Real-Time Virtual Sonography-Guided Ossicle Removal in Unresolved Osgood-Schlatter Disease.

Osgood-Schlatter disease (OSD) reduces participation in sports activities for adolescents, and, in unresolved cases of the disease in which daily life or sports activity after skeletal maturity are affected, surgical intervention to remove the ossicle is performed to alleviate symptoms. We present a real-time virtual sonography (RVS)-guided ossicle removal in unresolved OSD. The knee joint angle is set at 20°, which is the same position used in magnetic resonance imaging. A 1.5-cm longitudinal skin incision is made at the medial side of the tuberosity. An ultrasound probe covered with a sterile sleeve is then placed longitudinally at the level of tuberosity. The forceps is inserted to peel the patellar tendon off the posterior side of the ossicle. Then the anterior side of the ossicle is peeled off in both the transverse and longitudinal views. When the ossicle is unstable enough, forceps are used to grasp the ossicle and carefully remove it. RVS can see magnetic resonance imaging information in the surrounding area beyond what can be detected by the ultrasound probe, and RVS enables easy determination of the anatomical position of the ossicle, and removal of the ossicle is achieved with low invasiveness.

Gait analysis of patients with knee osteoarthiritis who can run versus cannot run.

BACKGROUND: Many middle-aged and older adults participate in running to maintain their health and fitness; however, some have to stop running due to osteoarthritis-attributed knee pain. It was unclear whether gait biomechanics and knee physical findings differ between those who can and cannot run. RESEARCH QUESTION: What are the gait and knee physical findings of patients with knee osteoarthritis who remain capable of running in comparison to those who are not capable of running? METHODS: This was a cross-sectional study, which recruited 23 patients over the age of 40 who had been diagnosed with knee osteoarthritis. Their knee joint ranges of motion and muscle strength, knee pain, and the maximum gait speed (walk as fast as possible) were measured. Knee alignment was calculated from X-ray images, and the knee joint extension angle and adduction moment during a self-selected gait speed were determined using motion analysis. Participants were divided into two groups-those able to run (n=11) and those unable to run (n=12). The measured and calculated outcomes were compared between groups, and logistic regression analyses of significantly different outcomes were performed. RESULTS: There were significant group differences in the maximum knee extension angle during stance phase (p = 0.027), maximum gait speed during the 10-m walk test (p = 0.014), knee pain during gait (p = 0.039) and medial proximal tibial angle by X-ray (p = 0.035). Logistic regression analyses revealed that the maximum knee extension angle during stance phase (OR: 1.44, 95%CI: 1.06¬1.94, p = 0.02) was a significant factor. SIGNIFICANCE: The ability to extend the knee during gait is an important contributing factor in whether participants with knee osteoarthritis are capable of running.

Low central sensitisation inventory score is associated with better post-operative outcomes of osteotomy around the knee.

PURPOSE: The purpose of this study was to investigate the potential association between central sensitisation inventory (CSI) scores and post-operative patient-reported outcomes (PROs) in patients underwent osteotomy around the knee (OAK), with a CSI cut-off score specific for knee osteoarthritis. METHODS: CSI scores were collected from 173 patients who underwent OAK, along with their knee injury and osteoarthritis outcome score (KOOS) and pain numeric rating scale (NRS) scores. Patients were divided into high-CSI score group and low-CSI score group with a cut-off score of 17. Multivariate linear regression was performed to test the association between CSI scores and post-operative outcomes. Pre-surgery KOOS and NRS scores and the rate of attainment of minimal clinically important difference (MCID) of KOOS scores was analysed as secondary outcomes. RESULTS: Low-CSI score group had significantly higher post-operative KOOS scores and lower pain NRS scores compared to the high-CSI score group (< p = 0.01) after adjusting for confounding factors. For pre-operative scores, only the KOOS-Symptom score was significantly different between the groups (64.7 ± 20.1 when CSI < 17 vs.55.1 ± 19.7 when CSI ≥ 17; p = 0.008). The low-CSI score group had significantly higher MCID achievement rates of KOOS-Pain, Symptom, and ADL than the high-CSI score group (86% vs. 68%; 74% vs. 55%; 86% vs. 67%, respectively; P < 0.05). CONCLUSIONS: This study established an association between post-operative CSI scores ≥ 17 and poorer outcomes following OAK, highlighting the potential value of the CSI in identifying patients in need of more comprehensive peri-operative pain management. LEVEL OF EVIDENCE: Level III. Retrospective comparative study.

