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Background:  The anatomic placement of anterior cruciate ligament (ACL) grafts is often assessed with postoperative imaging. In clinical practice, graft angles are measured to indicate anatomic placement on magnetic resonance imaging, whereas grid measurements are performed on computed tomography (CT). Recently, a study indicated that graft angle measurements could also be assessed on CT. No consensus has yet been reached on which measurement method is best suited to assess anatomic graft placement.    Purpose:  To compare the ability of grid measurements and angle measurements to identify anatomic versus nonanatomic tunnel placement on CT performed in patients undergoing ACL reconstruction.    Study Design:  Case series; Level of evidence, 4.    Methods:  A total of 100 knees undergoing primary reconstruction with a hamstring graft (HAM group), 91 undergoing reconstruction with a bone–patellar tendon–bone graft (BPTB group), and 117 undergoing revision ACL reconstruction (REV group) were assessed with CT. Grid measurements of the femoral and tibial tunnels and angle measurements of grafts were performed. Graft placement, rated as anatomic or nonanatomic, was assessed with both methods. Pearson chi-square, analysis of variance, Kruskal-Wallis, and weighted kappa tests were performed as appropriate.    Results:  The grid assessment classified 10% of the HAM group, 4% of the BPTB group, and 17% of the REV group as nonanatomic ( P  < .001). The angle assessment classified 37% of the HAM group, 54% of the BPTB group, and 47% of the REV group as nonanatomic. The weighted kappa between angle measurements and grid measurements was low in all groups (HAM: 0.009; BPTB: 0.065; REV: 0.041).    Conclusion:  The agreement between grid measurements and angle measurements was very low. The angle measurements seemed to overestimate nonanatomic tunnel placement. Grid measurements were better in identifying malpositioned grafts.

Computed Tomography Assessment of Anatomic Graft Placement After ACL Reconstruction: A Comparative Study of Grid and Angle Measurements