{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T00:47:03Z","timestamp":1786495623857,"version":"build-2736575974"},"reference-count":37,"publisher":"Georg Thieme Verlag KG","issue":"05","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Knee Surg"],"published-print":{"date-parts":[[2023,4]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Concomitant anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has been reported as an effective technique for providing rotational control of the knee. However, the intraoperative risk of collision with an ACL tunnel during the drilling for the femoral ALL tunnel has been described. The purpose of this study was to investigate the various femoral drilling procedures to avoid tunnel collisions during combined double-bundle ACL and ALL reconstruction. Nine cadaveric knees were used in this study. ACL drilling was performed through the anteromedial portal to footprints of the posterolateral bundle at 120\u00b0 (PL120) and 135\u00b0 (PL135) knee flexion and the anteromedial bundle at 120\u00b0 (AM120) and 135\u00b0 (AM135) knee flexion. ALL drilling was performed at 0\u00b0 (Cor0-ALL) and 30\u00b0 (Cor30-ALL) coronal angles using a Kirschner wire (K-wire). The distance between the ALL footprint and ACL K-wire outlets, axial angles of ALL K-wires colliding with ACL K-wires, and distances from the ALL footprint to the collision point were measured. From these values, the safe zone, defined as the range of axial angles in which no collisions or penetrations occurred, was identified by simulation of tunnels utilized for reconstruction grafts in each drilling procedure. The point-to-point distance from the ALL footprint to the K-wire outlet was significantly greater in the AM120 than the AM135 (13.5\u2009\u00b1\u20093.1, 10.8\u2009\u00b1\u20093.2\u2009mm; p\u2009=\u20090.048) and in the PL135 than the PL120 (18.3\u2009\u00b1\u20095.5, 16.1\u2009\u00b1\u20096.5\u2009mm; p\u2009=\u20090.005) conditions, respectively. During an ACL drilling combination of PL135\/AM120, a safe zone of\u2009&gt;\u200945\u00b0 in Cor30-ALL was identified. With a narrow safe zone during the PL135\/AM120 combination only, the risk of femoral tunnel collisions in combined double-bundle ACL and ALL reconstruction is high. AM drilling at 120\u00b0 and PL drilling at\u2009&gt;\u2009135\u00b0 knee flexion, combined with ALL drilling at 30\u00b0 coronal angle and\u2009&gt;\u200945\u00b0 axial angle, may reduce this risk.<\/jats:p>","DOI":"10.1055\/s-0041-1736196","type":"journal-article","created":{"date-parts":[[2021,10,10]],"date-time":"2021-10-10T00:22:25Z","timestamp":1633825345000},"page":"483-490","source":"Crossref","is-referenced-by-count":6,"title":["An Analysis of the Femoral Drilling Angle to Avoid Tunnel Collision during Double-Bundle Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction on the Knee"],"prefix":"10.1055","volume":"36","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2962-1287","authenticated-orcid":false,"given":"Yusuke","family":"Kawanishi","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Makoto","family":"Kobayashi","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7592-5858","authenticated-orcid":false,"given":"Sanshiro","family":"Yasuma","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiroaki","family":"Fukushima","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiro","family":"Kato","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Atsunori","family":"Murase","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Kasugai Joint & Sports Orthopedic Clinic, Kasugai, Aichi, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tetsuya","family":"Takenaga","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masahito","family":"Yoshida","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gen","family":"Kuroyanagi","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yohei","family":"Kawaguchi","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuko","family":"Nagaya","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hideki","family":"Murakami","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masahiro","family":"Nozaki","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"194","published-online":{"date-parts":[[2021,10,8]]},"reference":[{"issue":"07","key":"ref1","doi-asserted-by":"crossref","first-page":"596","DOI":"10.1136\/bjsm.2010.076364","article-title":"Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play","volume":"45","author":"C