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The anatomy of the ACL and its importance in ACL reconstruction

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Abstract

The anterior cruciate ligament (ACL) anatomy is very significant if a reconstruction is attempted after its rupture. An anatomic study should have to address, its biomechanical properties, its kinematics, its position and anatomic correlation and its functional properties. In this review, an attempt is made to summarize the most recent and authoritative tendencies as far as the anatomy of the ACL, and its surgical application in its reconstruction are concerned. Also, it is significant to take into account the anatomy as far as the rehabilitation protocol is concerned. Separate placement in the femoral side is known to give better results from transtibial approach. The medial tibial eminence and the intermeniscal ligament may be used as landmarks to guide the correct tunnel placement in anatomic ACL reconstruction. The anatomic centrum of the ACL femoral footprint is 43 % of the proximal-to-distal length of lateral, femoral intercondylar notch wall and femoral socket radius plus 2.5 mm anterior to the posterior articular margin. Some important factors affecting the surgical outcome of ACL reconstruction include graft selection, tunnel placement, initial graft tension, graft fixation, graft tunnel motion and healing. The rehabilitation protocol should come in phases in order to increase range of motion, muscle strength and leg balance, it should protect the graft and weightbearing should come in stages. The cornerstones of such a protocol remain bracing, controlling edema, pain and range of motion. This should be useful and valuable information in achieving full range of motion and stability of the knee postoperatively. In the end, all these advancements will contribute to better patient outcome. Recommendations point toward further experimental work with in vivo and in vitro studies, in order to assist in the development of new surgical procedures that could possibly replicate more closely the natural ACL anatomy and prevent future knee pathology.

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References

  1. Bannister LH, Berry MM, Collins P et al (1995) Knee joint. In: Gray’s anatomy, 38th edn. Churchill Livingstone, UK, pp 697–709

  2. Girgis FG, Marshall JL, Al Monajem ARS (1975) The cruciate ligaments of the knee joint. Clin Orthop 106:216

    Article  PubMed  Google Scholar 

  3. Clarke HD, Scott WN, Insall JN et al (2006) Anatomy. In: Inshall and scott surgery of the knee, 4th edn. Churchill Livingstone, USA, pp 3–66

  4. Arnoczky SP (1983) Anatomy of the anterior cruciate ligament. Clin Orthop Relat Res 172:19–25

    PubMed  Google Scholar 

  5. Buoncristiani AM, Tjoumakaris FP, Starman JS, Ferretti M, Fu FH (2006) Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 22(9):1000–1006

    Article  PubMed  Google Scholar 

  6. Welsh PR (1980) Knee joint structure and function. Clin Orthop 147:7

    PubMed  Google Scholar 

  7. Reider B, Marshall JL, Koslin B et al (1981) The anterior aspect of the knee joint: an anatomical study. J Bone Joint Surg Am 63:351

    PubMed  CAS  Google Scholar 

  8. Woo SL, Wu C, Dede O, Vercillo F, Noorani S (2006) Biomechanics and anterior cruciate ligament reconstruction. J Orthop Surg Res 1:2

    Article  PubMed  Google Scholar 

  9. Von Porat A, Roos EM, Roos H (2004) High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes. Ann Rheum Dis 63:269–273

    Article  Google Scholar 

  10. Piefer JW, Pflugner TR, Michael D. Hwang MD, Lubowitz JH (2012) Anterior cruciate ligament femoral footprint anatomy: systematic review of the 21st century literature. J Arthrosc Relat Surg (article in press)

  11. Ferretti A, Conteduca F, De Carli A, Fontana M, Mariani PP (1991) Osteoarthritis of the knee after ACL reconstruction. Int Orthop 15(4):367–371

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  13. Fithian DC, Paxton LW, Goltz DH (2002) Fate of the anterior cruciate ligament-injured knee. Orthop Clin North Am 33:621–636

