Optimization of Anteromedial Portal Femoral Tunnel Drilling With Flexible and Straight Reamers in Anterior Cruciate Ligament Reconstruction: A Cadaveric 3-Dimensional Computed Tomography Analysis

Purpose To use 3-dimensional custom CAD technology to evaluate how knee flexion angle affects femoral tunnel length and distance to the posterior wall when using curved and straight guides for drilling through the anteromedial portal (AMP). Methods Six cadaveric knees were placed in an external fixator at various degrees of flexion (90°, 110°, 125°, and maximum 135° to 140°). Computed tomography scans were obtained at all flexion points for 3-dimensional point-cloud models. Using custom CAD software, surgical guides through the AMP were replicated along with virtual tunnels at each flexion angle. Distance from the posterior cortex and tunnel dimensions were collected after 8-mm and 10-mm tunnel creation. Results At 90° of flexion, the average tunnel length down the posterior aspect of 8-mm tunnel was 25.0 mm (95% confidence interval [CI] 16.2-33.8) and 12.0 mm (95% CI 7.3-16.7) for curved and straight guides, respectively; 31.0 mm (95% CI 26.8-35.2) and 28.6 mm (95% CI 24.8-32.4) at 110°; 33.8 mm (95% CI 30.1-37.5) and 31.1 mm (95% CI 26.8-35.4) at 125°; and 35.0 mm (95% CI 34.1-35.9) and 35.5 mm (95% CI 34.2-36.8) with maximal flexion. Values between curved and straight guides are significantly different ( P < .001), with straight guides breaching the posterior wall at 90° and 110° of flexion in some specimens. The average distance to the posterior wall cortex was 0.9 mm (95% CI −1.5 to 3.3) and −0.6 mm (95% CI −2.3 to 1.1) for curved and straight guides, respectively, at 90° of flexion ( P = .014); 2.3 mm (95% CI −0.2 to 4.8) and −0.1 mm (95% CI −2.4 to 2.2) at 110° ( P = .001); 4.4 mm (95% CI 2.8-6.0) and 3.9 mm (95% CI 1.9-5.9) at 125° ( P = .299); and 6.7 mm (95% CI 6.2-7.2) and 8.3 mm (95% CI 6.1-10.5) at maximal flexion ( P = .184). Posterior wall blowout was noted when using 10-mm straight guides at both 90° (2 specimens) and 110° (3 specimens). Using 10-mm curved guides posterior blowout was noted in 1 specimen at 90°. Maximum footprint coverage occurred at 110° for straight guides and 90° for curved guides. Conclusions When using the AMP, flexible guides and reamers result in a greater distance of the tunnel to the femoral cortex while preserving adequate tunnel length at lower knee flexion angles. To create long femoral tunnels without breaching the posterior cortex, the knee should be flexed to at least 110° for curved reamers and 125° for straight. Clinical Relevance Femoral tunnel drilling through the AMP using curved and straight reamers