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Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

12-10-2023 | Magnetic Resonance Imaging | KNEE

Anterior cruciate ligament femoral footprint is oblong-ovate, triangular, or two-tears shaped in healthy young adults: three-dimensional MRI analysis

Authors: Jinrong Lin, Shurong Zhang, Enhui Xin, Meng Liang, Liqin Yang, Jiwu Chen

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 12/2023

Abstract

Purpose

This study aimed to evaluate the morphology of the anterior cruciate ligament (ACL) femoral footprint with three-dimensional magnetic resonance imaging (3D MRI) in healthy knees.

Methods

Fifty subjects with healthy knees were recruited, utilising 3D-SPACE sequences for ACL evaluation. The ACL was manually segmented, and the shape, size and location of the ACL femoral footprint were evaluated on a reformatted oblique-sagittal plane, which aligned closely with the ACL attachment. Statistical analysis included one-way ANOVA for continuous variables and Fisher's exact test for categorical variables, with a P value < 0.05 considered significant.

Results

Three types of ACL femoral footprint shape were identified, namely, oblong-ovate (OO) in 33 knees (66%), triangular (Tr) in 12 knees (24%) and two-tears (TT) in 5 knees (10%), with the mean areas being 58, 47 and 68 mm², respectively. Within group TT, regions with similar sizes but different locations were identified: high tear (TT-H) and low tear (TT-L). Notably, group OO demonstrated a larger notch height index, whilst group TT was characterised by a larger α angle and lateral femoral condyle index. A noticeable variation was observed in the location of the femoral footprint centre across groups, with group TT-L and group Tr showing a more distal position relative to the apex of the deep cartilage. According to the Bernard and Hertel (BH) grid, the ACL femoral footprint centres in group TT-L exhibited a shallower and higher position than other groups. Furthermore, compared to group OO and TT-H, group Tr showed a significantly higher position according to the BH grid.

Conclusion

In this study, the morphology of the ACL femoral footprint in healthy young adults was accurately evaluated using 3D MRI, revealing three distinct shapes: OO, Tr and TT. The different ACL femoral footprint types showed similar areas but markedly different locations. These findings emphasise the necessity of considering both the shape and precise location of the ACL femoral footprint during clinical assessments, which might help surgeons enhance patient-specific surgical plans before ACL reconstruction.

Level of evidence

IV.

Beard DJ, Davies L, Cook JA, Stokes J, Leal J, Fletcher H et al (2022) Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial. Lancet 400:605–615CrossRefPubMed

Bernard MHP, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10(1):14–21 (21–12)PubMed

Das A, Yadav CS, Gamanagatti S, Pandey RM, Mittal R (2019) Arthroscopic and 3D CT scan evaluation of femoral footprint of the anterior cruciate ligament in chronic ACL deficient knees. J Knee Surg 32:584–588CrossRefPubMed

Dimitriou D, Zou D, Wang Z, Helmy N, Tsai TY (2021) Anterior cruciate ligament bundle insertions vary between ACL-rupture and non-injured knees. Knee Surg Sports Traumatol Arthrosc 29:1164–1172CrossRefPubMed

Ferretti M, Ekdahl M, Shen W, Fu FH (2007) Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy 23:1218–1225CrossRefPubMed

Grassi A, Pizza N, Al-Zu’bi BBH, Fabbro GD, Lucidi GA, Zaffagnini S (2022) Clinical outcomes and osteoarthritis at very long-term follow-up after ACL reconstruction: a systematic review and meta-analysis. Orthop J Sports Med 10:23259671211062240CrossRefPubMedPubMedCentral

Han Y, Kurzencwyg D, Hart A, Powell T, Martineau PA (2012) Measuring the anterior cruciate ligament’s footprints by three-dimensional magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 20:986–995CrossRefPubMed

Hart A, Sivakumaran T, Burman M, Powell T, Martineau PA (2018) A prospective evaluation of femoral tunnel placement for anatomic anterior cruciate ligament reconstruction using 3-dimensional magnetic resonance imaging. Am J Sports Med 46:192–199CrossRefPubMed

He M, Li J (2022) Increased lateral femoral condyle ratio measured by MRI is associated with higher risk of noncontact anterior cruciate ligament injury. BMC Musculoskelet Disord 23:190CrossRefPubMedPubMedCentral

10.

Hensler D, Working ZM, Illingworth KD, Thorhauer ED, Tashman S, Fu FH (2011) Medial portal drilling: effects on the femoral tunnel aperture morphology during anterior cruciate ligament reconstruction. J Bone Jt Surg Am 93:2063–2071CrossRef

11.

Hodel S, Kabelitz M, Tondelli T, Vlachopoulos L, Sutter R, Fucentese SF (2019) Introducing the Lateral Femoral Condyle Index as a risk factor for anterior cruciate ligament injury. Am J Sports Med 47:2420–2426CrossRefPubMed

12.

Iriuchishima T, Ryu K, Aizawa S, Fu FH (2016) The difference in centre position in the ACL femoral footprint inclusive and exclusive of the fan-like extension fibres. Knee Surg Sports Traumatol Arthrosc 24:254–259CrossRefPubMed

13.

Iriuchishima T, Ryu K, Aizawa S, Fu FH (2015) Proportional evaluation of anterior cruciate ligament footprint size and knee bony morphology. Knee Surg Sports Traumatol Arthrosc 23:3157–3162CrossRefPubMed

14.

Iwahashi T, Shino K, Nakata K, Otsubo H, Suzuki T, Amano H et al (2010) Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography. Arthroscopy 26:S13-20CrossRefPubMed

15.