    Article  PubMed  Google Scholar 

  14. Woo SL, Gomez MA, Seguchi Y, Endo CM, Akeson WH (1983) Measurement of mechanical properties of ligament substance from a bone-ligament-bone preparation. J Orthop Res 1:22–29

    Article  PubMed  CAS  Google Scholar 

  15. Tallay A, Lim MH, Bartlett J (2008) Anatomical study of the human anterior cruciate ligament stump’s tibial insertion footprint. Knee Surg Sports Traumatol Arthrosc 16:741–746

    Article  PubMed  Google Scholar 

  16. Crawford C, Nyland J, Landes S, Jackson R, Chang HC, Nawab A, Caborn DN (2007) Anatomic double-bundle ACL reconstruction: a literature review. Knee Surg Sports Traumatol Arthrosc 15:946–964

    Article  PubMed  Google Scholar 

  17. Ferretti M, Doca D, Ingham SM, Cohen M, Fu FH (2012) Bony and soft tissue landmarks of the ACL tibial insertion site: an anatomical study. Knee Surg Sports Traumatol Arthrosc 20(1):62–68

    Article  PubMed  Google Scholar 

  18. Edwards A, Bull AM, Amis AA (2007) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament. Part 2: tibial attachment. Knee Surg Sports Traumatol Arthrosc 15(12):1414–1421

    Article  PubMed  Google Scholar 

  19. Forsythe B, Kopf S, Wong AK, Martins CA, Anderst W, Tashman S, Fu FH (2010) The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models. J Bone Joint Surg Am 92(6):1418–1426

    Article  PubMed  Google Scholar 

  20. Iriuchishima T, Tajima G, Ingham SJ, Shen W, Smolinski P, Fu FH (2010) Impingement pressure in the anatomical and nonanatomical anterior cruciate ligament reconstruction: a cadaver study. Am J Sports Med 38(8):1611–1617

    Article  PubMed  Google Scholar 

  21. 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(1):65–72

    Article  PubMed  Google Scholar 

  22. Colombet P, Robinson J, Christel P et al (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaver study. Arthroscopy 22:984–992

    Article  PubMed  Google Scholar 

  23. Darcy SP, Kilger RH, Woo SL, Debski RF (2006) Estimation of ACL forces by reproducing knee kinematics between sets of knees: a novel noninvasive methodology. J Biomech 39:2371–2377

    Article  PubMed  Google Scholar 

  24. Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett WE Jr (2008) Reconstruction technique affects femoral tunnel placement in ACL reconstruction. Clin Orthop Relat Res 466:1467–1474

    Article  PubMed  Google Scholar 

  25. 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 19:297–304

    Article  PubMed  Google Scholar 

  26. Arnold MP, Kooloos J, van Kampen A (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 9:194–199

    PubMed  CAS  Google Scholar 

  27. Scopp JM, Jasper LE, Belkoff SM, Moorman CT 3rd (2004) The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20:294–299

    Article  PubMed  Google Scholar 

  28. Wetzler MJ, Bartolozzi AR, Gillespie MJ, Rubenstein DL, Ciccotti MG, Miller LS (1996) Revision anterior cruciate ligament reconstruction. Oper Tech Orthop 6:181–189

    Article  Google Scholar 

  29. Zavras TD, Race A, Amis AA (2005) The effect of femoral attachment location on anterior cruciate ligament reconstruction: graft tension patterns and restoration of normal anterior-posterior laxity patterns. Knee Surg Sports Traumatol Arthrosc 13:92–100

    Article  PubMed  Google Scholar 

  30. Muneta T, Yamamoto H, Ishibashi T, Murakami S, Furuya K (1995) The effects of tibial tunnel placement and roofplasty on reconstructed anterior cruciate ligament knees. Arthroscopy 11:57–62

    Article  PubMed  CAS  Google Scholar 

  31. Bylski-Austrow DI, Grood ES, Hefzy MS, Holden JP, Butler DL (1990) Anterior cruciate ligament replacements: a mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension. J Orthop Res 8:522–531

