Indian Journal of Orthopaedics

https://doi.org/10.1007/s43465-021-00485-4

ORIGINAL ARTICLE

How Important is the Tunnel Position in Outcomes Post‑ACL

Reconstruction: A 3D CT‑Based Study
Vikram A. Mhaskar1,2 · Yogesh Jain1 · Pankaj Soni1 · Rajendra Fiske1 · Jitendra Maheshwari1,2

Received: 17 May 2021 / Accepted: 10 August 2021

© Indian Orthopaedics Association 2021

Abstract
Background  Drilling the femoral and tibial tunnels at their anatomical locations are critical for good outcomes and involve
seeing the footprints well. We intended to compare two techniques of drilling the tunnels and the patient-reported outcomes
and knee stability of patients undergoing single bundle ACL reconstruction using 3D CT to evaluate if the tunnels were
anatomical or not.
Materials and Methods  Sixty single bundle ACL reconstructions were analyzed, 30 each with Technique A and B. Pre-
operative and after a minimum 27 month follow-up Lysholm, IKDC, Tegner score, hop test, and Lachman test were noted.
3D CT was done to classify femoral tunnels positions as being well placed, slightly or grossly misplaced and tibial tunnels
as optimal or suboptimal and compared.
Results  Sixty ACL reconstructions had full follow-up with a mean follow-up of 34 months. There was no significant differ-
ence between tunnel positions between the two techniques. Well-placed femoral tunnel had better Lysholm score (62.2 ± 16.2
v/s 48.5 ± 17.2, p 0.002) and IKDC score (62.5 ± 14.3 v/s 52.7 ± 15.1, p 0.012).). Those who had their surgeries within
3 months of their injury had better hop test (4.4 ± 0.9 v/s 3.9 ± 1, p 0.034) and IKDC scores (62.5 ± 15.8 v/s 33.2 ± 13.8, p
0.026) as compared to those that had surgery done after 3 months
Conclusion  Tibial tunnel positions were optimal in most cases and did not differ between the two techniques. Well-placed
femoral tunnels and surgeries done within 3 months of the injury produced best results.

Keywords  ACL · ACL Reconstruction · Anterior Cruciate Ligament Reconstruction · Biological ACL Reconstruction ·
Stump Preservation ACL Reconstruction · 3D CT · Tunnel position · Transportal ACL reconstruction · Accessory portal ·
PROM post-ACL

Introduction

Anatomically reconstructed grafts have been shown to be

* Vikram A. Mhaskar biomechanically better than non-anatomical grafts [1,2].
drvikrammhaskar@gmail.com They also have better stability and earlier recovery than non-
Yogesh Jain anatomically reconstructed grafts [3]. To achieve more ana-
jainy134@gmail.com tomical graft position, Anterior Cruciate Ligament (ACL)
Pankaj Soni surgery has evolved over time. ACL reconstruction is done
pankaj.soni0206@gmail.com using a single or double bundle techniques and transportal
Rajendra Fiske or transtibial techniques. The transportal technique is shown
rajendra07115@gmail.com to have distinct advantages as compared to transtibial tech-
Jitendra Maheshwari niques as it produces more anatomical grafts [4, 5]. How-
Jitendra.Maheshwari@maxhealthcare.com ever there have not been significant differences in outcomes
of single and double bundle reconstructions [6–11]. The
1
Department of Orthopaedics, Max Smart Hospital Saket, ideal location of the femoral and tibial tunnels is where the
New Delhi 110017, India
native ACL was, but in chronic cases, the tibial and femo-
2
Knee & Shoulder Clinic, F7 East Of Kailash, ral remnants may not be present and we rely on anatomical
New Delhi 110017, India

