Transtibial Versus Independent Drilling Techniques for Anterior Cruciate Ligament Reconstruction: A Systematic Review, Meta-analysis, and Meta-regression

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Six randomized clinical studies were included in this meta-analysis to determine how clinical outcomes and knee laxity compare between preparation of the femoral tunnel in through independent drilling - such as anteromedial portal or an outside-in approach - and transtibial drilling in ACL reconstruction. Clinical trial results suggested a possible increase to Lysholm scores and lower instrumented anterior laxity with independent drilling versus transtibial drilling, but clinically, Lysholm score was comparable between groups. However, IKDC Objective and Tegner scores were comparable between independent and transtibial drilling techniques. Evidence from cadaveric studies indicated closer placement of the femoral tunnel to the native ACL footprint with independent drilling compared to transtibial drilling. Evidence from 22 high-quality studies in ACL reconstruction suggested similar rate of graft failure between methods.