Derotational Hybrid Closed-Wedge High Tibial Osteotomy for Knee Osteoarthritis With Patellar Subluxation Caused by Tibial Torsional Deformity.

Patellar subluxation and recurrent dislocation are commonly treated with medial patellofemoral ligament reconstruction, and patients with predisposing factors for these problems often require additional bony realignment procedures. However, these procedures mainly address problems in the axial plane, and patients with medial-compartmental knee osteoarthritis may require further realignment in the coronal plane. In this Technical Note article, we introduce our technique for derotational hybrid closed-wedge high tibial osteotomy. Using this technique, simultaneous 3-dimensional realignment in the axial, coronal, and sagittal planes can be achieved in patients with medial compartmental knee osteoarthritis and patellar subluxation caused by a tibial torsional deformity. The indications for the technique and the preoperative planning assessments involving a static torsional deformity analysis on computed tomography images and a dynamic gait analysis by our walking-on-paper method are presented. This is followed by a detailed description of the surgical procedure, together with consideration of the pearls and pitfalls of the procedure. A video of the surgery performed in a representative case with medial knee osteoarthritis and patellar subluxation in the right knee owing to an outward tibial torsion deformity is also provided.

Double-Row Root Repair with Bridging Centralization Using Double Nonsliding Anchors for Medial Meniscus Posterior Root Tear.

Medial meniscal posterior root tears disrupt the "hoop" function of the meniscus and may lead to knee osteoarthritis. Although root repair could be a key to osteoarthritis prevention, this surgery does not necessarily guarantee an optimal result even when combined with meniscal centralization and high tibial osteotomy. To address this issue, we made five modifications to the original combined approach, namely two anchors to fix the root, instead of one; bridging centralization instead of single centralization; release of the meniscotibial capsule vs no release; release of valgus stress before knot tying vs no release; and prohibiting postoperative cross-legged sitting and sitting on heels. The advantages of this approach over the original approach are numerous and comprise ease of performing concurrent open wedge high tibial osteotomy, shorter fixation distance, better anatomical reattachment of the meniscal root, increased bone-meniscus contact and contact pressure, and larger contact area between the capsule and tibial rim. The disadvantages of the approach are that knot-tying is cumbersome, pie-crusting of the medial collateral ligament is necessary in patients not undergoing open wedge high tibial osteotomy, and tears >3 mm from the attachment are a contraindication. We describe the steps in this modified approach in detail.

Flexion Contracture in Knee Osteoarthritis Can Be Fully Eliminated by Hybrid Closed Wedge High Tibial Osteotomy Using a Reduction-Insertion-Compression Handle.

In conventional closed-wedge high tibial osteotomy (CWHTO) with preservation of the medial hinge, flexion contracture cannot be improved because of the two-dimensional correction. Conversely, in hybrid CWHTO, for which the name is derived from a hybrid of the lateral closing and medial opening, the medial cortex is intentionally disrupted. The medial hinge disruption enables three-dimensional correction, which helps eliminate flexion contracture by decreasing posterior tibial slope (PTS). The fine adjustment of the anterior closing distance and thigh-compression technique further facilitates PTS control. In this study, we describe the use of the Reduction-Insertion-Compression Handle (RICH), which maximizes the benefits of hybrid CWHTO. This device permits accurate osteotomy reduction, easy screw insertion, and assists with providing sufficient compressive force at the osteotomy site, as well as the elimination of the flexion contracture. This Technical Note presents the details of using the RICH and the associated advantages and disadvantages in hybrid CWHTO for medial compartmental knee arthritis.

Femoral-varus tibial-valgus osteotomy (FVTVO) for neutrally-aligned knee osteoarthritis with severe joint line obliquity enables return to sports activities: A case series study.