Kim TK, Phillips M, Bhandari M, Watson J, Malhotra R (2017) What differences in morphologic features of the knee exist among patients of various races? A systematic review. Clin Orthop Relat Res 475:170–182CrossRefPubMed

16.

Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefPubMed

17.

Morales-Avalos R, Perelli S, Vilchez-Cavazos F, Castillo-Escobedo T, Pena-Martinez VM, Elizondo-Omana R et al (2022) The morphology of the femoral footprint of the anterior cruciate ligament changes with aging from a large semi-circular shape to a small flat ribbon-like shape. Knee Surg Sports Traumatol Arthrosc 30:3402–3413CrossRefPubMedPubMedCentral

18.

Parkar AP, Adriaensen M, Vindfeld S, Solheim E (2017) The anatomic centers of the femoral and tibial insertions of the anterior cruciate ligament: a systematic review of imaging and cadaveric studies reporting normal center locations. Am J Sports Med 45:2180–2188CrossRefPubMed

19.

Pearle AD, McAllister D, Howell SM (2015) Rationale for strategic graft placement in anterior cruciate ligament reconstruction: I.D.E.A.L. femoral tunnel position. Am J Orthop (Belle Mead NJ) 44:253–258PubMed

20.

Plaweski S, Petek D, Saragaglia D (2011) Morphometric analysis and functional correlation of tibial and femoral footprints in anatomical and single bundle reconstructions of the anterior cruciate ligament of the knee. Orthop Traumatol Surg Res 97:S75-79CrossRefPubMed

21.

Rahnemai-Azar AA, Sabzevari S, Irarrazaval S, Chao T, Fu FH (2016) Anatomical individualized ACL reconstruction. Arch Bone Jt Surg 4:291–297PubMedPubMedCentral

22.

Samim M (2021) 3D MRI models of the musculoskeletal system. Semin Musculoskelet Radiol 25:388–396CrossRefPubMed

23.

Scheffler SU, Maschewski K, Becker R, Asbach P (2018) In-vivo three-dimensional MR imaging of the intact anterior cruciate ligament shows a variable insertion pattern of the femoral and tibial footprints. Knee Surg Sports Traumatol Arthrosc 26:3667–3672CrossRefPubMed

24.

Shen L, Jin ZG, Dong QR, Li LB (2018) Anatomical risk factors of anterior cruciate ligament injury. Chin Med J (Engl) 131:2960–2967CrossRefPubMed

25.

Siebold R (2011) The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19:699–706CrossRefPubMed

26.

Siebold R, Axe J, Irrgang JJ, Li K, Tashman S, Fu FH (2010) A computerized analysis of femoral condyle radii in ACL intact and contralateral ACL reconstructed knees using 3D CT. Knee Surg Sports Traumatol Arthrosc 18:26–31CrossRefPubMed

27.

Siebold R, Ellert T, Metz S, Metz J (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 24:585–592CrossRefPubMed

28.

Sivakumaran T, Jaffer R, Marwan Y, Hart A, Radu A, Burman M et al (2021) Reliability of anatomic bony landmark localization of the ACL femoral footprint using 3D MRI. Orthop J Sports Med 9:23259671211042604CrossRefPubMedPubMedCentral

29.

Smigielski R, Zdanowicz U, Drwiega M, Ciszek B, Ciszkowska-Lyson B, Siebold R (2015) Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc 23:3143–3150CrossRefPubMed

30.

Smigielski R, Zdanowicz U, Drwiega M, Ciszek B, Williams A (2016) The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Jt J 98-B:1020–1026CrossRef

31.

Steckel H, Starman JS, Baums MH, Klinger HM, Schultz W, Fu FH (2007) Anatomy of the anterior cruciate ligament double bundle structure: a macroscopic evaluation. Scand J Med Sci Sports 17:387–392CrossRefPubMed

32.

Suruga M, Horaguchi T, Iriuchishima T, Yahagi Y, Iwama G, Tokuhashi Y et al (2017) Morphological size evaluation of the mid-substance insertion areas and the fan-like extension fibers in the femoral ACL footprint. Arch Orthop Trauma Surg 137:1107–1113CrossRefPubMed

33.

Sutton KM, Bullock JM (2013) Anterior cruciate ligament rupture: differences between males and females. J Am Acad Orthop Surg 21:41–50CrossRefPubMed

34.

Tashman S, Zandiyeh P, Irrgang JJ, Musahl V, West RV, Shah N et al (2021) Anatomic single- and double-bundle ACL reconstruction both restore dynamic knee function: a randomized clinical trial-part II: knee kinematics. Knee Surg Sports Traumatol Arthrosc 29:2676–2683CrossRefPubMedPubMedCentral

35.

Zauleck MK, Gabriel S, Fischmeister MF, Hirtler L (2014) Origin of the anterior cruciate ligament and the surrounding osseous landmarks of the femur. Clin Anat 27:1103–1110CrossRefPubMed

Title: Anterior cruciate ligament femoral footprint is oblong-ovate, triangular, or two-tears shaped in healthy young adults: three-dimensional MRI analysis
Authors: Jinrong Lin
Shurong Zhang
Enhui Xin
Meng Liang
Liqin Yang
Jiwu Chen
Publication date: 12-10-2023
Publisher: Springer Berlin Heidelberg
Keywords: Magnetic Resonance Imaging
Magnetic Resonance Imaging
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 12/2023
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-023-07606-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Anterior cruciate ligament femoral footprint is oblong-ovate, triangular, or two-tears shaped in healthy young adults: three-dimensional MRI analysis

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

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