Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction

  • Cristian JetteEmail author
  • Jaume Pomés
  • Sergi Sastre
  • David Gutierrez
  • Manuel Llusa
  • Andrés Combalia



To determine the best angle to drill the femoral tunnels of an anterolateral ligament (ALL) anatomic reconstruction combined with a single-bundle anterior cruciate ligament (ACL) reconstruction to avoid tunnel collisions and cortical disruption.


Ten cadaveric knees were studied. Single-bundle anatomic ACL femoral tunnels were arthroscopically drilled. The starting point of the ALL femoral tunnel was located posterior and superior to the lateral epicondyle. ALL tunnels were drilled at four different angulations: (1) 0° axial/0° coronal, (2) 0° axial/30° coronal superior, (3) 30° axial anterior/0° coronal, and (4) 30° axial anterior 30° coronal superior. Specimens were scanned by computed tomography to measure the relations of each trajectory with the ACL socket and the nearest cortical bone.


None of the four trajectories studied presented risk of collision with the ACL. The tunnel at 30° anterior/30° proximal presented the safest distance to the ACL socket (P = 0.01) [mean distance 18.6 mm (SD ± 6.7)]. However, both tunnels angled at 0° in the axial plane presented a high risk of posterior femoral cortex disruption (P = 0.01), either by close proximity or direct contact in some specimens (mean distance 3.1 mm (SD ± 2.8) at 0° axial/0° coronal and 3.7 mm (SD ± 2.2) at 0° axial/30° coronal).


When performing simultaneous ACL and ALL ligament reconstruction, the ALL femoral tunnel should be drilled with an angle of 30° anterior in the axial plane and 30° proximal in the coronal plane. Tunnels with an angle of 0° in the axial plane showed high risk of contact and disruption of the posterior femoral cortex; thus, these angles should be avoided. The clinical relevance of this work is that an ALL anatomical reconstruction does not represent a risk when performing a simultaneous ACL reconstruction as long as the ALL tunnel is reamed with a proximal and anterior angulation.


Anterolateral ligament Femoral tunnel drilling ACL reconstruction Anatomic reconstruction 



Anterior cruciate ligament


Anterolateral ligament


Lateral collateral ligament






Accessory anteromedial


Computed tomography


Analyses of variance


Lateral extra-articular tenodesis


Intercondylar notch


Posterior femoral cortex


Institutional Review Board


Intraclass correlation coefficient


Author contributions

CJ designed the study, carried out the anatomic dissection, arthroscopy procedures, and femoral tunnel placement and drafted the manuscript. JP carried out the image analysis and CT measurements. SS participated in the study design and coordination between departments. DG participated in the anatomic dissection, data gathering and performed the statistical analysis. ML participated in the coordination with the university and helped with the arthroscopy procedures. AC participated in the coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


The authors declare that no funding was received to perform this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was performed after ethical approval from the Institutional Review Board at the Univesity of Barcelona (IRB00003099).

Informed consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery and TraumatologyHospital ClinicBarcelonaSpain
  2. 2.Division of Musculoskeletal Radiology, Department of RadiologyHospital ClinicBarcelonaSpain
  3. 3.Department of Human AnatomyUniversity of Barcelona Medical SchoolBarcelonaSpain

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