Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study

We examined the arthroscopic appearance of the anterior cruciate ligament (ACL) attachment site on the femur in five fresh-frozen cadaver knees. First, the ACL was cut out, leaving a footprint of ligament-fibers with a length of 2 min intact. The ACL was consistently found to insert on the lateral wall of the notch. No fibers were found to attach high in the roof of the notch at the 12 o'clock position. Secondly, we tried to reach the anatomical attachment site with a femoral aiming guide through a correctly placed tibial tunnel. This proved to be impossible. The closest position that could be reached was at the margin of the anatomical attachment site. Investigation of the distal femur after complete, dissection confirmed these arthroscopic findings. Femoral aiming devices for use through the tibial tunnel aim for an isometric placement of the femoral tunnel, they do not aim for an anatomical position of the graft.