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Knee Surgery, Sports Traumatology, Arthroscopy
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 1/2012

01-01-2012 | Knee

The arrangement and the attachment areas of three ACL bundles

Authors: Hidenori Otsubo, Konsei Shino, Daisuke Suzuki, Tomoaki Kamiya, Tomoyuki Suzuki, Kota Watanabe, Mineko Fujimiya, Takehiko Iwahashi, Toshihiko Yamashita

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 1/2012

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Abstract

Purpose

Normal anterior cruciate ligament (ACL) can be divided into three fiber bundles—i.e., anteromedial (AM), intermediate (IM), and posterolateral (PL) bundles. However, their arrangement and attachment areas had remained unclear. The purpose of this study was to clarify the arrangement of these three ACL fiber bundles and their attachment sites, and to provide information on the tunnel placement in anatomical triple bundle ACL reconstruction.

Methods

Seven non-embalmed human frozen knees were used. ACL fibers were bluntly divided into three bundles. A different-colored thread was wound around each fiber bundle in a spiral. Macroscopical investigation was performed to clarify the arrangement of three ACL bundles. Each fiber bundle was carefully detached from the femur and tibia, and then the distribution of attachment sites of each fiber bundle was observed.

Results

In knee extension, all bundles consisting of AM, IM and PL bundles ran parallel to each other in the lateral view from the medial side. The AM bundle overlapped with the IM bundle, whereas the PL bundle ran parallel to them on the distal aspects. As the knee flexion increased, the bundles became twisted around each other. On the tibial side, the attachment areas of three fiber bundles formed a triangular shape showing arrangements of AM, IM and PL bundles on the anteromedial, anterolateral and posterior aspects, respectively. On the femoral side, the PL bundle was attached on the distal-posterior areas; the IM bundle was attached distal-anterior to the AM bundle. They were arranged in a triangular shape on the tibia side as well.

