Anteromedial Femoral Tunnel Placement Reduces Graft Failure Risk Without Affecting Rotational Stability in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To compare clinical outcomes and graft failure between anatomical femoral tunnel (FT) placement at the central and anteromedial bundle (AMB) positions. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search of PubMed, Cochrane, and Web of Science in November 2024 identified studies comparing AMB and central FT placement in anatomical single-bundle anterior cruciate ligament reconstruction. The risk of bias was assessed using the Risk Of Bias in Non-randomized Studies of Interventions tool. A qualitative synthesis was performed and presented graphically. RESULTS: Six studies with 841 patients (444 AMB FT, 397 central FT) were included. Weighted mean follow-up was 34.8 and 40.7 months for the AMB and central groups, respectively. Overall risk of bias was serious in 4 studies and moderate in 2. AMB FT placement was associated with a significantly lower risk of graft failure (74%-77% reduction) in 2 studies. However, concerns in risk of bias and consistency decreased the certainty in this finding. Evidence for patient-reported outcomes and anterior stability was mixed and of uncertain clinical importance. Although some studies reported statistically significant benefits for AMB FT placement (differences of <7 points for patient-reported outcomes and <1 mm for anterior stability), others found no significant difference. Rotational laxity showed a nonsignificant difference between groups in all studies. CONCLUSIONS: The current evidence is limited by methodological flaws and risk of bias. It suggests that AM FT placement might be associated with a lower risk of graft failure compared with central placement. The AM position might achieve better patient-reported outcomes and anterior stability, although the difference is not clinically significant. No evidence of a difference was found regarding rotational stability. LEVEL OF EVIDENCE: Level III, systematic review of Level II and III studies.