13
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landmarks to make our tunnels. These landmarks are based
on previously done studies [12, 13].
There have been studies in the past to evaluate the role
individual factors on patient-reported outcome measures and
stability post-ACL reconstruction. Tunnel position has been
found to be an important variable in these outcomes. Tunnel
positions can be assessed via X-ray and computed tomog-
raphy (CT) scan with CT being potentially more accurate
as it gives a three-dimensional picture of the femoral and
tibial tunnel apertures [14, 15]. There have been studies done
in the past to assess femur and tibial tunnels positions in
various techniques of doing ACL reconstructions [16, 17].
Femoral tunnel position has been shown to influence patient-
reported outcomes more than the tibial tunnel position [18].
Tunnel malposition is an iatrogenic complication and studies
have been done in the past which showed that when view-
ing the femoral footprint end on while drilling the femoral
tunnel produced tunnels that were more anatomic, but it was
not statistically significant [19].
Studies in the past have focused on individual tunnel
positions and based their acceptable tunnel positions on the
basis of the variation of individual tunnels from a set stand-
ard deviation [20]. However we have classified our femoral
and tibial tunnels based on whether they are optimal or not
based on previously done studies [21]. Apart from just tun-
nel positions, we have tried to compare individual surgical
and constitutional factors that may affect outcomes in our
cohort population.
The ultimate result of a surgery is measured by the
patients return to activity and pre-operative functional lev-
els that may be different for different individuals. However,
instrumented objective methods can also be used to measure
stability of individual ligaments. Studies in the past have
shown that even though there may not be statistically sig-
nificant differences in the objective arthrometric measure-
ment before and after surgery, subjective scores do show a
significant improvement [20].
The primary objective of this study was to evaluate if
optimal femoral and tibial tunnel position translated into
better stability and post-operative outcome measures. The
secondary objective was to evaluate if viewing the tibial
footprint from a high anteromedial portal while identifying
and drilling it gives a more anatomical tunnel position.
Materials and Methods
A total of 60 patients underwent arthroscopic ACL recon-
struction between Nov 2017 and Oct 2018 who fulfilled
the criteria of this study. Our inclusion criteria was single
bundle ACL reconstructions done by a single surgeon, the
first author VM in complete ACL tears using semitendino-
sus and gracilis grafts fixed with a particular button on the
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Indian Journal of Orthopaedics
femur and an interference screw on the tibia in all cases.
Clinical and Magnetic Resonance Imaging (MRI) was used
to diagnose the ACL tear, meniscus tear, or any associ-
ated injuries. Patients with multiligamentous knee injuries,
tibial avulsion, osteoarthritis, previous femoral fractures,
and congenital femoral and tibial abnormalities were
excluded from the study. All patients had a single bundle
ACL reconstruction. Pre-operative Lachman (International
Knee Documentation Committee) IKDC, Tegner, hop test
were done 24 h before surgery and at a minimum 27 month
follow-up. Age, Body Mass Index (BMI), and time since
injury were also noted in the patients. The ages was clas-
sified into < 25 or > 25 years, BMI into < 25 or > 25, and
times since injury into < 3 months or > 3 months.
Meniscus procedures were classified into medial
meniscectomies, lateral meniscectomies, medial menis-
cus repairs, or lateral meniscus repairs at the time of
arthroscopy. Cases where chondral lesions were present
were excluded. Graft diameters were noted at the time of
surgery.
Surgical Technique [19]
A single bundle ACL reconstruction using semitendino-
sus and gracilis grafts was done in all cases. Two tech-
niques were used to drill the femoral tunnel, either viewing
through a high anteromedial portal and drilling through a
far medial portal (Technique B) or viewing from a high
anterolateral portal and drilling from a far medial portal
(Technique A). The surgeon intended to drill the tunnel
at a distance of 5 mm from the posterior articular margin
and 5 mm from the inferior margin of the lateral aspect
of the notch. The tibial tunnel was drilled at the centre of
the tibial stump which was preserved, along the posterior
border of the anterior horn of the lateral meniscus either
viewing from the high anterolateral portal (Technique A)
or the high anteromedial portal (Technique B) Figs. 1, 2.
Fig. 1  Guide pin tip at the centre of the ACL tibial stump seen
through the high anteromedial portal
Indian Journal of Orthopaedics

Fig. 2  Graft seen passing from the tibia to the femur viewing from
the high anteromedial portal