Conclusion

This study clarified the arrangement of three fiber bundles of ACL and detailed geographical locations of their attachment sites. The detailed anatomic description of the natural ACL attachment might suggest to surgeons where to make tunnels during anatomical double/triple bundle ACL reconstruction.
Literature
1.
Amis AA, Dawkins GP (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 73:260–267PubMed
2.
Amis AA, Jakob RP (1998) Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 6(Suppl 1):S2–12PubMedCrossRef
3.
Arnoczky SP (1983) Anatomy of the anterior cruciate ligament. Clin Orthop Relat Res 172:19–25PubMed
4.
Benjamin M, Ralphs JR (2001) Entheses—the bony attachments of tendons and ligaments. Ital J Anat Embryol 106:151–157PubMed
5.
Colombet P, Robinson J, Christel P (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22:984–992PubMedCrossRef
6.
Dargel J, Pohl P, Tzikaras P et al (2006) Morphometric side-toside differences in human cruciate ligament insertions. Surg Radiol Anat 28:398–402PubMedCrossRef
7.
Ferretti M, Ekdahl M, Shen W, Fu FH (2007) Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy 23:1218–1225PubMedCrossRef
8.
Friederich NF, O’Brien WR (1992) Clinical application of biomechanic and functional anatomical findings of the knee joint. Orthopade 21:41–50PubMed
9.
Fujie H, Otsubo H, Shino K et al (2011) Mechanical functions of the three bundles consisting of the human anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc PMID:21541712
10.
Georgoulis AD (2007) Tibial rotation is not restored after ACL reconstruction with a hamstring graft. Clini Orthop Relat Res 454:89–94CrossRef
11.
Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231PubMedCrossRef
12.
Giron F, Cuomo P, Edwards A, Bull AM, Amis AA, Aglietti P (2007) Double-bundle “anatomic” anterior cruciate ligament reconstruction: a cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy 23:7–13PubMedCrossRef
13.
Harner CD, Baek GH, Vogrin TM et al (1999) Quantitative analysis of human cruciate ligament insertions. Arthroscopy 15:741–749PubMedCrossRef
14.
Hamada M, Shino K, Horibe S, Mitsuoka T, Miyama T, Shiozaki Y, Mae T (2001) Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endobutton femoral fixation: a prospective study. Arthroscopy 17:801–807PubMed
15.
Hart AJ, Buscombe J, Malone A, Dowd GS (2005) Assessment of osteoarthritis after reconstruction of the anterior cruciate ligament: a study using single-photon emission computed tomography at ten years. J Bone Joint Surg Br 87:1483–1487PubMedCrossRef
16.
Hutchinson MR, Ash SA (2003) Resident’s ridge: assessing the cortical thickness of the lateral wall and roof of the intercondylar notch. Arthroscopy 19:931–935PubMedCrossRef
17.
Iwahashi T, Shino K, Nakata K et al (2008) Assessment of the “functional length” of the three bundles of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 16:167–174PubMedCrossRef
18.
Iwahashi T, Shino K, Otsubo H et al (2010) Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography. Arthroscopy 26:S13–S20PubMedCrossRef
19.
Kopf S, Musahl V, Tashman S, Szczodry M, Shen W, Fu FH (2008) A systematic review of the femoral origin and tibial insertion morphology of the ACL. Arthroscopy 17:213–219
20.
Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T (2008) Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med 36:1675–1687PubMedCrossRef
21.
Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy 19:297–304PubMedCrossRef
22.
Luites JW, Wymenga AB, Blankevoort L et al (2007) Description of the attachment geometry of the anteromedial and posterolateral bundles of the ACL from arthroscopic perspective for anatomical tunnel placement. Knee Surg Sports Traumatol Arthrosc 15:1422–1431PubMedCrossRef
23.
Mae T, Shino K, Matsumoto N, Nakata K, Nakamura N, Iwahashi T (2006) Force sharing between two grafts in the anatomical two-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 14:505–509PubMedCrossRef
24.
Maeda A, Shino K, Horibe S, Nakata K, Buccafusca G (1996) Anterior cruciate ligament reconstruction with multistranded autogenous semitendinosus tendon. Am J Sports Med 24:504–509PubMedCrossRef
25.
Mochizuki T, Muneta T, Nagase T, Shirasawa S, Akita K, Sekiya I (2006) Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy 22:356–361PubMedCrossRef
26.
Mommersteeg TJ, Kooloos JG, Roeling FQ et al (1995) The fibre bundle anatomy of human cruciate ligaments. J Anat 187:461–471PubMed
27.
Morimoto Y, Ferretti M, Ekdahl M, Smolinski P, Fu FH (2009) Tibiofemoral joint contact area and pressure after single- and double-bundle anterior cruciate ligament reconstruction. Arthroscopy 25:62–69PubMedCrossRef
28.
Muneta T, Takakuda K, Yamamoto H (1997) Intercondylar notch width and its relation to the configuration and cross-sectional area of the anterior cruciate ligament. A cadaveric knee study. Am J Sports Med 25:69–72PubMedCrossRef
29.
Musahl V, Voos JE, O’Loughlin PF, Choi D, Stueber V, Kendoff D, Pearle AD (2010) Comparing stability of different single- and double-bundle anterior cruciate ligament reconstruction techniques: a cadaveric study using navigation. Arthroscopy 26:S41–S48PubMedCrossRef
30.
Norwood LA, Cross MJ (1979) Anterior cruciate ligament: functional anatomy of its bundles in rotatory instabilities. Am J Sports Med 7:23–26PubMedCrossRef
31.
Odensten M, Gillquist J (1985) Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 67:257–262PubMed
32.
Otsubo H, Shino K, Nakamura N, Nakata K, Nakagawa S, Koyanagi M (2007) Arthroscopic evaluation of ACL grafts reconstructed with the anatomical two-bundle technique using hamstring tendon autograft. Knee Surg Sports Traumatol Arthrosc 15:720–728PubMedCrossRef
33.
Paschos NK, Gartzonikas D, Barkoula NM, Moraiti C, Paipetis A, Matikas TE, Georgoulis AD (2010) Cadaveric study of anterior cruciate ligament failure patterns under uniaxial tension along the ligament. Arthroscopy 26:957–967PubMedCrossRef
34.
Pietrini SD, Ziegler CG, Anderson CJ, Wijdicks CA, Westerhaus BD, Johansen S, Engebretsen L, Laprade RF (2011) Radiographic landmarks for tunnel positioning in double-bundle ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 19:792–800PubMedCrossRef
35.
Pombo MW, Shen W, Fu FH (2008) Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy 24:1168–1177PubMedCrossRef
36.
Purnell ML, Larson AI, Clancy W (2008) Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 36:2083–2090PubMedCrossRef
37.
Shino K, Nakata K, Otsubo H et al (2005) Anatomic anterior cruciate ligament reconstruction using two double-looped hamstring tendon grafts via twin femoral and triple tibial tunnels. Oper Tech Orthop Surg 15:130–134CrossRef
38.
Shino K, Nakata K, Nakamura N, Toritsuka Y, Nakagawa S, Horibe S (2005) Anatomically oriented anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft via rectangular socket and tunnel: a snug-fit and impingement-free grafting technique. Arthroscopy 21:1402PubMed
39.
Shino K, Nakata K, Nakamura N, Toritsuka Y, Horibe S, Nakagawa S, Suzuki T (2008) Rectangular tunnel double-bundle anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft to mimic natural fiber arrangement. Arthroscopy 24:1178–1183PubMedCrossRef
40.
Shino K, Suzuki T, Iwahashi T (2010) The resident’s ridge as an arthroscopic landmark for anatomical femoral tunnel drilling in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1164–1168PubMedCrossRef
41.
Siebold R, Ellert T, Metz S et al (2008) Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for double-bundle bone tunnel placement—a cadaver study. Arthroscopy 24:585–592PubMedCrossRef
42.
Siebold R, Ellert T, Metz S et al (2008) Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy 24:154–161PubMedCrossRef
43.
Takahashi M, Doi M, Abe M et al (2006) Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med 34:787–792PubMedCrossRef
44.
Toritsuka Y, Amano H, Kuwano M, Iwai T, Mae T, Ohzono K, Shino K (2009) Outcome of double-bundle ACL reconstruction using hamstring tendons. Knee Surg Sports Traumatol Arthrosc 17:456–463PubMedCrossRef
45.
Tsukada H, Ishibashi Y, Tsuda E, Fukuda A, Toh S (2008) Anatomical analysis of the anterior cruciate ligament femoral and tibial footprints. J Orthop Sci 13:122–129PubMedCrossRef
46.
Yamakami Y et al (1998) The accuracy of square measure of regions of interest using an NIH image. J Showa Univ Dent Soc 18:400–405
47.
Zantop T, Wellmann M, Fu FH, Petersen W (2008) Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 36:65–72PubMedCrossRef
48.
Zhao J, Huangfu X (2010) Arbitrary starting point of separation affects morphology of the 2 bundles of anterior cruciate ligament at insertion sites. Arthroscopy 26:184–191PubMedCrossRef
Metadata
Title
The arrangement and the attachment areas of three ACL bundles
Authors
Hidenori Otsubo
Konsei Shino
Daisuke Suzuki
Tomoaki Kamiya
Tomoyuki Suzuki
Kota Watanabe
Mineko Fujimiya
Takehiko Iwahashi
Toshihiko Yamashita
Publication date
01-01-2012
Publisher
Springer-Verlag
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 1/2012
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-011-1576-z

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