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Tibial ACL insertion site length: correlation between preoperative MRI and intra-operative measurements

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

This study was undertaken primarily to identify the tibial insertion site length of ruptured ACL fibres in patients undergoing primary ACL reconstruction. A secondary aim was to evaluate the correlation of pre- and intra-operative measurements.

Methods

In 146 patients undergoing primary ACL reconstruction, a preoperative measurement on MRI of the tibial ACL insertion site length was taken by two raters and then compared with single surgeon’s intra-operative measurements using a specialized ruler. Inclusion criteria were primary ACL reconstruction and MRI performed within 3 months prior to surgery on one specific MRI machine at the study centre. Inter-rater and intra-rater reliability based on intra class correlation (ICC) was calculated. Additionally, correlation between preoperative and postoperative measurements and the anthropometric data was assessed using Pearson correlation.

Results

The tibial ACL insertion site had a mean length of 16.6 ± 1.6 mm (11.9–21.0) as measured by MRI, and 16.4 ± 1.6 mm (11.0–20.0) as measured intra-operatively. The ICCs for intra- and inter-rater reliability of the MRI measurements were 0.99 (95 % CI 0.97; 0.99; p < 0.001) and 0.81 (95 % CI 0.75; 0.86; p < 0.001), respectively. Regression analysis demonstrated, after controlling for subject height and weight, that the MRI measurements significantly predicted intra-operative measurement of tibial insertion site length (β = 0.796; R 2-change 0.77; p < 0.001).

Conclusion

Preoperative measurement of the tibial ACL length is possible using MRI and can be a valuable aid in more efficient preoperative planning given the knowledge of expected dimensions of special knee structures.

Level of evidence

III.

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References

  1. Aglietti P, Giron F, Losco M, Cuomo P, Ciardullo A, Mondanelli N (2010) Comparison between single- and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial. Am J Sports Med 38:25–34

    Article  PubMed  Google Scholar 

  2. Ahldén M, Sernert N, Karlsson J, Kartus J (2013) A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction. Am J Sports Med 41:2484–2491

    Article  PubMed  Google Scholar 

  3. Araujo P, van Eck CF, Torabi M, Fu FH (2013) How to optimize the use of MRI in anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 21:1495–1501

    Article  PubMed  Google Scholar 

  4. Araujo PH, van Eck CF, Macalena JA, Fu FH (2011) Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19:1239–1242

    Article  PubMed  PubMed Central  Google Scholar 

  5. Bedi A, Musahl V, O’Loughlin P, Maak T, Citak M, Dixon P, Pearle AD (2010) A comparison of the effect of central anatomical single-bundle anterior cruciate ligament reconstruction and double-bundle anterior cruciate ligament reconstruction on pivot-shift kinematics. Am J Sports Med 38:1788–1794

    Article  PubMed  Google Scholar 

  6. Bernthal NM, Seeger LL, Motamedi K, Stavrakis AI, Kremen TJ, McAllister DR, Motamedi AR (2011) Can the reparability of meniscal tears be predicted with magnetic resonance imaging? Am J Sports Med 39:506–510

    Article  PubMed  Google Scholar 

  7. Björnsson H, Desai N, Musahl V, Alentorn-Geli E, Bhandari M, Fu F, Samuelsson K (2013) Is double-bundle anterior cruciate ligament reconstruction superior to single-bundle? A comprehensive systematic review. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2666-x

    Google Scholar 

  8. Camp CL, Stuart MJ, Krych AJ, Levy BA, Bond JR, Collins MS, Dahm DL (2013) CT and MRI measurements of tibial tubercle-trochlear groove distances are not equivalent in patients with patellar instability. Am J Sports Med 41:1835–1840

    Article  PubMed  Google Scholar 

  9. Colombet P, Robinson J, Christel P, Franceschi J-P, Djian P, Bellier G, Sbihi A (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22:984–992

    Article  PubMed  Google Scholar 

  10. Desai N, Björnsson H, Musahl V, Bhandari M, Petzold M, Fu FH, Samuelsson K (2014) Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 22:1009–1023

