Femoral Tunnel Technique
Moderate evidence supports that in patients undergoing intra-articular ACL reconstruction the practitioner could use either a tibial independent approach or transtibial approach for the femoral tunnel, because the measured outcomes are similar.

Rationale
There were seven moderate, one low, and one very low strength studies that compared intra-articular ACL reconstruction with use of a tibial independent to a transtibial approach to create the femoral drill hole.9, 18, 44, 73, 74, 78, 81, 82, 98

Research on this recommendation did not evaluate the techniques used for ACL reconstructions in skeletally immature patients. The tibial independent approach included both outside-in and medial portal drilling techniques. The studies demonstrate no consistent differences between the two techniques in objective metrics or patient reported outcomes. Meta-analysis of the study demonstrated no difference in IKDC knee exam or Lysholm scores.

Potential Harms of Implementation
As with all surgical techniques, there are potential complications such as malposition of the femoral tunnel or femoral tunnel blowout.

Future Research
Prospective randomized trials comparing the results of ACL reconstruction with femoral tunnels created using tibial independent and trans-tibial approaches should be performed to evaluate difference in objective metrics including limits of knee motion, and patient reported outcomes.
 

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