Background: Re-alignment surgeries for uni-compartmental knee osteoarthritis, such as high tibial osteotomy (HTO) for varus knees or distal femoral osteotomy (DFO) for valgus knees, are recognized as standard strategies. However, the treatment strategy has not been established for patients with a neutrally-aligned osteoarthritic knee with severe joint line obliquity (JLO) owing to the combination of a valgus femur and a varus tibia; i.e., type II coronal plane alignment of the knee (CPAK). total knee arthroplasty (TKA) can be an option for CPAK type II-aligned osteoarthritis in older inactive patients. Here, we hypothesized that joint line horizontalization by femoral-varus tibial-valgus osteotomy (FVTVO), which may reduce the shear stress induced by JLO, could be a treatment option for CPAK type II-aligned osteoarthritis in young active patients who wish to return to sports (RTS) activity. Our aim in this study was to evaluate the postoperative results of FVTVO with RTS. Methods: Our indications for FVTVO are as follows: JLO >5°; mechanical medial proximal tibial angle (mMPTA) < 87°; mechanical lateral distal femoral angle (mLDFA) < 87°; typical osteoarthritis patterns for CPAK type II on magnetic resonance images, namely osteoarthritic change of the lateral tibial spine, medial slip of the femur, and/or lateral meniscal extrusion from the lateral femoral condyle; and flexion contracture <10°. We enrolled patients who wished to RTS and who had a pre-symptom Tegner score ≥5 and had completed at least a 1-year follow-up. For FVTVO, closed-wedge DFO was performed in all femurs; both closed-wedge HTO and open-wedge HTO were used in the tibia, depending on the situation. Range of motion exercises began on the first postoperative day, and full weight-bearing was permitted 6 weeks postoperatively. Jogging was permitted 3 months postoperatively after confirming bone union, and patients could gradually return to their sports activity 6-12 months' postoperatively. The Japanese Orthopaedic Association (JOA) score and knee flexion range were assessed preoperatively and at the last follow-up. Tegner activity scale scores were assessed presymptom, preoperatively, and at the last follow-up. The hip-knee-ankle (HKA) angle, JLO, mMPTA, and mLDFA were evaluated radiologically, and meniscal extrusions, osteoarthritic change, and/or bone marrow edema were assessed on magnetic resonance images. Results: One man and two women were included in this case series. Two were competitive athletes and one was a mountain climber. The patients' ages were 69, 46, and 57 years (Case 1, 2, and 3, respectively). All patients' CPAK type was converted from type II to type V; i.e., neutral-aligned knee with a neutral joint line, postoperatively. All patients returned to their presymptom sports activity level by the final follow-up. The presymptom/preoperative/final follow-up Tegner scale in Case 1, 2, and 3 were 6/1/6, 5/2/5, and 7/3/7, respectively. Conclusion: Joint line horizontalization by FVTVO for patients with a neutral-aligned knee with severe JLO provided highly satisfactory clinical results and successfully led to RTS.

Simultaneous bilateral total knee arthroplasty is safe and effective for patients in different ages.

BACKGROUND: Simultaneous bilateral total knee arthroplasty is considered beneficial for patients with bilateral end-stage knee osteoarthritis, even though there could be potential postoperative complications. Presently, there is a paucity of evidence of the efficacy and safety of SB-TKA for elderly patients. This study aimed to compare the clinical outcomes of simultaneous bilateral total knee arthroplasty by different age groups. METHODS: A total of 216 knees of 108 patients, who underwent simultaneous bilateral total knee arthroplasty for osteoarthritis at our hospital between April 2015 and September 2018, were divided into three groups based on age: 60s (44 knees), 70s (106 knees), and 80s (66 knees). Perioperative data and postoperative clinical outcomes 1 year after surgery were compared between the age groups. RESULTS: The patients in the Group 60s were characterized by a higher body mass index (BMI) (P < 0.01), a lower pre-operative knee function score (P < 0.01), longer operation time (P < 0.01), greater intra-operative (P < 0.01), and postoperative bleeding (P = 0.026). No significant difference was found in terms of occurrence of various postoperative complications, although deep vein thrombosis and delirium occurred slightly more frequently in the Group 70s and the Group 80s than in the Group 60s group. The Knee Society Knee Score, a function score, and patient satisfaction scores were significantly improved in all groups 1 year after surgery. Moreover, these indexes of clinical outcomes were similar among the three groups. CONCLUSION: Performing simultaneous bilateral total knee arthroplasty in 80s patients was found to be as safe and effective as in the 60s and 70s patients. LEVEL OF EVIDENCE: 3 (A retrospective cohort study).

Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft.

PURPOSE: The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft. METHODS: Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann-Whitney test or the t-test. RESULTS: Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02). STUDY DESIGN: This was a level 3 retrospective study. CONCLUSION: Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.

Simultaneous Correction of Varus Deformity and Posterior Tibial Slope by Modified Hybrid Closed-Wedge High Tibial Osteotomy.

A large posterior tibial slope has been proven to be a risk factor for anterior cruciate ligament (ACL) injuries, ACL graft failure, and medial meniscus posterior root tear. In addition, such pathologies often are accompanied by varus alignment. Thus, simultaneous varus and slope-correction osteotomy is required in such cases. High tibial osteotomy (HTO) is a well-established treatment for medial compartment knee osteoarthritis. Several HTO surgical techniques have been proposed, and hybrid closed-wedge HTO has been found to correct both varus deformity and a large posterior tibial slope via modification of the transverse osteotomy procedure. This Technical Note describes a modified hybrid closed-wedge HTO for simultaneous varus and slope correction in patients with ACL deficiency and/or medial meniscus posterior root tear involving both varus deformity and a large posterior tibial slope. This technique may reduce the risk of failure of the ACL graft and/or repaired medial meniscus posterior root.

Proximal tibiofibular joint (PTFJ) dislocation due to Ehlers-Danlos syndrome: posterolateral open-wedge high tibial osteotomy combined with medial closed-wedge distal femoral osteotomy can correct the severe valgus deformity with a markedly increased tibial posterior slope.

Ehlers-Danlos syndrome (EDS) causes joint hypermobility and joint dislocation. Since there are no reports of proximal tibiofibular joint (PTFJ) dislocation caused by EDS, little is known about the long-term course of this disease. A woman in her 40s presented with a posterolaterally depressed tibial condyle and severe valgus deformity caused by a long-standing PTFJ dislocation due to EDS. Considering the pathology, posterolateral open-wedge high tibial osteotomy (PLOWHTO) and medial closed-wedge distal femoral osteotomy were performed according to the deformity analysis. A favourable short-term clinical outcome was obtained and the PTFJ dislocation was reduced over time. Although PLOWHTO has several pitfalls, it is a logical and useful surgical technique that can help treat posterolateral dysplasia of the tibial plateau concomitant with severe valgus deformity, regardless of joint laxity, if performed with attention to pitfalls.

Ankle-Angle-Adjusting Fibular Osteotomy in Closed Wedge High Tibial Osteotomy.

Closed-wedge high tibial osteotomy (CWHTO) may be carried out to realign the knee in patients with knee osteoarthritis who do not meet the criteria for open-wedge high tibial osteotomy or total knee arthroplasty. The procedure involves both fibular and tibial osteotomy, and care is needed to prevent peroneal nerve and vessel injury during fibular osteotomy. Notably, use of a tourniquet may mask the development of hematomas or aneurysms until after surgery. We developed a 3-step ankle-angle-adjusting (triple-A) technique to relax the muscles, allowing easy retraction of the peroneal vessels. Crucially, the procedure does not require a tourniquet, thus allowing bleeding to be detected and stopped during surgery. The process involves adjusting the ankle angle by plantar-flexion and applying varus stress to highlight the tension difference between the lateral and posterior compartments; plantar-flexion of the great toe to loosen the flexor hallucis longus muscle, thus exposing the fibular posterior aspect; and valgus stress to loosen the peroneus longus muscle. The muscles can then be retracted sufficiently to allow distal and proximal osteotomies to be performed, and any bleeding can be detected and resolved before wound closure. This technique may improve the ease and safety of fibular osteotomy in patients undergoing CWHTO.

