Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 24, Issue 9, pp 2752–2757 | Cite as

Blumensaat’s line is not always straight: morphological variations of the lateral wall of the femoral intercondylar notch

  • Takanori IriuchishimaEmail author
  • Keinosuke Ryu
  • Shin Aizawa
  • Freddie H. Fu



The purpose of this study was to evaluate the morphological variations of the lateral wall of the femoral intercondylar notch.


Fifty-two non-paired human cadaver knees were used. All soft tissues around the knee were resected except the ACL. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch parallel to the plane of the femoral bone shaft. The ACL was carefully dissected, and the periphery of the ACL insertion site was outlined on the femoral side. An accurate lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The morphological variations of Blumensaat’s line, the height and area of the lateral wall of the femoral intercondylar notch and the size of the femoral ACL footprints were measured with Image J software.


Blumensaat’s line exhibited three types of morphological variations. A straight line was observed in 19 knees (37 %) (straight type). A protrusion spanning less than half of the line was observed at the proximal part of Blumensaat’s line in 10 knees (19 %) (small hill type). A protrusion spanning more than half of the line was observed at the proximal part of the line in 23 knees (44 %) (large hill type). In some knees with this large hill type variation, the appearance was similar to that of anterior spur. No significant differences between these three types were observed in either the height and area of the lateral wall of the femoral intercondylar notch or the area of the femoral ACL footprint.


In conclusion, Blumensaat’s line has three types of morphological variations (straight, small hill and large hill types). For the clinical relevance, when ACL surgery is performed in knees with small or large hill type variations, surgeons should pay close attention to femoral tunnel evaluation and placement, especially for the use of Quadrant method. The grid placement of Quadrant method would be changed in the knees of these type variations.


