Evaluating the Femoral-Side Critical Corner in Posterior Cruciate Ligament Reconstruction: The Effect of Outside-In Versus Inside-Out Creation of Femoral Tunnels on Graft Contact Pressure in a Synthetic Knee Model.

ABSTRACT

PURPOSE: To characterize and compare the graft contact characteristics of outside-in (OI) and inside-out (IO) femoral tunnels during single-bundle reconstruction of the anterolateral bundle of the posterior cruciate ligament in a synthetic knee model. METHODS: Femoral tunnels were separately made in 16 synthetic femora (8 OI and 8 IO). Achilles tendon allografts were fixed using suspensory fixation with a pressure sensor between the allograft and femoral tunnel. Grafts were cyclically loaded; force, contact area, contact pressure, and peak pressure at the aperture were measured. This process was repeated using the same allograft to assess the other tunnel angle in a separate specimen. RESULTS: IO specimens showed higher mean contact pressure at all loading cycles, with significance shown at 50 N (P = .02). Peak pressure was also greater in IO specimens at all loading cycles and reached statistical significance at 100 N (P = .04). IO specimens had a lower contact area at 150 N (P = .04). No statistically significant differences in force were observed between the 2 groups. CONCLUSIONS: OI creation of the femoral tunnel for anterolateral bundle reconstruction of the posterior cruciate ligament resulted in decreased mean and peak contact pressures at the femoral aperture compared with IO tunnel creation at the specific trajectories and loading parameters tested in this synthetic femoral model. These biomechanical data suggest that OI creation of the femoral tunnel may help reduce in vivo graft contact pressure at the femoral aperture. CLINICAL RELEVANCE These data suggest that a tunnel drilled from OI may result in less graft pressure at the femoral aperture, which may prevent graft elongation and optimize graft survival.