The effect of intraoperative fluoroscopy on the accuracy of femoral tunnel placement in single-bundle anatomic ACL reconstruction

The purpose of the current study was to investigate the potential effect of intraoperative fluoroscopy on the accuracy of femoral tunnel placement in anatomic ACL reconstruction, using an ideal anatomic point as reference and evaluating postoperative tunnel placement based on 3D CT. An experienced ACL surgeon, using the anatomic approach for femoral tunnel placement, relying on intraarticular landmarks and remnants of the torn ACL-and novel to the fluoroscopic assist-was introduced to its use. A prospective series of patients was included where group 1 (without fluoroscopy) and group 2 (with fluoroscopy) both had postoperative CT scans so that femoral tunnel position could be evaluated and compared to an ideal tunnel centre based on anatomic studies by using the Bernard and Hertel grid. Group 2, where fluoroscopy was used, had a mean femoral tunnel that was closer to the ideal anatomic centre than group 1. In the Bernard and Hertel grid, the distance in the high-low axis (y-axis) was found significantly closer (P = 0.001), whilst the deep-shallow axis (x-axis) and a total absolute distance were not significantly closer to the ideal described anatomic centre. Intraoperative fluoroscopy was found effective as an aid for placing the femoral tunnel in a more accurate position, as compared to a desired anatomic centre. Although the concept of the "one-size-fits-all" approach for tunnel placement is debatable, the avoidance of grossly misplaced tunnels is the benefit of using fluoroscopy during ACL reconstruction. The authors hold that fluoroscopy is readily available, safe and easy to use and therefore a good aid in the anatomic approach for graft tunnel placement, for example, in a learning situation, in revision cases and when performing low volumes of such surgery. III.