Two-incision anterior cruciate ligament reconstruction uses an outside-in femoral drilling technique. Advantages include anatomic femoral tunnel placement and increased versatility with regard to graft position and fixation in the femoral tunnel or distal femur. The authors believe that transtibial femoral tunnel drilling is inferior because of nonanatomic femoral tunnel placement and the requirement of the posterior footprint placement of the tibial tunnel. Indications for outside-in femoral drilling include revision anterior cruciate ligament reconstruction, drilling an all-epiphyseal tunnel in skeletally immature patients, long bone-patellar tendon-bone autografts when using more than 45 mm of tendon, and cases in which the leg cannot be hyperflexed for accessory anteromedial portal drilling.
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