Incidence of Convergence Between Distally and Anteriorly Oriented ALL Femoral Tunnels and ACL Femoral Tunnels in Combined ACL and ALL Reconstruction: 3-Dimensional Computed Tomography Analysis of 227 Patients

Background: Adjusting the direction of the anterolateral ligament (ALL) femoral tunnel is suggested to avoid tunnel convergence during anterior cruciate ligament (ACL) reconstruction. Yet, there has been no in vivo clinical study reporting the effect of changing the direction of the ALL tunnel on the incidence of convergence with the ACL tunnel. Purpose: To report the incidence of convergence between the ACL femoral tunnel and a distally and anteriorly directed ALL femoral tunnel and to determine a safe distal angle and anterior angle. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 227 patients undergoing concomitant ALL and anatomic single-bundle ACL reconstruction between January 2020 and December 2022 were retrospectively reviewed. The tunnel convergence rate, angular orientation of the tunnels, and distance between tunnels were obtained using postoperative computed tomography. The patients were grouped based on the direction of the ALL tunnel (transverse vs distal anterior) and the presence of tunnel convergence (convergence vs no convergence). Results: The overall tunnel convergence rate was 53.3% (121/227 patients). Tunnel convergence was observed less frequently in the distal anterior group (33.7%) than in the transverse group (65.2%) (P < .001). The no convergence group showed an ALL tunnel oriented more distally (20.2 degrees +/- 11.1 degrees) and anteriorly (19.5 degrees +/- 10.2 degrees) compared with the convergence group (8.7 degrees +/- 6.5 degrees and 6.9 degrees +/- 5.3 degrees, respectively) (P = .005 and P = .008, respectively). There were no cases of tunnel convergence for ALL tunnels >24.3 degrees distally and >25.5 degrees anteriorly. There was no difference in the angle of the ACL femoral tunnel between all groups. Conclusion: A distally and anteriorly directed ALL femoral tunnel reduced the incidence of convergence with the ACL femoral tunnel. A distal angle >24.3 degrees and an anterior angle >25.5 degrees of an ALL tunnel are suggested to safely avoid convergence with the ACL tunnel.