One of the most critical steps in knee ACL Reconstruction is the anatomic placement of the femoral tunnel – the so-called ACL Femoral Anatomic Footprint. This could lead to tunnel misplacement – the main reason for ACL revision surgery.
The femoral native ACL attachment site is described as an oval-shaped divided into two bundles: the anteromedial (AM) and the posterolateral (PL) bundles.
Several theories and methods have been described to a proper tunnel positioning such as 10 o’clock position (right knee) and 2 o’clock position (left knee) - in a single bundle technique or the use of intraoperative fluoroscopy.
The most accurate anatomic landmark for arthroscopic ACL reconstruction is the native ACL remnant.
The Lateral Intercondylar Ridge (LIR)/”Resident´s Ridge" defines the upper border of the ACL and the ACL femoral drilling should aim for the Lateral Bifurcate Ridge, which divides the AM and PL bundle fibers.
However, cross-sectional area of the PL and AM bundles is variable from patient-to-patient, the location of the Lateral Bifurcate Ridge, when present, does not necessarily represent the true center of the ACL femoral attachment site.
Dear Chahine and Edvin, thank you for your reply.
Can you please share your ACLR technique: anatomic references, Transtibial Drilling VS Anteromedial Drilling VS Outside-In VS Outside-In Retrograde Drilling, Clock-face references, ACL ruler VS ACL Femoral Aimer, intraoperative fluoroscopy?
I try to look for the 50/50%, usually using the remanent ACL as a guide.
Thank you Juan Pablo. I love your approach!!!An easy and fast reference...which corresponds to the Lateral Bifurcate Ridge, which can be identified arthroscopically in 48% of the knees and runs perpendicular to the Lateral Intercondylar Ridge (LIR) and divides the ACL femoral attachment site into the attachment site areas for the PL and AM bundles.
Acute cases cal Tammany may help and always use Lateral ridge and choose pt posterior to it in single bundle reconstruction and keep tunnel more horizontal. (Use always anatomical approach)
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