L Ardern","year":"2011","journal-title":"Br J Sports Med"},{"issue":"03","key":"ref2","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1177\/0363546515618387","article-title":"An in vitro robotic assessment of the anterolateral ligament, part 1: secondary role of the anterolateral ligament in the setting of an anterior cruciate ligament injury","volume":"44","author":"M T Rasmussen","year":"2016","journal-title":"Am J Sports Med"},{"issue":"08","key":"ref3","doi-asserted-by":"crossref","first-page":"960","DOI":"10.1111\/sms.12524","article-title":"The role of the anterolateral ligament in ACL insufficient and reconstructed knees on rotatory stability: A biomechanical study on human cadavers","volume":"26","author":"M Tavlo","year":"2016","journal-title":"Scand J Med Sci Sports"},{"issue":"11","key":"ref4","doi-asserted-by":"crossref","first-page":"937","DOI":"10.2106\/JBJS.15.00344","article-title":"biomechanical assessment of the anterolateral ligament of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability","volume":"98","author":"R Thein","year":"2016","journal-title":"J Bone Joint Surg Am"},{"issue":"13","key":"ref5","doi-asserted-by":"crossref","first-page":"3177","DOI":"10.1177\/0363546520956266","article-title":"Outcomes after isolated acute anterior cruciate ligament reconstruction are inferior in patients with an associated anterolateral ligament injury","volume":"48","author":"M F Sobrado","year":"2020","journal-title":"Am J Sports Med"},{"issue":"03","key":"ref6","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1177\/0363546515620183","article-title":"An in vitro robotic assessment of the anterolateral ligament, part 2: anterolateral ligament reconstruction combined with anterior cruciate ligament reconstruction","volume":"44","author":"M Nitri","year":"2016","journal-title":"Am J Sports Med"},{"issue":"16","key":"ref7","doi-asserted-by":"crossref","first-page":"1482","DOI":"10.2106\/JBJS.20.01680","article-title":"Reconstruction for chronic ACL tears with or without anterolateral structure augmentation in patients at high risk for clinical failure: a randomized clinical trial","volume":"103","author":"J Chen","year":"2021","journal-title":"J Bone Joint Surg Am"},{"issue":"09","key":"ref8","doi-asserted-by":"crossref","first-page":"962","DOI":"10.1055\/s-0040-1701220","article-title":"Clinical results of combined ACL and anterolateral ligament reconstruction: a narrative review from the SANTI study group","volume":"34","author":"A Saithna","year":"2021","journal-title":"J Knee Surg"},{"issue":"07","key":"ref9","doi-asserted-by":"crossref","first-page":"1547","DOI":"10.1177\/0363546516686057","article-title":"anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group","volume":"45","author":"B Sonnery-Cottet","year":"2017","journal-title":"Am J Sports Med"},{"issue":"09","key":"ref10","doi-asserted-by":"crossref","first-page":"2648","DOI":"10.1016\/j.arthro.2019.03.059","article-title":"Combined reconstruction of the anterolateral ligament in patients with anterior cruciate ligament injury and ligamentous hyperlaxity leads to better clinical stability and a lower failure rate than isolated anterior cruciate ligament reconstruction","volume":"35","author":"C P Helito","year":"2019","journal-title":"Arthroscopy"},{"issue":"03","key":"ref11","doi-asserted-by":"crossref","first-page":"e453","DOI":"10.1016\/j.eats.2016.01.032","article-title":"Anterolateral ligament reconstruction technique: an anatomic-based approach","volume":"5","author":"J Chahla","year":"2016","journal-title":"Arthrosc Tech"},{"issue":"11","key":"ref12","doi-asserted-by":"crossref","first-page":"3151","DOI":"10.1007\/s00167-015-3783-5","article-title":"Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee","volume":"23","author":"J O Smith","year":"2015","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"04","key":"ref13","doi-asserted-by":"crossref","first-page":"e691","DOI":"10.1016\/j.eats.2016.02.028","article-title":"Percutaneous reconstruction of the anterolateral ligament of the knee with a polyester tape","volume":"5","author":"A M Wagih","year":"2016","journal-title":"Arthrosc