Risk analysis of tibial tunnel collision in multiligamentous knee reconstructions - Arthroscopic popliteus tendon reconstruction with anteromedial tibial tunnel drilling - 19/07/25

Doi : 10.1016/j.otsr.2025.104335

Steven Heylen ^a,^b,^c,⁎ , Annemieke Van Haver ^d, Peter Verdonk ^d,^e, Matthias Krause ^f, Jozef Michielsen ^f,^g
^a Department of Trauma and Orthopaedics, Heilig Hart Ziekenhuis Lier, 2500 Lier, Belgium
^b Orthopaedic Research and Education Foundation, OrthoClinic Lier, 2500 Lier, Belgium
^c University of Antwerp, Faculty of Medicine and Health Sciences, PhD Department, 2018 Antwerp, Belgium
^d More Institute, Orthopedic Research Department, AZ Monica Hospital, 2018 Antwerp, Belgium
^e OrthoCA Orthopaedic Center, 2018 Antwerp, Belgium
^f Department of Trauma Surgery and Orthopaedics, UKE, Hamburg, Germany
^g Department of Orthopaedic Surgery, Antwerp University Hospital, 2650 Edegem, Belgium

^⁎Corresponding author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 19 July 2025

Abstract

Background

Drilling the tibial tunnel in tibiofibular-based posterolateral corner (PLC) reconstructions is usually performed with a starting point from Gerdy’s tubercle. Drilling this tunnel from the anteromedial tibial cortex could reduce the risk of popliteal neurovascular injury but increase the risk of tunnel collision.

Hypothesis

The purpose of this study is to assess the risk of tunnel collision in tibiofibular based reconstructions with a tibial tunnel drilled from the anteromedial cortex versus drilled from the anterolateral cortex.

Methods

A total of 18 Computed Tomography scans were performed postoperatively in patients with an anterior cruciate ligament (ACL) reconstruction. Imageprocessing software was used to make a 3D model of the tibia and the trajectory and volume of the ACL tunnel was integrated into the model. Virtual posterior cruciate ligament (PCL) and PLC tunnels were added to the model according to the ideal location of the exit points in the current literature. The starting point for the PCL tunnel was inferomedial to the ACL tunnel. Five virtual tunnel locations for PLC reconstruction were added to the model: lateral, inferolateral, inferior, inferomedial and medial. Tunnel collision and distances were calculated.

Results

There was no collision with the lateral, inferolateral or inferior PLC tunnels. The inferomedial and medial PLC tunnels collided with the ACL and/or PCL tunnels in 13 patients. One-way ANOVA test did not show a significantly significant difference in mean distance to the ACL or PCL tunnel for the lateral, inferolateral or inferior PLC tunnels (p > 0.05).

Discussion

When drilling the PLC reconstruction tunnel from the anteromedial cortex in case of a multiligamentous knee reconstruction, our study shows that drilling should start from the lateral, inferolateral or inferior position relative to the ACL and PCL reconstruction tunnels to avoid tunnel collision.