Eccentric Graft Positioning Within the Femoral Tunnel Aperture in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal and Outside-In Techniques

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Ellipticity of the femoral tunnel aperture, which is considered to better restore the native anterior cruciate ligament (ACL) footprint after ACL reconstruction, is different according to the femoral tunneling technique used. How much of the femoral tunnel aperture is filled with graft in different tunneling techniques has yet to be evaluated.


The aim of this study was to evaluate and compare the graft filling area and graft position within the femoral tunnel aperture in ACL reconstruction using the transportal (TP) and outside-in (OI) techniques.

Study Design:

Randomized controlled trial; Level of evidence, 1.


A total of 70 patients were randomized to undergo double-bundle ACL reconstruction using either the TP (n = 35) or OI (n = 35) technique. The aperture filling was evaluated by calculating the ratio of the cross-sectional area of the graft to that of the femoral tunnel, and the graft center position within the tunnel was assessed using immediate postoperative magnetic resonance imaging.


The cross-sectional area of the femoral anteromedial (AM) tunnel aperture in the TP group (605.5 ± 112.7 mm2) was larger than that in the OI group (537.9 ± 126.8 mm2). The cross-sectional area of the femoral posterolateral (PL) tunnel aperture in the TP group (369.9 ± 88.3 mm2) did not differ significantly from that of the OI group (387.9 ± 87.0 mm2). The grafts filled only 52.0% of the AM tunnel and 55.3% of the PL tunnel in the TP group, compared with 54.9% of the AM tunnel and 54.4% of the PL tunnel in the OI group, but there was no statistically significant difference (P > .05). The AM graft center was positioned 1.7 ± 0.6 mm from the center of the tunnel aperture in the TP group and 1.6 ± 0.5 mm in the OI group, and the PL graft center was positioned 1.4 ± 0.4 mm from the center in the TP group and 1.3 ± 0.4 mm in the OI group, with no significant intergroup differences (P = .406 and P = .629, respectively). In the OI group, the PL graft center was positioned more perpendicular to the Blumensaat line in relation to the tunnel aperture center (-10.8° ± 7.6°) compared with the TP group (-4.0° ± 11.8°) (P = .04).


The grafts did not fill the tunnel aperture area in either group, and the centers of the grafts differed slightly from the centers of the tunnel apertures. The finding of eccentric graft positioning in the tunnel with condensation in a particular direction in each technique might suggest the necessity of an underreamed femoral tunnel for graft. In addition, it may be useful to standardize the starting position of the femoral tunnel according to anatomic landmarks.

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