Comparison of tissue pharmacokinetics of esflurbiprofen plaster with flurbiprofen tablets in patients with knee osteoarthritis: A multicenter randomized controlled trial.

This open-label, multicenter, prospective, randomized controlled trial aimed to determine the effectiveness of esflurbiprofen plaster (SFPP) and flurbiprofen tablets (FPTs) on knee osteoarthritis in patients scheduled for total knee arthroplasty by comparing the transfer of esflurbiprofen and flurbiprofen to tissues and fluids. Thirty-eight patients were randomly assigned in a 1:1 ratio to receive SFPP or FPT. Both groups were then divided into four subgroups, according to whether they received the final dose of SFPP or FPT at 2, 7, 12, or 24 h before planned surgery. The primary endpoints were the esflurbiprofen concentrations in synovium, synovial fluid, and plasma. Areas under concentration-time curves (AUC0-24 h ) of esflurbiprofen were calculated for each group. Pain was assessed using a numeric rating scale (NRS) 7 days before and immediately before surgery. The AUC0-24 h in the synovium were 4401.24 and 4862.70 ng·h/g in the SFPP and FPT groups, respectively. Maximum esflurbiprofen concentrations were observed in the synovium, synovial fluids, and plasma after SFPP application for 12 h. The NRS results indicated a long-lasting effect of SFPP. The AUC of the synovial esflurbiprofen concentration of SFPP indicated that the SFPP is transferred to the synovium and synovial fluid in high concentration. The efficient deep-tissue transfer of esflurbiprofen suggests that its pharmacokinetic characteristics differ from those of conventional topical NSAIDs. This study was prospectively registered in the Japan Registry of Clinical Trials (registration number: jRCTs031180228).

Arthroscopic Centralization Using Knotless Anchors for Extruded Medial Meniscus.

The load-distributing function is most critical in meniscal function, and meniscal extrusion suggests failure of this function, leading to the progression of osteoarthritis. The arthroscopic centralization technique has been developed to reduce meniscal extrusion; however, existing arthroscopic techniques sometimes fail to reduce the most extruded region, especially in cases with a medial meniscus (MM) posterior root tear, in which the most extruded region is on the posterior border of the medial collateral ligament, which is very difficult to approach. This Technical Note describes an arthroscopic technique for extrusion of the MM in which a centralization technique using knotless anchors efficiently reduces the MM extrusion at the posteromedial part and consequently restores the MM function. This technique efficiently reduces MM extrusion and restores its function, thus preventing the progression of osteoarthritis.

Two-Year Outcomes After Meniscoplasty by Capsular Advancement With the Application of Arthroscopic Centralization Technique for Lateral Compartment Knee Osteoarthritis.

BACKGROUND: A high prevalence of osteoarthritis (OA) progression in patients with lateral meniscal defects has been reported. However, optimal management techniques for active patients remain ill-defined. HYPOTHESIS: Meniscoplasty by capsular advancement with the application of the centralization technique would improve clinical and radiological outcomes in patients with lateral compartment OA attributed to lateral meniscal defects. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 27 patients were enrolled who had undergone meniscoplasty by capsular advancement for lateral compartment OA attributed to lateral meniscal defects. In these patients, the meniscotibial capsule was released from the tibia and advanced with the remaining meniscus onto the rim of the tibial plateau to reform a meniscus-like configuration. Measures of clinical outcomes included clinical examination, Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Knee injury and Osteoarthritis Outcome Score (KOOS), subjective rating scales regarding recovery of the operated knee, and sports performance level. Measures of radiographic outcomes included meniscal extrusion width or regeneration of the meniscus-like tissue on magnetic resonance imaging and lateral joint space width on standing extension anteroposterior and Rosenberg views. All clinical and radiographic outcomes were reported preoperatively and 2 years postoperatively, except magnetic resonance imaging findings, which were reported preoperatively and 1 year postoperatively. RESULTS: The clinical outcomes were significantly improved 2 years postoperatively as compared with baseline: Lysholm score, IKDC subjective score, and KOOS subscores (all P < .0001). The patients' subjective recovery (P < .0001) and sports performance level (P < .0001) were also improved. One year postoperatively, 10 of 11 patients who had no meniscus remaining at the middle segment showed more than one-third the volume of meniscal tissue-like regeneration, and meniscal extrusion width was significantly reduced as compared with baseline in the remaining 16 patients (P = .0006). Joint space width increased at 2 years on the standing anteroposterior view (P < .0001) and the Rosenberg view (P = .0001). CONCLUSION: Meniscoplasty of the lateral meniscus by capsular advancement improved clinical and radiographic outcomes at 2-year follow-up in patients with lateral compartment OA attributed to lateral meniscal defects.