    Article  PubMed  Google Scholar 

  11. Edwards A, Bull AMJ, Amis AA (2008) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament. Part 2: femoral attachment. Knee Surg Sports Traumatol Arthrosc 16:29–36

    Article  PubMed  Google Scholar 

  12. Edwards A, Bull AMJ, Amis AA (2007) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament: part 1: tibial attachment. Knee Surg Sports Traumatol Arthrosc 15:1414–1421

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  14. Hofbauer M, Muller B, Murawski CD, van Eck CF, Fu FH (2014) The concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction. Knee Surg Sports Traumatol Arthrosc 22:979–986

    CAS  PubMed  Google Scholar 

  15. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Individualized anterior cruciate ligament surgery: a prospective study comparing anatomic single- and double-bundle reconstruction. Am J Sports Med 40:1781–1788

    Article  PubMed  Google Scholar 

  16. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med 40:512–520

    Article  PubMed  Google Scholar 

  17. 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 21:789–796

    Article  PubMed  Google Scholar 

  18. Iwahashi T, Shino K, Nakata K, Otsubo H, Suzuki T, Amano H, Nakamura N (2010) Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography. Arthroscopy 26:S13–S20

    Article  Google Scholar 

  19. Izawa T, Okazaki K, Tashiro Y, Matsubara H, Miura H, Matsuda S, Hashizume M, Iwamoto Y (2011) Comparison of rotatory stability after anterior cruciate ligament reconstruction between single-bundle and double-bundle techniques. Am J Sports Med 39:1470–1477

    Article  PubMed  Google Scholar 

  20. Kondo E, Merican AM, Yasuda K, Amis AA (2011) Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions. Am J Sports Med 39:279–288

    Article  PubMed  Google Scholar 

  21. 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 39:108–113

    Article  PubMed  Google Scholar 

  22. Lohmander LS, Ostenberg A, Englund M, Roos H (2004) High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players 12 years after anterior cruciate ligament injury. Arthritis Rheum 50:3145–3152

    Article  CAS  PubMed  Google Scholar 

  23. Mayr HO, Willkomm D, Stoehr A, Schettle M, Suedkamp NP, Bernstein A, Hube R (2012) Revision of anterior cruciate ligament reconstruction with patellar tendon allograft and autograft: 2- and 5-year results. Arch Orthop Trauma Surg 132:867–874

    Article  PubMed  Google Scholar 

  24. Meredick RB, Vance KJ, Appleby D, Lubowitz JH (2008) Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 36:1414–1421

    Article  Google Scholar 

  25. Miyawaki M, Hensler D, Illingworth KD, Irrgang JJ, Fu FH (2014) Signal intensity on magnetic resonance imaging after allograft double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 22:1002–1008

    Article  PubMed  Google Scholar 

  26. Nikolaou VS, Efstathopoulos N, Sourlas I, Pilichou A, Papachristou G (2009) Anatomic double-bundle versus single-bundle ACL reconstruction: a comparative biomechanical study in rabbits. Knee Surg Sports Traumatol Arthrosc 17:895–906

    Article  PubMed  Google Scholar 

  27. Noh JH, Yi SR, Song SJ, Kim SW, Kim W (2011) Comparison between hamstring autograft and free tendon Achilles allograft: minimum 2-year follow-up after anterior cruciate ligament reconstruction using EndoButton and Intrafix. Knee Surg Sports Traumatol Arthrosc 19:816–822

    Article  PubMed  Google Scholar 

  28. Park S-J, Jung Y-B, Jung H-J, Jung H-J, Shin HK, Kim E, Song K-S, Kim G-S, Cheon H-Y, Kim S (2010) Outcome of arthroscopic single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a preliminary 2-year prospective study. Arthroscopy 26:630–636

