Skip to Content

Non-Anatomic Tunnel Position Increases the Risk of Revision ACL Reconstruction

March 30, 2022

A study recently published in Knee Surgery, Sports Traumatology, Arthroscopy to discuss increased risk for revision ACL reconstruction was conducted by several orthopaedic experts including UPMC Orthopaedic Care physicians Jonathan Hughes, MD, Bryson Lesniak, MD, and Volker Musahl, MD.

Anterior cruciate ligament (ACL) graft failure is a complication that may require revision ACL reconstruction (ACL-R). Non-anatomic placement of the femoral tunnel is thought to be a frequent cause of graft failure; however, there is a lack of evidence to support this belief. The purpose of this study was to determine if non-anatomic femoral tunnel placement is associated with increased risk of revision ACL-R.

After screening all 315 consecutive patients who underwent primary single-bundle ACL-R by a single senior orthopedic surgeon between January 2012 and January 2017, 58 patients were found to have both strict lateral radiographs and a minimum of 24 months follow-up without revision. From a group of 456 consecutive revision ACL-R, patients were screened for strictly lateral radiographs and 59 patients were included in the revision group. Femoral tunnel placement for each patient was determined using a strict lateral radiograph taken after the primary ACL-R using the quadrant method.

The center of the femoral tunnel was measured in both the posterior-anterior (PA) and proximal-distal (PD) dimensions and represented as a percentage of the total distance (normal center of anatomic footprint: PA 25% and PD 29%).

In the PA dimension, the revision group had significantly more anterior femoral tunnel placement compared with the primary group. Among patients who underwent revision, those with non-traumatic chronic failure had statistically significant more anterior femoral tunnel placement than those who experienced traumatic failure. In the PD dimension, the revision group had significantly more proximal femoral tunnel placement compared with the primary group.

In this retrospective study of 58 patients with successful primary ACL-R compared with 59 patients with failed ACL-R, anterior and proximal (high) femoral tunnels for ACL-R were shown to be independent risk factors for ACL revision surgery. As revision ACL-R is associated with patient and economic burden, particular attention should be given to achieving an individualized, anatomic primary ACL-R. Surgeons may reduce the risk of revision ACL-R by placing the center of the femoral tunnel within the anatomic ACL footprint.

Read more about this study on PubMed.

Other study authors include:

Collaborators not affiliated with the University of Pittsburgh:

Ravi Vaswani, MD
Hospital for Special Surgery

Sean J. Meredith, MD
University of Maryland Medical School

Jon Karlsson, MD, PhD
Sahlgrenska Academy, Gothernburg University