Anterior cruciate ligament Anatomy Intercondylar notch Blumensaat’s line 



Anterior cruciate ligament


Antero-medial bundle


Postero-lateral bundle


  1. 1.
    Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10:14–22PubMedGoogle Scholar
  2. 2.
    Davis TJ, Shelbourne KD, Klootwyk TE (1999) Correlation of the intercondylar notch width of the femur to the width of the anterior and posterior cruciate ligaments. Knee Surg Sports Traumatol Arthrosc 7:209–214CrossRefPubMedGoogle Scholar
  3. 3.
    Farrow LD, Chen MR, Cooperman DR, Goodfellow DB, Robbin MS (2008) Radiographic classification of the femoral intercondylar notch posterolateral rim. Arthroscopy 24:1109–1114CrossRefPubMedGoogle Scholar
  4. 4.
    Ferretti M, Ekdahl M, Shen W, Fu FH (2007) Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy 23:1218–1225CrossRefPubMedGoogle Scholar
  5. 5.
    Fu FH (2011) Double-bundle ACL reconstruction. Orthopedics 34(4):281–283CrossRefPubMedGoogle Scholar
  6. 6.
    Iriuchishima T, Ryu K, Yorifuji H, Aizawa S, Fu FH (2014) Commonly used ACL autograft areas do not correlate with the size of the ACL footprint or the femoral condyle. Knee Surg Sports Traumatol Arthrosc 22:1573–1579CrossRefPubMedGoogle Scholar
  7. 7.
    Iriuchishima T, Tajima G, Shirakura K, Morimoto Y, Kubomura T, Horaguchi T, Fu FH (2011) In vitro and in vivo AM and PL tunnel positioning in anatomical double bundle anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 131:1085–1090CrossRefPubMedGoogle Scholar
  8. 8.
    Iriuchishima T, Ingham SJ, Tajima G, Horaguchi T, Saito A, Tokuhashi Y, Van Houten AH, Aerts MM, Fu FH (2010) Evaluation of the tunnel placement in the anatomical double-bundle ACL reconstruction: a cadaver study. Knee Surg Sports Traumatol Arthrosc 18:1226–1231CrossRefPubMedGoogle Scholar
  9. 9.
    Iriuchishima T, Tajima G, Ingham SJ, Shen W, Smolinski P, Fu FH (2010) Impingement pressure in the anatomical and non anatomical anterior cruciate ligament reconstruction: a cadaver study. Am J Sports Med 38:1611–1617CrossRefPubMedGoogle Scholar
  10. 10.
    Iriuchishima T, Shirakura K, Yorifuji H, Aizawa S, Murakami T, Fu FH (2013) ACL footprint size is correlated with the height and area of the lateral wall of femoral intercondylar notch. Knee Surg Sports Traumatol Arthrosc 21:789–796CrossRefPubMedGoogle Scholar
  11. 11.
    Iriuchishima T, Shirakura K, Fu FH (2013) Graft impingement in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21:664–670CrossRefPubMedGoogle Scholar
  12. 12.
    Jacobsen K, Bertheussen K, Gjerloff CC (1974) Characteristics of the line of Blumensaat. An experimental analysis. Acta Orthop Scand 45:764–771CrossRefPubMedGoogle Scholar
  13. 13.
    Karlsson J, Irrgang JJ, van Eck CF, Samuelsson K, Mejia HA, Fu FH (2011) Anatomic single- and double-bundle anterior cruciate ligament reconstruction. Part 2: clinical application of surgical technique. Am J Sports Med 39:2016–2026CrossRefPubMedGoogle Scholar
  14. 14.
    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 36:1675–1687CrossRefPubMedGoogle Scholar
  15. 15.
    Kopf S, Musahl V, Tashman S, Szczodry M, Shen W, Fu FH (2009) A systematic review of the femoral origin and tibial insertion morphology of the ACL. Knee Surg Sports Traumatol Arthrosc 17:213–219CrossRefPubMedGoogle Scholar
  16. 16.
    Kopf S, Pombo MW, Szczodry M, Irrgang JJ, Fu FH (2011) Size variability of the human anterior cruciate ligament insertion sites. Am J Sports Med 39:108–1013CrossRefPubMedGoogle Scholar
  17. 17.
    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 15:1422–1431CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Maeyama A, Hoshino Y, Debandi A et al (2011) Evaluation of rotational instability in the anterior cruciate ligament deficient knee using triaxial accelerometer: a biomechanical model in porcine knees. Knee Surg Sports Traumatol Arthrosc 19:1233–1238CrossRefPubMedGoogle Scholar
  19. 19.
    Muneta T, Koga H, Mochizuki T et al (2007) A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double bundle techniques. Arthroscopy 23:618–628CrossRefPubMedGoogle Scholar
  20. 20.
    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 25:69–72CrossRefPubMedGoogle Scholar
  21. 21.
    Okada E, Matsumoto M, Ichihara D et al (2011) Cross-sectional area of posterior extensor muscles of the cervical spine in asymptomatic subjects: a 10-year longitudinal magnetic resonance imaging study. Eur Spine J 20:1567–1573CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Piefer JW, Pflugner TR, Hwang MD, Lobowitz JH (2012) Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature. Arthroscopy 28:872–881CrossRefPubMedGoogle Scholar
  23. 23.
    Seyahi A, Atalar AC, Koyuncu LO, Cinar BM, Demirhan M (2006) Blumensaat line and patellar height. Acta Orthop Traumatol Turc 40:240–247PubMedGoogle Scholar
  24. 24.
    Shin SH, Jeon IH, Kim HJ et al (2010) Articular surface area of the coronoid process and radial head in elbow extension: surface ration in cadavers and a computed tomography in vivo. J Hand Surg Am 35:1120–1125CrossRefPubMedGoogle Scholar
  25. 25.
    Shino K, Nakata K, Nakamura N et al (2008) Rectangular tunnel double-bundle anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft to mimic natural fiber arrangement. Arthroscopy 24:1178–1183CrossRefPubMedGoogle Scholar
  26. 26.
    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 24:585–592CrossRefPubMedGoogle Scholar
  27. 27.
    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 24:154–161CrossRefPubMedGoogle Scholar
  28. 28.
    Steiner ME, Murray MM, Rodeo SA (2008) Strategies to improve anterior cruciate ligament healing and graft placement. Am J Sports Med 36:176–189CrossRefPubMedGoogle Scholar
  29. 29.
    Stijak L, Randonjic V, Nikolic V, Blagojevic Z, Aksic M, Filipovic B (2009) Correlation between the morphometric parameters of the anterior cruciate ligament and the intercondylar width: gender and age difference. Knee Surg Sports Traumatol Arthrosc 17:812–817CrossRefPubMedGoogle Scholar
  30. 30.
    Tompkins M, Ma R, Hogan MV, Miller MD (2011) What’s new in sports medicine. J Bone Joint Surg Am 93:789–797CrossRefPubMedGoogle Scholar
  31. 31.
    van Eck CF, Kopf S, van Dijk CN, Fu FH, Tashman S (2011) Comparison of 3-dimensional notch volume between subjects with and subjects without anterior cruciate ligament rupture. Arthroscopy 27:1235–1241CrossRefPubMedGoogle Scholar
  32. 32.
    van Eck CF, Martins CA, Vyas SM, Celentano U, van Dijk CN, Fu FH (2010) Femoral intercondylar notch shape and dimensions in ACL-injured patients. Knee Surg Sports Traumatol Arthosc 18:1257–1262CrossRefGoogle Scholar
  33. 33.
    Wolters F, Vrooijink SH, Van Eck CF, Fu FH (2011) Does notch size predict ACL insertion site size? Knee Surg Sports Traumatol Arthrosc 19:S17–S21CrossRefPubMedGoogle Scholar
  34. 34.
    Wu E, Chen M, Cooperman D, Victoroff B, Goodfellow D, Farrow LD (2011) No correlation of height or gender with anterior cruciate ligament footprint size. J Knee Surg 24:39–43CrossRefPubMedGoogle Scholar
  35. 35.
    Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H (2006) Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy 22:240–251CrossRefPubMedGoogle Scholar
  36. 36.
    Yasuda K, van Eck CF, Hoshino Y, Fu FH, Tashman S (2011) Anatomic single-and double-bundle anterior cruciate ligament reconstruction. Part 1: basic science. Am J Sports Med 39:1789–1799CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  • Takanori Iriuchishima
    • 1
    • 3
    Email author
  • Keinosuke Ryu
    • 2
  • Shin Aizawa
    • 3
  • Freddie H. Fu
    • 4
  1. 1.Department of Orthopaedic SurgeryKamimoku Hot Springs HospitalMinakamiJapan
  2. 2.Department of Orthopaedic SurgeryNihon University HospitalTokyoJapan
  3. 3.Department of Functional MorphologyNihon University School of MedicineTokyoJapan
  4. 4.Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghUSA

Personalised recommendations