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Cited by 238Knee injuries and reconstruction techniquesTendon Structure and TreatmentFoot and Ankle Surgery

Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees

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Śmigielski, Robert, Zdanowicz, Urszula, Drwięga, Michał, Ciszek, Bogdan, Ciszkowska-Łysoń, Beata, Siebold, Rainer·2015·Knee Surgery, Sports Traumatology, Arthroscopy
DOI 10.1007/s00167-014-3146-7PMC PMC4611008
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Abstract

PURPOSE: Recently, the configuration of the anterior cruciate ligament (ACL) from its direct femoral insertion to midsubstance was found to be flat. This might have an important impact for anatomical ACL reconstruction. The purpose of this anatomical study was to evaluate the macroscopic appearance of the ACL from femoral to midsubstance. METHODS: The ACL was dissected in 111 human fresh frozen cadaver knees from its femoral insertion to midsubstance, and the shape was described. The anatomical findings were documented on digital photographs and on video. Thirty knees were sent for computed tomography (CT), magnetic resonance imaging (MRI) and histology of the femoral ACL insertion. RESULTS: Two millimetres from its direct femoral insertion, the ACL fibres formed a flat ribbon in all dissected knees without a clear separation between AM and PL bundles. The ribbon was in exact continuity of the posterior femoral cortex. The width of the ribbon was between 11.43 and 16.18 mm and the thickness of the ACL was only 2.54-3.38 mm. 3D CT, MRI and the histological examination confirmed above findings. CONCLUSION: This is a detailed anatomical study describing the ribbon-like structure of the ACL from its femoral insertion to midsubstance. A key point was to carefully remove the surface fibrous membrane of the ACL. A total of 2-3 mm from its bony femoral insertion, the ACL formed a flat ribbon without a clear separation between AM and PL bundles. The ribbon was in exact continuity of the posterior femoral cortex. The findings of a flat ligament may change the future approach to femoral ACL footprint and midsubstance ACL reconstruction and to graft selection.

