.78 < 0.001
Sagittal TT vs OI 14.83 2.52 8.74 20.93 < 0.001
AM portal vs OI -1.36 2.15 -6.58 3.84 > 0.999

{
TT vs AM portal 24.99 1.81 20.61 29.38 < 0.001
Axial TT vs OI 25.90 1.98 21.11 30.69 < 0.001
AM portal vs OI 0.91 1.69 -3.19 5.00 > 0.999
* TT, transtibial; AM, anteromedial; OI, outside-in

Table IV. Differences in femoral tunnel lengths (coronal, sagittal, axial)

95% Confidence Interval

` Technique* Mean difference Standard error Lower Upper p value

{
TT vs AM portal 10.68 0.95 8.38 12.99 < 0.001
Coronal TT vs OI 11.63 1.04 9.11 14.15 < 0.001
AM portal vs OI 0.95 0.89 -1.21 3.10 0.871

{
TT vs AM portal 10.70 0.97 8.34 13.06 < 0.001
Sagittal TT vs OI 11.69 1.06 9.12 14.27 < 0.001
AM portal vs OI 0.99 0.91 -1.21 3.19 0.829

{
TT vs AM portal 10.00 0.98 7.62 12.37 < 0.001
Axial TT vs OI 10.68 1.07 8.09 13.28 < 0.001
AM portal vs OI 0.69 0.92 -1.53 2.90 > .999
* TT, transtibial; AM, anteromedial; OI, outside-in

The mean length of femoral tunnel was significantly
greater in the TT group than in the AM portal and OI
groups in all three CT planes (p < 0.001 each). In contrast,
no differences in tunnel length were observed between the
AM portal and OI groups (Table IV).
Discussion
By using in vivo post-operative 3D-CT, we compared graft-
bending angles and femoral tunnel length after hamstring
reconstruction of the ACL between the TT, AM portal and
OI techniques. The principal finding of the study was that
the graft-bending angle of the TT technique was more acute
in the sagittal and axial planes but less acute in the coronal
plane than the angles seen in the other two groups. We also
found that femoral tunnel length was greater in the TT
group than in the AM portal and OI groups in all three
planes.
Many studies8,20-22 have investigated the position of the
opening of the femoral tunnel and its orientation angle after
conventional ACL reconstruction using the TT technique,
and anatomical ACL reconstruction using the AM portal or
OI technique. However, there have been few direct simulta-
neous comparisons of graft-bending angle and femoral tun-
nel length after single bundle reconstruction of the
ACL, which have used in vivo 3D-CT. To date, only two
studies have compared graft-bending angles in patients
after double-bundle ACL reconstruction using the TT and
AM portal technique and these yielded contradictory
results. One study, which used fresh-frozen cadaveric
knees, compared the 3D bending angle of the graft at the