Tech"},{"issue":"02","key":"ref14","doi-asserted-by":"crossref","first-page":"611","DOI":"10.1007\/s00167-018-5200-3","article-title":"High risk of tunnel convergence during combined anterior cruciate ligament and anterolateral ligament reconstruction","volume":"27","author":"K Smeets","year":"2019","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"01","key":"ref15","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1007\/s00167-014-3363-0","article-title":"Tunnel collision during simultaneous anterior cruciate ligament and posterolateral corner reconstruction","volume":"24","author":"J C Gali","year":"2016","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"02","key":"ref16","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1016\/j.arthro.2012.08.015","article-title":"Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model","volume":"29","author":"P E Gelber","year":"2013","journal-title":"Arthroscopy"},{"issue":"03","key":"ref17","doi-asserted-by":"crossref","first-page":"777","DOI":"10.1007\/s00167-013-2705-7","article-title":"Influences of knee flexion angle and portal position on the location of femoral tunnel outlet in anterior cruciate ligament reconstruction with anteromedial portal technique","volume":"23","author":"K Osaki","year":"2015","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"11","key":"ref18","doi-asserted-by":"crossref","first-page":"3411","DOI":"10.1007\/s00167-019-05388-4","article-title":"Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction","volume":"27","author":"C Jette","year":"2019","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"11","key":"ref19","doi-asserted-by":"crossref","first-page":"2578","DOI":"10.1177\/0363546517712231","article-title":"Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 10-year results","volume":"45","author":"S J\u00e4rvel\u00e4","year":"2017","journal-title":"Am J Sports Med"},{"issue":"08","key":"ref20","doi-asserted-by":"crossref","first-page":"2395","DOI":"10.1007\/s00167-017-4804-3","article-title":"Double-bundle anterior cruciate ligament reconstruction is better than single-bundle reconstruction in terms of objective assessment but not in terms of subjective score","volume":"26","author":"F AH El-Sherief","year":"2018","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"05","key":"ref21","doi-asserted-by":"crossref","first-page":"1414","DOI":"10.1007\/s00167-017-4781-6","article-title":"Anatomic double bundle ACL reconstruction outperforms any types of single bundle ACL reconstructions in controlling dynamic rotational laxity","volume":"26","author":"A Maeyama","year":"2018","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"06","key":"ref22","doi-asserted-by":"crossref","first-page":"872","DOI":"10.1016\/j.arthro.2011.11.026","article-title":"Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature","volume":"28","author":"J W Piefer","year":"2012","journal-title":"Arthroscopy"},{"issue":"05","key":"ref23","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1016\/j.arthro.2008.11.010","article-title":"Potential risks of femoral tunnel drilling through the far anteromedial portal: a cadaveric study","volume":"25","author":"M Nakamura","year":"2009","journal-title":"Arthroscopy"},{"issue":"05","key":"ref24","doi-asserted-by":"crossref","first-page":"838","DOI":"10.1007\/s00167-011-1632-8","article-title":"Comparative risk of common peroneal nerve injury in far anteromedial portal drilling and transtibial drilling in anatomical double-bundle ACL reconstruction","volume":"20","author":"M Otani","year":"2012","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"10","key":"ref25","doi-asserted-by":"crossref","first-page":"1108","DOI":"10.1016\/j.arthro.2009.05.018","article-title":"Effect of knee flexion angle on length and orientation of posterolateral femoral tunnel drilled through anteromedial portal during anatomic double-bundle anterior cruciate ligament reconstruction","volume":"25","author":"G Basdekis","year":"2009","journal-title":"Arthroscopy"},{"issue":"06","key":"ref26","doi-asserted-by":"crossref","first-page":"747","DOI":"10.1007\/s00167-009-0902-1","article-title":"The relationship of lateral anatomic structures to exiting guide pins during femoral tunnel preparation utilizing an accessory medial portal","volume":"18","author":"L D