Post‑operative 3D CT Evaluation
Fig. 3  Technique to determine femoral tunnel position on a 3D CT
The post-operative three-dimensional (3D) CT scan of the image of the lateral wall of the femoral notch
knee were done within a week of the arthroscopy and femo-
ral and tibial tunnel positions was evaluated.
the anterior-to-posterior and medial-to-lateral distance. A
Femoral Tunnel Evaluation region-of-interest tool was used to fit the best-fit circle on the
tibial aperture and its centre was marked. A perpendicular
A true lateral view of the medial wall of the lateral femo- was drawn from the centre of tibial aperture to the anterior
ral condyle with neutral rotation was reconstructed and the (DA) and medial border (DM) of this grid and noted [21].
medial condyle subtracted to see the lateral wall of the notch. The individual tunnels were categorized into optimal or
The femoral tunnel position was evaluated using the quad- suboptimal, DA < 31 or > 44.2 and DM < 36.3 or > 52 was
rant method by Bernard et al. [22]. A reference frame was considered suboptimal based on previous literature. Even
drawn with the superior border at the Blumensaat’s line of one measurement out of this range classified the tunnel as
the intercondylar notch and inferior border at the lowest mar- sub optimal.
gin of the lateral wall of the intercondylar notch. The ante-
rior and posterior borders of the frame were drawn touching Rehabilitation
the anterior most and posterior most points of the lateral
wall of the intercondylar notch, respectively. The footprint Those patients that had an ACL or an ACL with meniscec-
was covered by the best-fit circle using the region-of-interest tomy were allowed to bear weight as tolerated on post op
tool (ROI) in the CT software that covered all borders of the Day 1. Static quadriceps and range of motion exercises were
femoral tunnel. After marking the centre of the circle, per-
pendiculars were drawn to the length and breadth of the rec-
tangle. DS represents distance from centre to superior border
and DP the distance from centre to posterior border (Fig. 3).
The individual tunnels were categorized according to their
relationship with the lateral inter condylar ridge. Type I
(well-placed) tunnels, Type II (slightly malpositioned), and
Type III (grossly malpositioned) were those located superior
and anterior to the ridge [19].

Tibial Tunnel Position (Fig. 4)

A craniocaudal view of the upper surface of the tibia was

obtained after subtracting the femur and patella from the 3D
CT image of the knee. A reference frame was drawn aligned
with medial-to-lateral and anterior-to-posterior anatomical
tibial axes. The total width of the tibial axes was between Fig. 4  Technique to determine tibial tunnel position on a 3D CT scan

13

begun after 24 h of the procedure. The patient used crutches
for 10 days till they felt confident of walking independently
and the quadriceps had started contracting well. No running,
jogging, or sports was allowed for 6 months post-surgery.
Driving was allowed after 1 month of the procedure. In those
that had a meniscus repair, the only difference in the reha-
bilitation was that they were kept non weight bearing for
6 weeks with a range of motion brace. Range of motion was
commenced after 24 h but limited to 0–90° of flexion for
6 weeks. The rest of the rehab was same.
Statistical Methods
Statistical analysis was performed using SPSS Statisti-
cal Software version 22.0 and R.3.2.0. Two-sample t test
was used for the comparison of means of improvement in
scores between group created based on Quality of treatment,
Tibial Quality, Injury to Surgery month. One-way ANOVA
(Analysis of variance) was used for comparison of means
Table 1  Number of Type I & II femoral tunnels, optimal and subopti-
mal tibial tunnels overall, and optimal tibial
Femoral type 1 tunnels
Femoral type 2 tunnels
Total optimal tibial tunnels using both techniques
Total suboptimal tibial tunnels using both techniques
Technique A optimal tibial tunnels
Technique B optimal tibial tunnels
Fig. 5  Mean tibial tunnel posi-
tions by the two techniques
versus Tsukada et al. and Flor-
ent et al. that are the other two
3D CT-based studies
13
Indian Journal of Orthopaedics
of improvement in scores for Repair Type variable. P value
of < 0.05 was considered significant.
Results
A total of 60 knees were evaluated (52 of them right and 8
left knees). There were 41 male and 19 female patients. The
mean follow-up was 34 months with minimum follow-up
of 27 months. There were 32 Type I femoral tunnels and 28
Type II femoral tunnels and no Type III tunnels (Table 1).
There were 52 optimal and 8 sub optimal tibial tunnels.
Technique A had 24 optimal tunnels and Technique B had
28 optimal tunnels (Table 1). The mean DM distance was
43.03 ± 1.973 in Technique A and 43.43 ± 1.959 in Tech-
nique B. The DA in Technique A was 35 0.67 ± 5.168 and
38.32 ± 4.327 in Technique B with no statistically significant
difference between the two techniques p 0.434 (Fig. 5).
Other than the preop Lysholm score which was lower in
the Type I femoral tunnel group (32.4 ± 16.2 v/s 43.4 ± 18,
p 0.016), there was no statistically significant difference in
the postop Lysholm score, pre- and postop Lachman test,
pre- and postop hop test, pre- and postop Tegner score, pre-
32
and postop IKDC score, age, and BMI between Type 1 and
28
Type 2 tunnels and graft diameter.
52
However, there was a statistically significant difference
8
in the improvement of the Lysholm score (62.2 ± 16.2 v/s
24
48.5 ± 17.2, p 0.002) and the IKDC score (62.5 ± 14.3
28
v/s 52.7 ± 15.1, p 0.012) post-surgery in those with good
Indian Journal of Orthopaedics