    Article  PubMed  CAS  Google Scholar 

  32. Amis AA, Jakob RP (1998) Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 6 S1:S2–12

    Google Scholar 

  33. Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL: radiographic quadrant method. Am J Knee Surg 10:14–21

    PubMed  CAS  Google Scholar 

  34. Giron F, Cuomo P, Aglietti P, Bull AM, Amis AA (2006) Femoral attachment of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 14:250–256

    Article  PubMed  Google Scholar 

  35. Giron F, Buzzi R, Aglietti P (1999) Femoral tunnel position in anterior cruciate ligament reconstruction using three techniques: a cadaver study. Arthroscopy 15:750–756

    Article  PubMed  CAS  Google Scholar 

  36. Kohn D, Busche T, Carls J (1998) Drill hole position in endoscopic anterior cruciate ligament reconstruction: results of an advanced arthroscopy course. Knee Surg Sports Traumatol Arthrosc 6(Suppl 1):S13–S15

    Article  PubMed  Google Scholar 

  37. Georgoulis AD, Papadonikolakis A, Papageorgiou CD, Mitsou A, Stergiou N (2003) Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament-deficient and reconstructed knee during walking. Am J Sports Med 31:75–79

    PubMed  Google Scholar 

  38. Wittstein J, Kaseta M, Sullivan R, Garrett WE (2009) Incidence of the remnant femoral attachment of the ruptured ACL. Clin Orthop Relat Res 467:2691–2694

    Article  PubMed  Google Scholar 

  39. Howell SM, Gittins ME, Gottlieb JE, Traina SM, Zoellner TM (2001) The relationship between the angle of the tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament reconstruction. Am J Sports Med 29:567–574

    PubMed  CAS  Google Scholar 

  40. Li G, Wuerz TH, DeFrate LE (2004) Feasibility of using orthogonal fluoroscopic images to measure in vivo joint kinematics. J Biomech Eng 126:314–318

    Article  PubMed  Google Scholar 

  41. Abebe ES, Kim JP, Utturkar GM, Taylor DC, Spritzer CE, Moorman CT 3rd, Garrett WE, DeFrate LE (2011) The effect of femoral tunnel placement on ACL graft orientation and length during in vivo knee flexion. J Biomech 7 44(10):1914–1920

    Google Scholar 

  42. Paulos LE, Karistinos A, Walker JA (2006) “Criteria” -based rehabilitation of surgically reconstructed and nonsurgically treated anterior cruciate ligament injuries. In: Inshall and scott surgery of the knee, 4th edn. Churchill Livingstone, pp 693–714

  43. Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE (2006) Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sports Phys Ther 36(6):385–402

    Article  PubMed  Google Scholar 

  44. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45(7):596–606

    Article  PubMed  Google Scholar 

  45. Georgoulis AD, Ristanis S, Moraiti CO, Paschos N, Zampeli F, Xergia S, Georgiou S, Patras K, Vasiliadis HS, Mitsionis G (2010) ACL injury and reconstruction: clinical related in vivo biomechanics. Orthop Traumatol Surg Res 96(8 Suppl):119–128

    Article  Google Scholar 

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Authors and Affiliations

  1. Second Department of Orthopaedic Surgery, University of Athens, Medical School, Athens, Greece

    K. Markatos, M. K. Kaseta, S. N. Lallos, D. S. Korres & N. Efstathopoulos

  2. Konstantopouleio Hospital, 3-5 Agias Olgas Str., 142 33, Athens, Greece

    K. Markatos

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  1. K. Markatos
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  2. M. K. Kaseta
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  4. D. S. Korres
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Markatos, K., Kaseta, M.K., Lallos, S.N. et al. The anatomy of the ACL and its importance in ACL reconstruction. Eur J Orthop Surg Traumatol 23, 747–752 (2013). https://doi.org/10.1007/s00590-012-1079-8

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  • DOI: https://doi.org/10.1007/s00590-012-1079-8

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