Farrow","year":"2010","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"07","key":"ref27","doi-asserted-by":"crossref","first-page":"1606","DOI":"10.1177\/0363546515578253","article-title":"The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis","volume":"43","author":"M I Kennedy","year":"2015","journal-title":"Am J Sports Med"},{"issue":"06","key":"ref28","doi-asserted-by":"crossref","first-page":"854","DOI":"10.1177\/03635465030310062101","article-title":"The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon","volume":"31","author":"R F LaPrade","year":"2003","journal-title":"Am J Sports Med"},{"issue":"03","key":"ref29","doi-asserted-by":"crossref","first-page":"452","DOI":"10.1038\/bmt.2012.244","article-title":"Investigation of the freely available easy-to-use software \u2018EZR\u2019 for medical statistics","volume":"48","author":"Y Kanda","year":"2013","journal-title":"Bone Marrow Transplant"},{"issue":"09","key":"ref30","doi-asserted-by":"crossref","first-page":"2110","DOI":"10.1177\/0363546519854220","article-title":"High risk of tunnel convergence in combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis","volume":"47","author":"V Jaecker","year":"2019","journal-title":"Am J Sports Med"},{"issue":"03","key":"ref31","doi-asserted-by":"crossref","first-page":"e285","DOI":"10.1016\/j.eats.2013.03.003","article-title":"Combined reconstruction of the anterior cruciate ligament and posterolateral corner with a single femoral tunnel","volume":"2","author":"F J Angelini","year":"2013","journal-title":"Arthrosc Tech"},{"issue":"10","key":"ref32","doi-asserted-by":"crossref","first-page":"3024","DOI":"10.1007\/s00167-016-4071-8","article-title":"Combined reconstruction of the posterior cruciate ligament and medial collateral ligament using a single femoral tunnel","volume":"25","author":"M B Bonadio","year":"2017","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"06","key":"ref33","doi-asserted-by":"crossref","first-page":"e1253","DOI":"10.1016\/j.eats.2016.08.003","article-title":"Combined anterior cruciate ligament and anterolateral ligament reconstruction","volume":"5","author":"B Sonnery-Cottet","year":"2016","journal-title":"Arthrosc Tech"},{"issue":"08","key":"ref34","doi-asserted-by":"crossref","first-page":"e881","DOI":"10.1016\/j.eats.2018.04.011","article-title":"Combined double bundle anterior cruciate ligament reconstruction and anterolateral ligament reconstruction","volume":"7","author":"I Mediavilla","year":"2018","journal-title":"Arthrosc Tech"},{"issue":"04","key":"ref35","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1016\/j.knee.2015.10.006","article-title":"Graft bending angle is correlated with femoral intraosseous graft signal intensity in anterior cruciate ligament reconstruction using the outside-in technique","volume":"23","author":"J H Ahn","year":"2016","journal-title":"Knee"},{"issue":"01","key":"ref36","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1186\/s12891-017-1599-9","article-title":"Influence of change of tunnel axis angle on tunnel length during double-bundle ACL reconstruction via the transportal technique","volume":"18","author":"J H Wang","year":"2017","journal-title":"BMC Musculoskelet Disord"},{"issue":"01","key":"ref37","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1186\/s40634-019-0198-0","article-title":"Anteversion and length of the femoral tunnel in ACL reconstruction: in-vivo comparison between rigid and flexible instrumentation","volume":"6","author":"F Wein","year":"2019","journal-title":"J Exp Orthop"}],"container-title":["The Journal of Knee Surgery"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/www.thieme-connect.de\/products\/ejournals\/pdf\/10.1055\/s-0041-1736196.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,3,30]],"date-time":"2023-03-30T00:22:50Z","timestamp":1680135770000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.thieme-connect.de\/DOI\/DOI?10.1055\/s-0041-1736196"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,10,8]]},"references-count":37,"journal-issue":{"issue":"05","published-online":{"date-parts":[[2023,3,29]]},"published-print":{"date-parts":[[2023,4]]}},"URL":"https:\/\/doi.org\/10.1055\/s-0041-1736196","archive":["Portico","CLOCKSS"],"relation":{},"ISSN":["1538-8506","1938-2480"],"issn-type":[{"value":"1538-8506","type":"print"},{"value":"1938-2480","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,10,8]]}}}