Table 2  Comparison of improvement in scores (post–pre) by type of Discussion

femoral tunnel
Parameters PROMs and stability scores ACL reconstruction has evolved over the years into a more
Type I Type II p value anatomical technique so as to replicate the original ACL
origin and insertion. Tunnel position has taken prepon-
Lysholm score 62.2 ± 16.2 48.5 ± 17.2 0.002 derance in recent times as it has been identified as one
Hop test 4.2 ± 0.9 4.0 ± 1.0 0.435 of the most important aspect of the procedure that deter-
Tegner 4.0 ± 1.2 3.6 ± 1.1 0.181 mines outcomes [23]. Outcomes have been measured on
IKDC 62.5 ± 14.3 52.7 ± 15.1 0.012 the basis of patient-reported outcome measures, stability
Lachman 2.6 ± 0.6 2.2 ± 0.8 0.062 of the knee, and activity levels.
This study used two techniques of doing an ACL recon-
struction, which were different from each other as viewing,
Table 3  Comparison of improvement in scores (post–pre) by quality and drilling from the medial side gives an end on view
in optimal tibial tunnels of the femoral footprint and shows the whole course of
Parameters Quality of treatment the ACL graft from tibia to its femoral attachment in one
Type I Type II p value
frame. However, the other technique views the femoral
footprint from the side, and hence, it was hypothesized
Lysholm score 61.3 ± 15.7 50.9 ± 17.6 0.031 that the femoral tunnel position may be less anatomic.
Hop test 4.2 ± 0.9 3.9 ± 1.1 0.421 Though the number of optimal tibial tunnels and well-
Tegner 3.9 ± 1.1 3.6 ± 1.2 0.337 placed Type 1 femur tunnels was more in Technique B,
IKDC 61.5 ± 13.4 55.2 ± 14.2 0.113 this was not statistically significant [19]. Future studies
Lachman 2.5 ± 0.6 2.2 ± 0.8 0.145 with larger numbers should be done to evaluate whether
doing an ACL reconstruction with viewing through a high
anteromedial portal and drilling through a low far medial
femoral tunnels (Table 2). There was no statistically sig- portal produces better tunnel positions.
nificant improvement in any of the outcome measures when The results of our study seem to suggest that femoral
the optimal and suboptimal tibial tunnels were compared. tunnel position and time since injury are the most impor-
There was also statistically significant improvement in the tant factors affecting outcomes. Tibial tunnel position was
Lysholm score of patients who had an optimal tibial tunnel more or less constant in the study with most of the tunnels
with a Type 1 Femoral tunnel in comparison to an optimal being optimally placed at the location. This could be the
tibial tunnel and Type II femoral tunnel (61.3 ± 15.7 v/s reason as our technique of drilling the tibial tunnel used a
50.9 ± 17.6, p 0.031) (Table 3). definitive anatomical landmark as its location, which does
Those that were < 25 years did not have any statistically not change with flexion or extension of the knee. Using the
significant improvement in any outcome measures as com- SAMMBA technique of remnant preservation at the tibial
pared to those over 25. Those that had their surgery within stump is shown to give near anatomic tibial tunnels, which
3 months of the index injury had better hop test (4.4 ± 0.9 may be another reason for more consistent tibial tunnels.
v/s 3.9 ± 1, p 0.034) and IKDC scores (62.5 ± 15.8 v/s This suggests that the view of the tibial footprint is more
33.2 ± 13.8, p 0.026) as compared to those that had surgery or less consistent with either portal being used to view
done after 3 months. There were no statistically significant it and is consistent with the current literature [19]. The
differences in outcomes of those with BMI < or > 25, those femoral tunnel position was made 5 mm from the posterior
that had lateral/medial meniscus repairs or excisions or inpa- and inferior articular margin, which could make the tunnel
tients with graft diameter > or < 9 mm as all the patients had position change depending on the degree of knee flexion.
a graft > 8 mm. This may be the cause of more variability in the tunnel
position as compared to the tibia, though none of the tun-
nels were grossly misplaced. The improvement in Lysholm
Complications and IKDC scores were significantly better in those patients
who had well-placed femoral tunnel as compared to those
Two patients had stitch abscesses at the graft harvest site with a slightly misplaced tunnel position indicating the
that healed with antibiotics and dressing. One patient had importance of avoiding misplaced tunnels. Techniques that
persistent pain in the medial compartment knee at 30 month provide better visualization of the femoral footprint need
follow-up that was diagnosed as early medial compartment evaluation in larger series of patients to have more consist-
osteoarthritis of the knee. The knee was stable, the femoral ent tunnel positions.
tunnel was Type II, and the tibial tunnel was optimal.

