Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction

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The femoral tunnel in anterior cruciate ligament (ACL) reconstruction can be created using transtibial, anteromedial portal, or outsideto-in techniques. The outsideto-in technique is less commonly performed because it requires an additional incision on the distal lateral aspect of the femur. In the transtibial technique, the femoral tunnel is drilled through the tibial tunnel and through the anteromedial portal in the anteromedial portal technique. The anteromedial portal technique allows femoral tunnel drilling independent of the placement of the tibial tunnel.

Recent studies have shown the superiority of the anteromedial portal technique over the transtibial technique. The anteromedial portal technique may more accurately position the femoral tunnel in the center of the ACL femoral footprint than the transtibial technique (Figure 1).1-5 Anteromedial portal drilling may lead to improved Lachman and anterior drawer tests, although clinical results have not been shown to be significantly different.1

Although the popularity of the anteromedial portal technique is growing, many surgeons are uncomfortable changing from the transtibial technique. Anteromedial portal drilling requires knee hyperflexion during use of the drill guide, guidewire, and cannulated drill, which is awkward and requires an additional assistant to stabilize the knee in hyperflexion during this critical surgical step.

The figure-4 position is a standard knee arthroscopy position most knee arthroscopists are comfortable with that can be used to easily obtain the necessary hyperflexion for femoral tunnel creation via the anteromedial portal. To the author’s knowledge, anteromedial portal femoral tunnel drilling in the figure-4 position has not been previously described.

Materials and Methods

Twenty consecutive patients underwent ACL reconstruction with patellar tendon autograft using the anteromedial technique in the figure-4 position. Mean patient age was 22.5 years (range, 15-34 years). Eleven patients were women, and 9 were men. All patients were followed for a minimum of 4 months postoperatively.