Definitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction

The purpose of this prospective study was to define constant anatomic intraarticular and extraarticular landmarks that can be used as definitive reference points to reproducibly create a tibial tunnel for anterior cruciate ligament (ACL) reconstruction that (1) results in an impingement-free graft in full extension without an intercondylar roofplasty; (2) positions the tibial tunnel's intraarticular orafice sagittally central in the original ACL insertion without visually guessing; (3) positions the tibial tunnel such that the sagittal tunnel-plateau angle is parallel with the sagittal intercondylar roof-plateau angle in full extension to minimize shear seen by the graft at the tibial tunnel inlet, and by doing so; (4) maximizes tunnel length to avoid patellar tendon graft-tunnel length mismatch allowing for endosteal interference screw fixation on both sides of the joint. Anatomic dissections in 50 knees showed the ACL sagittal central insertion point on the intercondylar floor averages 7 mm (range 7 to 8 mm) sagittally anterior to the anterior margin of the posterior cruciate ligament (PCL) with the knee flexed 90 degrees such that the PCL may be used as a reliable reference landmark for locating the ACL sagittal central insertion. This constant relationship was found to be independent of knee size. Extraarticularly, beginning the tibial tunnel sagittally 1 cm above the superior (sartorial) border of the pes anserinus insertion and coronally 1.5 cm posteromedial from the medial margin of the tibial tubercle along the superior surface of the pes, directed toward the sagittal central ACL insertion, led to a sagittal tunnel-plateau angle that averaged 68 degrees (range 64 degrees to 72 degrees) with a corresponding tunnel length that averaged 58 mm (range 50 to 65 mm) in 23 knees. This data correlated well with data obtained clinically in a series of 50 consecutive ACL reconstructions using intraarticular PCL and extraarticular pes anserine-medial tibial tubercle referenced tibial tunnels in which postoperative full extension lateral radiographs confirmed a sagittal tunnel-plateau angle parallel or near parallel with the intercondylar roof-plateau angle in all cases averaging 68 degrees +/- 3.8 degrees. Tibial tunnel length averaged 60 mm (range 52 to 66 mm) and in no case was there a patellar tendon autograft-tunnel length mismatch.