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Meta-Analysis
. 2026 Feb;54(2):465-474.
doi: 10.1177/03635465251360229. Epub 2026 Jan 6.

Anterior Cruciate Ligament Reconstruction With Femoral Tunnel Anteromedial Portal Antegrade Drilling Versus Retrograde Drilling Techniques Using Hamstring Graft Has No Difference in Clinical Outcomes or Complications: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Udit Dave  1 , Jared Rubin  2 , Alexander Mamonov  3 , Andrew S Bi  1 , Myles Atkins  1 , Johnathon R McCormick  1 , Fernando Gómez-Verdejo  1 , Jorge Chahla  1 , Nikhil N Verma  1
Affiliations
Meta-Analysis

Anterior Cruciate Ligament Reconstruction With Femoral Tunnel Anteromedial Portal Antegrade Drilling Versus Retrograde Drilling Techniques Using Hamstring Graft Has No Difference in Clinical Outcomes or Complications: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Udit Dave et al. Am J Sports Med. 2026 Feb.

Abstract

Background: There are multiple techniques for femoral tunnel creation for anterior cruciate ligament (ACL) reconstruction, with most modern techniques revolving around retrograde drilling or anteromedial (AM) portal drilling.

Purpose: To compile and quantify patient-reported outcomes and complication rates in patients who undergo hamstring ACL reconstruction with femoral tunnel creation via AM portal drilling versus retrograde drilling techniques.

Study design: Systematic review and meta-analysis; Level of evidence, 1.

Methods: In accordance with PRISMA guidelines, PubMed, Embase, and Cochrane Library databases were searched in August 2024 for studies published after 2004. Studies were included if they (1) were level 1 randomized controlled trials, (2) comprised patients who underwent primary ACL reconstruction utilizing hamstring tendon autograft, and (3) compared femoral tunnels created via AM portal antegrade drilling versus retrograde drilling techniques. Studies that were not written in English or did not directly compare patients being treated with either femoral tunnel technique were excluded. Data were pooled with a DerSimonian-Laird random effects model, and risk of bias was assessed with the Cochrane RoB 2 tool.

Results: The initial search identified 1003 studies, of which 5 randomized controlled trials were included in this study with a total of 557 patients: 280 in the AM portal cohort and 277 in the retrograde drilling cohort. Mean ages across the cohorts ranged from 26.4 to 34.2 years. All patients had a minimum 6 months of follow-up. Descriptive data were similar between graft cohorts, and studies had low risk of bias and low heterogeneity. The mean difference in International Knee Documentation Committee score for the retrograde drilling versus AM portal cohorts was 1.0 (95% CI, -0.3 to 2.3). The odds ratios (ORs) for retrograde drilling versus AM portal showed no significant differences for revision ACL (OR, 2.1; 95% CI, -0.5 to 8.9), overall reoperation (OR, 1.1; 95% CI, 0.5-2.4), and total complications (OR, 1.0; 95% CI, 0.5-2.0).

Conclusion: Primary ACL reconstruction has no significant differences in patient-reported outcomes, complications, or revision ACL rates when femoral tunnels are created via AM portal antegrade drilling versus retrograde drilling techniques. Decisions regarding ACL reconstruction technique should be tailored to individual patient needs and surgeon preference.

Keywords: ACL; all-inside; anteromedial portal; hamstring tendon autograft; outside-in; retrograde femoral drilling.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: J.C. has received consulting fees from CONMED Linvatec, Ossur, RTI Surgical, Smith & Nephew, and Vericel Corp; hospitality payments from Breg Inc, DePuy Synthes Sales, Joint Restoration Foundation, Medical Device Business Services, Pacira Pharmaceuticals, and SI-Bone Inc; and support for education from Midwest Associates. N.N.V. has received hospitality payments from Abbot Laboratories, Axonics Inc, Boston Scientific Corporation, Foundation Fusion Solutions LLC, IBSA Pharma Inc, Nalu Medical Inc, Nevro Corp, Orthofix Medical Inc, Pacira Pharmaceuticals Incorporated, Relievant Medsystems Inc, Salix Pharmaceuticals, Spinal Simplicity LLC, Vericel Corporation, and Vertos Medical Inc; research support from Arthrex, Breg, Ossur, Smith & Nephew, and Stryker; consulting fees from Medacta USA Inc; support for education from Medwest Associates; and intellectual property royalties from Arthrex, Smith & Nephew, Stryker, and Graymonbt Professional Products. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

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