ACL reconstruction: Can the transtibial technique achieve optimal tunnel positioning? A radiographic study

Placement of the femoral tunnel performing ACL reconstruction can be performed using a transtibial technique. Theoretically, this procedure bears the risk of a vertical placement of the femoral tunnel in the intercondylar notch. We assessed tunnel positioning radiographically using the transtibial technique. Postoperative anteroposterior and lateral knee radiographs in 30 patients/knees (19 men, 11 women) undergoing ACL reconstruction using a 4-strand single bundle hamstrings tendon graft by a single surgeon, using a standardized technique, were retrospectively evaluated. Mean age at the time of operation was 27 years (range 16-42). Two experienced independent orthopaedic fellows, not having participated in the management of those patients, performed the radiographic measurements. Mean graft inclination angle was 19 degrees (SD 2). In the sagittal plane the femoral tunnel was placed at 85% (SD 4), posteriorly across Blumensaat's line and the tibial tunnel at 43% (SD 3). Intraobserver Spearman-Brown coefficient was 0.78 and the intraclass correlation was 0.70 (substantial agreement). The values presented are consistent with optimal tunnel positioning according to anatomic and clinical studies. Standardized surgical technique and anatomical landmarks can achieve optimal tunnel positioning using the transtibial technique for ACL reconstruction.