Patella tendon autograft use and A-shaped femoral notch are associated with more anterior and proximal femoral tunnel placement during anterior cruciate ligament reconstruction
In brief
Patellar tendon grafts were more common in the most-anterior ACL tunnels: 38% vs 22%
In a retrospective series of 372 primary ACL reconstructions, bone-patellar tendon-bone grafts were more common among patients in the most-anterior tunnel-position group than in the rest of the cohort, while quadriceps tendon grafts were less common. A-shaped notches, smaller lateral femoral condyles and female sex were linked to more proximal placement; these associations do not establish cause and effect.
- Journal
- Journal of experimental orthopaedics (Q1)
- Published
- 22 March 2026
- Study design
- Retrospective cohort
- Evidence level
- Level 3, Low (CEBM 3b)
- Authors
- Sahil Dadoo, Koji Nukuto, Efstathios Konstantinou, Jumpei Inoue, Jacob Hartline, Jonathan D Hughes, et al.
- PMID
- 42899268
- DOI
- 10.1002/jeo2.70694
Why clinicians should know about it
- Picked for Anatomy (paper of the day, 21 October 2026): Femoral notch morphology associated with ACL tunnel placement
Abstract
PURPOSE: The purpose of this study was to evaluate the impact of surgical and anatomical variables, including graft type, femoral notch width and shape, posterior cruciate ligament (PCL) width and lateral femoral condyle (LFC) diameter, on femoral tunnel position during anterior cruciate ligament reconstruction (ACLR). METHODS: All consecutive patients who underwent primary ACLR between 2017 and 2021 were retrospectively reviewed. Femoral tunnel position was evaluated in the posterior-to-anterior (P-A) and proximal-to-distal (P-D) directions using the quadrant method. Surgical and anatomical variables (including patient demographics, ACLR graft type, femoral notch width and shape, PCL width and LFC diameter) were compared between the most anterior and proximal quartiles of femoral tunnel positions to the rest of the cohort to identify variables associated with anterior and proximal femoral tunnel placement. Statistical tests included independent t test, Mann-Whitney U test and χ 2 test as appropriate, with significance set to p < 0.050. RESULTS: A total of 372 patients (mean age: 25 years; 190 [51%] females) were included for analysis. Compared to the non-anterior group, the anterior quartile group had a higher proportion of bone-patellar tendon-bone (BPTB) autografts (38% BPTB vs. 22% BPTB; p = 0.002) and lower proportion of quadriceps tendon (QT) autografts (29% QT vs. 50% QT; p = 0.002). Compared to the non-proximal group, the proximal quartile group had a higher proportion of A-shape femoral notches (53% vs. 39%; p = 0.016) and smaller LFC diameter (30.4 vs. 31.3 mm; p = 0.048). Female patients additionally had 1.9 times higher odds of proximal femoral tunnel placement compared to male patients. CONCLUSION: BPTB autograft use was associated with more anterior femoral tunnel placement, while an A-shape femoral notch, smaller LFC diameter and female sex were associated with more proximal femoral tunnel placement during primary ACLR. For clinical relevance, these data may be useful to surgeons to identify demographic, surgical and anatomical variables that may influence femoral tunnel position during primary ACLR. LEVEL OF EVIDENCE: Level IV, case series.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.