Skip to main content
SpringerLink
Log in

The importance of Blumensaat’s line morphology for accurate femoral ACL footprint evaluation using the quadrant method

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

Abstract

Purpose

The purpose of this study was to evaluate the difference in the center position of the ACL footprint based on grid placement using the quadrant method according to the morphological variations of the Blumensaat’s line.

Methods

Fifty-nine non-paired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch, and the digital images were evaluated using Image J software. The femoral ACL footprint was periphery outlined and the center position was automatically measured. Following Iriuchishima’s classification, the morphology of the Blumensaat’s line was classified into straight, small hill, and large hill types. From the images, grid quadrants were placed as: Grid (1) without consideration of hill existence and not including the chondral lesion. Grid (2) without consideration of hill existence and including the chondral lesion. Grid (3) with consideration of hill existence and not including the chondral lesion. Grid (4) with consideration of hill existence and including the chondral lesion.

Results

The straight type consisted of 19 knees, the small hill type 13 knees, and the large hill type 27 knees. Depending on the quadrant grid placement, significant center position difference was observed both in the shallow–deep, and high–low direction. When hill existence was considered, the center position of the ACL was significantly changed to a high position.

Conclusion

The center position of the ACL footprint exhibited significant differences according to Blumensaat’s line morphology. For 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 when using the quadrant method.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Abbreviations

ACL:

Anterior cruciate ligament

AM:

Antero-medial bundle

PL:

Postero-lateral bundle

References

  1. Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg 10:14–22

    CAS  PubMed  Google Scholar 

  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 7:209–214

    Article  CAS  PubMed  Google Scholar 

  3. Farrow LD, Chen MR, Cooperman DR, Goodfellow DB, Robbin MS (2008) Radiographic classification of the femoral intercondylar notch posterolateral rim. Arthroscopy 24:1109–1114

    Article  PubMed  Google Scholar 

  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 23:1218–1225

    Article  PubMed  Google Scholar 

  5. Fu FH (2011) Double-bundle ACL reconstruction. Orthopedics 34(4):281–283

    Article  PubMed  Google Scholar 

  6. Iriuchishima T, Ryu K, Aizawa S, Fu FH (2016) Blumensaat’s line is not always straight: morphological variations of the lateral wall of the femoral intercondylar notch. Knee Surg Sports Traumatol Arthrosc 24:2752–2757

    Article  PubMed  Google Scholar 

  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 131:1085–1090

    Article  PubMed  Google Scholar 

  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 18:1226–1231

    Article  PubMed  Google Scholar 

  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 38:1611–1617

    Article  PubMed  Google Scholar 

  10. 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 24:254–259

    Article  PubMed  Google Scholar 

  11. Iriuchishima T, Shirakura K, Fu FH (2013) Graft impingement in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21:664–670

    Article  PubMed  Google Scholar 

  12. Jacobsen K, Bertheussen K, Gjerloff CC (1974) Characteristics of the line of Blumensaat. An experimental analysis. Acta Orthop Scand 45:764–771

    Article  CAS  PubMed  Google Scholar 

  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 39:2016–2026

    Article  PubMed  Google Scholar 

  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 36:1675–1687

    Article  PubMed  Google Scholar 

  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 17:213–219

    Article  PubMed  Google Scholar 

  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 39:108–1013

    Article  PubMed  Google Scholar 

  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 15:1422–1431

    Article  PubMed  PubMed Central  Google Scholar 

  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 19:1233–1238

    Article  PubMed  Google Scholar 

  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 23:618–628

    Article  PubMed  Google Scholar 

  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 25:69–72

    Article  CAS  PubMed  Google Scholar 

  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 20:1567–1573

    Article  PubMed  PubMed Central  Google Scholar 

  22. Piefer JW, Pflugner TR, Hwang MD, Lobowitz JH (2012) Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature. Arthroscopy 28:872–881

    Article  PubMed  Google Scholar 

  23. Seyahi A, Atalar AC, Koyuncu LO, Cinar BM, Demirhan M (2006) Blumensaat line and patellar height. Acta Orthop Traumatol Turc 40:240–247

    PubMed  Google Scholar 

  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 35:1120–1125

    Article  PubMed  Google Scholar 

  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 24:1178–1183

    Article  PubMed  Google Scholar 

  26. Siebold R, Ellert T, Metz S, Mets 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 24:585–592

    Article  PubMed  Google Scholar 

  27. 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 

  28. Steiner ME, Murray MM, Rodeo SA (2008) Strategies to improve anterior cruciate ligament healing and graft placement. Am J Sports Med 36:176–189

    Article  PubMed  Google Scholar 

  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 17:812–817

    Article  PubMed  Google Scholar 

  30. Tompkins M, Ma R, Hogan MV, Miller MD (2011) What’s new in sports medicine. J Bone Joint Surg Am 93:789–797

    Article  PubMed  Google Scholar 

  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 27:1235–1241

    Article  PubMed  Google Scholar 

  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 18:1257–1262

    Article  Google Scholar 

  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–S21

    Article  PubMed  Google Scholar 

  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 24:39–43

    Article  PubMed  Google Scholar 

  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 22:240–251

    Article  PubMed  Google Scholar 

  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 39:1789–1799

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan

    Yoshiyuki Yahagi, Takashi Horaguchi & Makoto Suruga

  2. Department of Orthopaedic Surgery, Kamimoku Hot Springs Hospital, Minakami, Japan

    Takanori Iriuchishima

  3. Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan

    Takanori Iriuchishima & Shin Aizawa

  4. Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan

    Yasuaki Tokuhashi

Authors
  1. Yoshiyuki Yahagi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Takanori Iriuchishima
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Takashi Horaguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Makoto Suruga
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yasuaki Tokuhashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Shin Aizawa
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Takanori Iriuchishima.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interests.

Ethical approval

This study was performed in accordance with ethics principles of the Declaration of Helsinki and was conducted with the institutional review boards of Nihon University School of Medicine.

Funding

No financial contributions were received for this study.

Informed consent

For this type of formal consent is not required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yahagi, Y., Iriuchishima, T., Horaguchi, T. et al. The importance of Blumensaat’s line morphology for accurate femoral ACL footprint evaluation using the quadrant method. Knee Surg Sports Traumatol Arthrosc 26, 455–461 (2018). https://doi.org/10.1007/s00167-017-4501-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-017-4501-2

Keywords

Search

Navigation