Synovial fluid-derived mesenchymal cells have non-inferior chondrogenic potential and can be utilized for regenerative therapy as substitute for synovium-derived cells.

Recent progress in the field of mesenchymal stem cell (MSC) biology has enabled their clinical application. In the autologous cell transplantation therapy, the source of MSCs are quite important to reduce patients' physical burden. In this study, we isolated MSCs from the synovial fluid (SF) and synovial membrane (Syn) of the same patients and compared the biological characteristics of them. In vitro and in vivo experiments indicated the non-inferior chondrocytic differentiation and articular cartilage regeneration potential of SF-MSCs compared to that of Syn-MSCs; however, SF-MSCs showed less proliferative potential than Syn-MSCs in vitro. Flow cytometry-based multiplex surface antigen expression analyses indicated that SF-MSCs exhibit fewer cells positive for CD140, which is a functional growth factor receptor for MSCs. Nevertheless, we obtained enough SF-MSCs for transplantation within several passages. Since arthrocentesis is routinely performed during outpatient care in the consultation room and is less invasive than synovial biopsy, MSC derived from synovial fluid could be considered an attractive cell source for cartilage regenerative therapy as a substitute for Syn-MSC. Developing these cells for clinical application may greatly benefit patients undergoing autologous MSC transplantation therapy.

Anatomic femoral tunnel placement is difficult by the transtibial technique: comparison of three different femoral tunnel drilling techniques in double-bundle anterior cruciate ligament reconstructions.

PURPOSE: To compare the position and direction of femoral and tibial tunnels for both the anteromedial bundle (AMB) and posterolateral bundle (PLB) among three different femoral tunnel drilling techniques, transtibial (TT), transportal (TP), and outside-in (OI) techniques, in anatomic double-bundle ACL reconstruction to clarify advantages and disadvantages of each technique. METHODS: One-hundred and thirty-nine patients underwent primary ACL reconstruction with an autologous semitendinosus tendon in our institution between 2014 and 2016. Thirteen patients were excluded according to the exclusion criteria. Of the 126 patients, 98 patients agreed to be included in this study. Patients were then randomized into three groups according to the femoral tunnel drilling technique; the TT, TP, and OI groups. Femoral and tibial tunnel angles and positions were measured using three-dimensional computed tomography. RESULTS: Of patients who agreed to be included in this study, eight patients (seven in TT and one in OI) were excluded since the femoral tunnel could not be created at the intended position. Eighty-six patients (29 in TT, 29 in TP, and 28 in OI) were included for the analyses. Tunnel angles, as well as tunnel lengths, had significant differences among different techniques depending on each technique's characteristics. In terms of tunnel position, femoral tunnel positions of both the AMB and PLB in the TT group were significantly higher than those in the TP group (AMB: p = 0.003, PLB: p = 0.001), and the PLB tunnel position in the TP group had significantly smaller vaciance than that in the TT group (p = 0.004) and OI group (0.002). CONCLUSIONS: The femoral tunnel positions created by the TT technique were significantly higher, with larger variance, than the TP technique in double-bundle ACL reconstruction, although the positions seemed to be within anatomical footprint. In addition, there were several cases in which femoral tunnels could not be created at the intended position by the TT technique. LEVEL OF EVIDENCE: I.