Editorial Commentary : Manually Contoured Femoral Head and Neck Allograft Is a Versatile and Cost‐Conscious Option for Tunnel Bone Grafting During 2‐Stage Revision Anterior Cruciate Ligament Reconstruction; Radiographic Tun

Abstract

Tunnel malposition is among the most common technical causes of failure after anterior cruciate ligament reconstruction, and tunnel osteolysis can further complicate revision by limiting anatomic tunnel placement and secure graft fixation. When existing tunnels cannot be safely incorporated into a single‐stage revision, first‐stage tunnel bone grafting remains an important consideration. Multiple graft sources are available, including iliac crest autograft, reamer‐irrigator‐aspirator‐harvested autograft, allograft bone dowels and chips, and synthetic substitutes; however, comparative evidence remains heterogeneous, and no option has shown clear superiority. Manually contoured femoral head and neck allograft is an appealing option because multiple structural dowels can be fashioned from a single graft and tailored to irregular or combined femoral and tibial tunnel defects. Recent computed tomography‐based evidence has shown high mean filling of reamed tibial tunnels, lower filling of femoral tunnels, significantly greater tibial than femoral filling across all measurements, no perioperative or postoperative complications, and lower modeled graft‐material costs than prefabricated allograft dowels. Although radiographic percent filling is a promising metric, future investigation will need to further define which tunnel defects truly require staging and correlate quantitative computed tomography findings with fixation quality, patient‐reported outcomes, and subsequent graft survival.