Knee rotation influences the femoral tunnel angle measurement after anterior cruciate ligament reconstruction: a 3-dimensional computed tomography model study.

Purpose: Femoral tunnel angle (FTA) has been proposed as a metric for evaluating whether ACL reconstruction was performed anatomically. In clinic, radiographic images are typically acquired with an uncertain amount of internal/external knee rotation. The extent to which knee rotation will influence FTA measurement is unclear. Furthermore, differences in FTA measurement between the two common positions (0° and 45° knee flexion) have not been established. The purpose of this study was to investigate the influence of knee rotation on FTA measurement after ACL reconstruction.

Methods: Knee CT data from 16 subjects were segmented to produce 3D bone models. Central axes of tunnels were identified. The 0° and 45° flexion angles were simulated. Knee internal/external rotations were simulated in a range of ± 20°. FTA was defined as the angle between the tunnel axis and femoral shaft axis, orthogonally projected into the coronal plane.

Results: Femoral tunnel angle was positively/negatively correlated with knee rotation angle at 0°/45° knee flexion. At 0° knee flexion, FTA for anterio-medial (AM) tunnels was significantly decreased at 20° of external knee rotation. At 45° knee flexion, more than 16° external or 19° internal rotation significantly altered FTA measurements for single-bundle tunnels; smaller rotations (± 9° for AM, ± 5° for PL) created significant errors in FTA measurements after double-bundle reconstruction.

Conclusion: Femoral tunnel angle measurements were correlated with knee rotation. Relatively small imaging malalignment introduced significant errors with knee flexed 45°. This study supports using the 0° flexion position for knee radiographs to reduce errors in FTA measurement due to knee internal/external rotation.