    Article  PubMed  Google Scholar 

  29. Pombo MW, Shen W, Fu FH (2008) Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy 24:1168–1177

    Article  PubMed  Google Scholar 

  30. 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 36:2083–2090

    Article  PubMed  Google Scholar 

  31. Rabuck SJ, Middleton KK, Maeda S, Fujimaki Y, Muller B, Araujo PH, Fu FH (2012) Individualized anatomic anterior cruciate ligament reconstruction. Arthrosc Tech 1:e23–e29

    Article  PubMed  PubMed Central  Google Scholar 

  32. Reed ME, Villacis DC, Hatch GFR, Burke WS, Colletti PM, Narvy SJ, Mirzayan R, Vangsness CT (2013) 3.0-Tesla MRI and arthroscopy for assessment of knee articular cartilage lesions. Orthopedics 36:e1060–e1064

    Article  PubMed  Google Scholar 

  33. Schreiber VM, van Eck CF, Fu FH (2010) Anatomic double-bundle ACL reconstruction. Sports Med Arthrosc 18:27–32

    Article  PubMed  Google Scholar 

  34. Schwartzberg R, Snyder K, Reuss B (2014) Preoperative measurement of ACL insertion sites. J Knee Surg. doi:10.1055/s-0034-1371770

    PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  36. Siebold R, Ellert T, Metz S, Metz J (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 24:154–161

    Article  PubMed  Google Scholar 

  37. Snow M, Stanish WD (2010) Double-bundle ACL reconstruction: how big is the learning curve? Knee Surg Sports Traumatol Arthrosc 18:1195–1200

    Article  Google Scholar 

  38. Suomalainen P, Järvelä T, Paakkala A, Kannus P, Järvinen M (2012) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 5-year results. Am J Sports Med 40:1511–1518

    Article  PubMed  Google Scholar 

  39. Takahashi M, Doi M, Abe M, Suzuki D, Nagano A (2006) Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med 34:787–792

    Article  PubMed  Google Scholar 

  40. Taketomi S, Inui H, Nakamura K, Hirota J, Sanada T, Masuda H, Takeda H, Tanaka S, Nakagawa T (2014) Clinical outcome of anatomic double-bundle ACL reconstruction and 3D CT model-based validation of femoral socket aperture position. Knee Surg Sports Traumatol Arthrosc 22:2194–2201

    Article  PubMed  Google Scholar 

  41. Tsukada S, Fujishiro H, Watanabe K, Nimura A, Mochizuki T, Mahakkanukrauh P, Yasuda K, Akita K (2014) Anatomic variations of the lateral intercondylar ridge: relationship to the anterior margin of the anterior cruciate ligament. Am J Sports Med 42:1110–1117

    Article  PubMed  Google Scholar 

  42. van Eck CF, Lesniak BP, Schreiber VM, Fu FH (2010) Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy 26:258–268

    Article  PubMed  Google Scholar 

  43. Wolters F, Vrooijink SHA, van Eck CF, Fu FH (2011) Does notch size predict ACL insertion site size? Knee Surg Sports Traumatol Arthrosc 19(Suppl 1):S17–S21

    Article  PubMed  Google Scholar 

  44. Yabroudi MA, Irrgang JJ (2013) Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction. Clin Sports Med 32:165–175

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank Yihe Huang, from the Department of Orthopaedic Surgery, University of Pittsburgh Medical Center for statistical analysis. There was no funding for this study.

Conflict of interest

The authors declare that they have no potential conflicts of interest, related to the presented work.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA

    Harald K. Widhalm, Levent Surer, Nikhil Kurapati, Claudia Guglielmino, James J. Irrgang & Freddie H. Fu

  2. Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria

    Harald K. Widhalm

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  1. Harald K. Widhalm
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  2. Levent Surer
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Correspondence to Harald K. Widhalm.

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Widhalm, H.K., Surer, L., Kurapati, N. et al. Tibial ACL insertion site length: correlation between preoperative MRI and intra-operative measurements. Knee Surg Sports Traumatol Arthrosc 24, 2787–2793 (2016). https://doi.org/10.1007/s00167-014-3473-8

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  • DOI: https://doi.org/10.1007/s00167-014-3473-8

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