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 GRAFT-BENDING ANGLE AND FEMORAL TUNNEL LENGTH AFTER SINGLE-BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
opening of the femoral tunnel after anatomical double-bun-
dle ACL reconstruction using the TT and the AM portal
techniques and found that the anteromedial (AM) and pos-
terolateral (PL) graft-bending angles were significantly
more acute in the TT group than in the AM portal group.17
That study, however, both used cadaveric knees and did not
use 3D-CT measurements, rather using a 3D virtual com-
puter simulation to make a virtual graft and virtual tunnel.
The complexities of virtual measurement may reduce the
reliability of its findings. A second study used in vivo 3D-
CT to compare bending angles in patients who had under-
gone reconstruction of the ACL using the single-bundle TT
and double-bundle AM portal techniques and found that
the AM and PL graft-bending angles were significantly
more acute in the AM portal than in the TT group.18 That
study measured the graft-bending angle on in vivo 3D-CT
images using OsiriX imaging software, which made the cre-
ation of a 3D model of the distal femur possible. The one
plane on 3D CT, where the centres of the extra- and intra-
articular openings of the femoral tunnel and the centre of
the intra-articular opening of the tibial tunnel were viewed
together, was chosen to measure graft-bending angle. Since
bending angle and femoral tunnel length were measured in
only one plane, these results may not accurately reflect dif-
ferences in graft-bending angle between the TT and AM
portal techniques. Furthermore, a difference in the number
of femoral tunnels (single- vs double-bundle) may have
reduced the accuracy of these results.
Unexpectedly, the graft-bending angles of the TT group
were more acute in the sagittal and axial planes but less acute
in the coronal plane than those of the AM portal and OI
groups. These results were similar to previous findings in the
sagittal and axial planes17 and in the coronal plane.18 The
differences in our study may be due in part to our use of in
vivo 3D CT to measure bending angle and to the fact that all
our patients underwent single-bundle ACL reconstruction.
Also, the bending angles in our study were measured in three
planes using a simple standardised CPR method to enhance
the accuracy of our measured values. Only one previous
study23 which measured bending angle using in vivo 3D-CT
reported that OI resulted in a larger graft-bending angle than
the AM portal technique. That study, however, also com-
pared the graft-bending angles of double-bundle ACL recon-
struction and measured bending angle in only one CT plane,
despite using OsiriX imaging software. Interestingly, we
found that the bending angles of single-bundle ACL recon-
struction were similar for the AM portal and OI techniques,
with the exception of the coronal bending angle.
Although 3D-CT is a useful and precise method for
directly determining the ACL graft-bending angle, the use
of CT data sets often requires long post-image processing
times as well as trained technicians on workstations. CPR is
a simple technique for the post-operative determination of
tunnel length and graft-bending angle along the graft
driving course and gives an accurate estimate of the graft-
bending angle.16,24,25
VOL. 96-B, No. 6, JUNE 2014
749
Previous studies16,26,27 have reported that the AM portal
technique shortens the available length of the femoral tun-
nel. A comparison of femoral tunnel length created by
either the TT or AM portal technique using ten pair-
matched fresh-frozen cadaveric knees found that the length
of the femoral tunnel was shorter in the AM portal group
than in the TT group. Also, a comparison of femoral tunnel
length in 12 paired cadaveric knees found that the length of
the femoral tunnel was significantly shorter using the AM
portal technique than the OI technique.4 Our study simul-
taneously compared femoral tunnel length after ACL
reconstruction by three techniques (TT, AM portal, OI)
using in vivo 3D CT. We found that the length of femoral
tunnel after anatomical ACL reconstruction techniques,
including both the AM and OI techniques, was shorter than
that after using the TT technique. Interestingly, our findings
showed no differences in the length of femoral tunnel
between the AM portal and OI groups. Differences between
studies may have been caused by the lack of a standardised
starting point for the lateral femoral condyle and the rela-
tively arbitrary guide angle setting in OI. Other differences
may be due to differences in the knee flexion angle used in
the AM portal technique.
Because graft-bending angle and length of femur tunnel
are of clinical relevance in ACL reconstruction, we compared
both parameters in the three groups of patients. An acute
graft-bending angle may result in more repetitive bending
stress on the graft at the femoral tunnel opening that may be
due to increased abrasive force at the contact area on the
sharp edge of the bone tunnel opening, and may result in
graft failure.28,29 A shorter length of femur tunnel may be
associated with lower pull-out strength and decreased graft
healing as the graft has less grip on the short tunnel.
We found that the graft-bending angle of the TT group
was greater in the sagittal and axial planes but less in the
coronal plane than the angles in the AM portal and OI
groups. The length of femoral tunnel was shorter in the AM
portal and OI groups than in the TT group in all three
planes. Because we did not compare the clinical outcomes
among the three groups, we could not determine which of
these techniques was superior to the others. Although the
length of femoral tunnel was shorter in the AM portal and
OI groups than in the TT group, the mean length of femoral
tunnel was > 30 mm in both the AM portal and OI groups.
A tunnel length of 30 mm is regarded as the minimum nec-
essary length,30 because 15 mm of graft inside the femoral
tunnel is regarded as sufficient for graft healing.31 Addi-
tional studies, however, are needed to determine the clinical
relevance of these differences in bending angles and femoral
tunnel lengths between the three techniques. These addi-
tional studies may also show which of these three tech-
niques is superior to the others.
This study has several limitations. Firstly, it was retro-
spective in design. However, data about graft-bending
angle and femoral tunnel length were recorded prospec-
tively because we routinely perform post-operative 3D-CT
750 Y. S. SHIN, K. H. RO, J. H. JEON, D. H. LEE
immediately after ACL reconstruction. This can highlight
any complications associated with the femoral tunnel, such
as a posterior wall blow-out fracture of the lateral femoral
condyle in patients treated using the TT technique. It can
also provide valuable feedback, particularly in making
decisions about the femoral tunnel. However, the hazards
of exposure to radiation should be considered before CT is
used routinely in the immediate post-operative period. The
safe level of ionising radiation has not been determined,
although the cumulative effective whole-body dose during
one post-operative CT scan is not very high; roughly the
equivalent of two chest radiographs.32 Secondly, recon-
struction of the ACL was carried out by a single surgeon.
Although we tried to standardise the three techniques used
in this study, it may be difficult to differentiate clearly
between the techniques when performed by a single sur-
geon, due to overlaps in surgical technique. However, the
surgeon who performed these operations was highly expe-
rienced with these protocols and attempted to standardise
the three techniques, especially in terms of drilling of the
femoral tunnel. This is likely to have minimised any bias
resulting from a single surgeon series. Thirdly, 120° of flex-
ion could not be achieved in obese patients, despite our
attempts to standardise the knee flexion angle. However,
the effect of a slight decrease in knee flexion due to obesity
probably had little effect on the length of the resultant
femur tunnel. Finally, graft CT images were less visible in
the axial than in coronal or sagittal plane. However, a
lower graft angle from the posterior condylar line results in
a less acute angle in the axial plane because the more hori-
zontal femoral tunnel in the axial plane, which was perpen-
dicular to the femoral shaft axis, prevents an acute graft-
bending angle23 due to the course of the graft from the
intra-articular opening of the tibial tunnel to an extra-artic-
ular opening of the femoral tunnel, through the intra-
articular opening of the femoral tunnel.
This work was supported by Korea University Grants (K1400580).
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
This article was primary edited by J. Scott and first proof edited by A. Ross.
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