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Correlation Between Femoral Tunnel Length and Tunnel Position in ACL Reconstruction
Daniel Hensler, MD1; Zachary M. Working, MD2; Kenneth D. Illingworth, MD2; Scott Tashman, PhD2; Freddie H. Fu, MD, DSc(Hon), DPs(Hon)2
1 Department for Trauma Surgery, Trauma Center Murnau, Murnau 82418, Germany
2 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA 15213. E-mail address for F.H. Fu: ffu@upmc.edu
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Investigation performed at the Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. One or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Nov 20;95(22):2029-2034. doi: 10.2106/JBJS.L.01315
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The position of the femoral tunnel affects the osseous geometry available for drilling during anterior cruciate ligament (ACL) reconstruction. The length of the tunnel changes with changes in the tunnel position and may have implications for femoral fixation.


Forty-seven patients with a single-bundle ACL reconstruction underwent computed tomography (CT) evaluation to generate three-dimensional (3D) CT bone models. With use of a previously described anatomic coordinate system, the center of the femoral tunnel was quantified in the posterior-anterior and proximal-distal dimensions on 3D CT. Tunnel length was defined as the distance between the centers of the intra-articular and extra-articular tunnel apertures. The reconstructed knees were dichotomized by anatomy and technique into anatomic (n = 20) and nonanatomic (n = 27) groups as well as according to whether they had undergone medial portal drilling (n = 20) or transtibial drilling (n = 27) for analysis. In addition, a review of the literature on the relationship between tunnel length and tendon-to-bone healing was performed.


Femoral tunnels drilled with nonanatomic footprints were longer (mean [and standard deviation], 43.6 ± 8.5 mm; range, 28.2 to 60.7 mm) than tunnels drilled with anatomic footprints (31.0 ± 6.3 mm; 21.2 to 42.5 mm) (p < 0.001). Tunnels drilled transtibially (44.4 ± 7.6 mm; 32.5 to 60.7 mm) were significantly longer than tunnels drilled through the medial portal (29.8 ± 5.0 mm; 21.2 to 40.3 mm) (p < 0.001). There was a strong correlation between tunnel length and posterior-anterior femoral tunnel position (r = 0.78, p < 0.05), with more anterior tunnel positioning associated with greater tunnel length. There was no correlation between posterior-distal femoral tunnel position and tunnel length (r = −0.05; p = 0.74). There was no consensus in the literature regarding adequate tunnel length for biologic fixation.


Femoral tunnels drilled with anatomic footprints had sufficient length for adequate femoral fixation. Femoral tunnels positioned anterior to the native insertion of the ACL were longer than those in anatomic position.

Clinical Relevance: 

The results of this study can help the surgeon to consider the relationship between tunnel position and subsequent tunnel length in ACL reconstruction.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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