13

The age and BMI of the patients did not seem to affect
outcomes, as most of the patients were of a similar age group
and there were no obese patients in this subset. There was
no statistically significant difference in the age and BMI of
patients in the tunnel groups compared.
Patients that had their operation within 3 months of their
injury had better IKDC and hop test scores. This could be
attributed to the fact that lesser injuries to surrounding struc-
tures or their capacity to heal are better when operated upon
early. A chronic ACL deficient knee may lead to degenera-
tive changes and injury to secondary stabilizers over a period
of time worsening outcomes.
Meniscus surgery did not seem to affect outcomes as in
most cases, there was either no meniscus surgery or they
were repaired, that is shown to preserve the biomechanics of
the knee. The minority of cases that had a partial meniscec-
tomy was smaller in number and could be a possible reason
for not influencing outcomes. Also, the follow-up was for
34 months, longer follow-up might be necessary to conclu-
sively identify the role of meniscus surgery on outcomes.
Studies in the past have used CT and X-rays to measure tun-
nel positions as well as outcome measures for stability and
PROM’s post-ACL reconstruction. Behrend et al. that ana-
lyzed 50 ACLs done by 17 surgeons of different experience
levels by doing X-rays for tunnel position and IKDC scores
for PROMs and the KT 1000 for stability and showed that
tibial malpositions were better tolerated than femoral mal-
positions, which was consistent with our study [24]. More
experienced surgeons had better outcomes; our study had
the advantage of a single surgeon (VM) doing all the surger-
ies. Sadoghi et al. analyzed single bundle BPTB and dou-
ble bundle hamstring ACLR’s with short 1 year follow-up
showed better stability and PROMs when the reconstruction
was more anatomical. Mild alterations within the anatomic
ACL footprint did not have significantly different outcomes.
This study used 2 SD from the mean value of the tunnel
positions as the cut off for the tunnel being anatomic and this
was not compared to any anatomic study or previous studies
about the ideal tunnel position. Our study took all previously
done studies into consideration before classifying the tunnel
on the tibial side as anatomic or non-anatomic and did not
base it on any mean or SD of our own tunnels in the series,
whereas classifying the femoral tunnels was done based on
an anatomic classification system published earlier. Kazemi
et al. classified femoral tunnels based on the angle they made
on an AP radiography with the anatomic axis of the femur
as low 30–45° or high 45–60°, and found that low poste-
rior tunnels had higher knee scores at a mean 23.6 month
follow-up [18]. This does not take into consideration the
exact tunnel position but just the trajectory of the tunnel
in a tunnel-view X-ray that does not relate to the anatomic
insertion point in the notch unlike our study [18]. Two other
studies have reported on the effect of tunnel positions using
13
Indian Journal of Orthopaedics
3D CT on stability and patient-reported outcomes. How-
ever, the follow-up was only for 12 and 30.3 months only.
They also just reported on the PROMs and stability based
on individual tunnel positions and not on whether they were
considered anatomic or not [3, 20]. Our study also had the
advantage of having the longest mean follow-up as compared
to previously done studies.
There were a few drawbacks of our study the inclusion
of cases with meniscus surgery could have potentially
affected outcomes. Also not having an objective measure
like a KT 1000/arthrometer machine to measure transla-
tion could make AP stability subjective. However, the hop
test is a practical measure of stability with the whole body
weight being on the operated limb while hopping [25]. Also,
previously done studies have proven that though objective
methods of stability may not change significantly, subjective
scores do improve and ultimately patient satisfaction is of
paramount importance and an improvement in subjective
scores are indicative of that.
None of the patients had persistent instability or any
major complications only minor ones like two stitch
abscesses, indicating that tunnels that are not grossly mis-
placed produced stable knees in this study.
We can conclude that in our subset of patients, femoral
tunnel position was the single most important factor affect-
ing outcomes post -ACL reconstruction.
Declarations 
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical standard statement  This study was approved by the Max
Healthcare Ethics Committee.
Informed consent  Informed consent was taken from every patient
recruited in this study as per the protocol sanctioned by the Max
Healthcare Ethics Committee.
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