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  1. [1]Adachi N Ochi M Uchio Y Iwasa J Kuriwaka M Ito Y Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons J Bone Joint Surg Br 2004 86 4 515 520 15174545
  2. [3]Amis AA Jakob RP Anterior cruciate ligament graft positioning, tensioning and twisting Knee Surg Sports Traumatol Arthrosc 1998 6 Suppl 1 S2 S12 10.1007/s001670050215 9608456 · DOI
  3. [4]Anderson AF Dome DC Gautam S Awh MH Rennirt GW Correlation of anthropometric measurements, strength, anterior cruciate ligament size, and intercondylar notch characteristics to sex differences in anterior cruciate ligament tear rates Am J Sports Med 2001 29 1 58 66 11206258
  4. [5]Arnoczky SP Anatomy of the anterior cruciate ligament Clin Orthop Relat Res 1983 172 19 25 6821989
  5. [6]Baer GS Ferretti M Fu FH Fu FHCSB Anatomy of the ACL Current concepts in ACL reconstruction 2008 Thorofare SLACK 21 32
  6. [7]Benjamin M Toumi H Ralphs JR Bydder G Best TM Milz S Where tendons and ligaments meet bone: attachment sites (‘entheses’) in relation to exercise and/or mechanical load J Anat 2006 208 4 471 490 10.1111/j.1469-7580.2006.00540.x 16637873 PMC2100202 · DOI
  7. [8]Buoncristiani AM Tjoumakaris FP Starman JS Ferretti M Fu FH Anatomic double-bundle anterior cruciate ligament reconstruction Arthroscopy 2006 22 9 1000 1006 10.1016/j.arthro.2006.06.005 16952731 · DOI
  8. [9]Cohen SB VanBeek C Starman JS Armfield D Irrgang JJ Fu FH MRI measurement of the 2 bundles of the normal anterior cruciate ligament Orthopedics 2009 32 9 70 75 10.3928/01477447-20090728-35 19750997 · DOI
  9. [10]Colombet P Robinson J Christel P Franceschi JP Djian P Bellier G Sbihi A Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study Arthroscopy 2006 22 9 984 992 10.1016/j.arthro.2006.04.102 16952729 · DOI
  10. [11]Dargel J Pohl P Tzikaras P Koebke J Morphometric side-to-side differences in human cruciate ligament insertions Surg Radiol Anat 2006 28 4 398 402 10.1007/s00276-006-0107-y 16607464 · DOI
  11. [12]Dienst M Schneider G Altmeyer K Voelkering K Georg T Kramann B Kohn D Correlation of intercondylar notch cross sections to the ACL size: a high resolution MR tomographic in vivo analysis Arch Orthop Trauma Surg 2007 127 4 253 260 10.1007/s00402-006-0177-7 16807752 · DOI
  12. [13]Duthon VB Barea C Abrassart S Fasel JH Fritschy D Menetrey J Anatomy of the anterior cruciate ligament Knee Surg Sports Traumatol Arthrosc 2006 14 3 204 213 10.1007/s00167-005-0679-9 16235056 · DOI
  13. [14]Edwards A Bull AM Amis AA The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament. Part 2: femoral attachment Knee Surg Sports Traumatol Arthrosc 2008 16 1 29 36 10.1007/s00167-007-0410-0 17957351 · DOI
  14. [15]Ferretti M Ekdahl M Shen W Fu FH Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study Arthroscopy 2007 23 11 1218 1225 10.1016/j.arthro.2007.09.008 17986410 · DOI · Paper page
  15. [16]Ferretti M Levicoff EA Macpherson TA Moreland MS Cohen M Fu FH The fetal anterior cruciate ligament: an anatomic and histologic study Arthroscopy 2007 23 3 278 283 10.1016/j.arthro.2006.11.006 17349471 · DOI
  16. [17]Fu FH Bennett CH Lattermann C Ma CB Current trends in anterior cruciate ligament reconstruction. Part 1: biology and biomechanics of reconstruction Am J Sports Med 1999 27 6 821 830 10569374
  17. [18]Fu FH Karlsson J A long journey to be anatomic Knee Surg Sports Traumatol Arthrosc 2010 18 9 1151 1153 10.1007/s00167-010-1222-1 20668836 · DOI
  18. [19]Girgis FG Marshall JL Monajem A The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis Clin Orthop Relat Res 1975 106 216 231 10.1097/00003086-197501000-00033 1126079 · DOI
  19. [20]Hamada M Shino K Horibe S Mitsuoka T Miyama T Shiozaki Y Mae T Single-versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endoButton femoral fixation: a prospective study Arthroscopy 2001 17 8 801 807 10.1016/S0749-8063(01)90002-7 11600976 · DOI
  20. [21]Harner CD Baek GH Vogrin TM Carlin GJ Kashiwaguchi S Woo SL Quantitative analysis of human cruciate ligament insertions Arthroscopy 1999 15 7 741 749 10.1016/S0749-8063(99)70006-X 10524822 · DOI
  21. [22]Hashemi J Mansouri H Chandrashekar N Slauterbeck JR Hardy DM Beynnon BD Age, sex, body anthropometry, and ACL size predict the structural properties of the human anterior cruciate ligament J Orthop Res 2011 29 7 993 1001 10.1002/jor.21245 21246609 · DOI
  22. [23]Hutchinson MR Ash SA Resident’s ridge: assessing the cortical thickness of the lateral wall and roof of the intercondylar notch Arthroscopy 2003 19 9 931 935 10.1016/j.arthro.2003.09.002 14608310 · DOI
  23. [24]Iriuchishima T Yorifuji H Aizawa S Tajika Y Murakami T Fu FH Evaluation of ACL mid-substance cross-sectional area for reconstructed autograft selection Knee Surg Sports Traumatol Arthrosc 2014 22 1 207 213 10.1007/s00167-012-2356-0 23263230 · DOI
  24. [25]Iwahashi T Shino K Nakata K Otsubo H Suzuki T Amano H Nakamura N Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography Arthroscopy 2010 26 9 Suppl S13 S20 10.1016/j.arthro.2010.01.023 20667684 · DOI
  25. [26]Jacobsen K Osteoarthrosis following insufficiency of the cruciate ligaments in man. A clinical study Acta Orthop Scand 1977 48 5 520 526 10.3109/17453677708989742 596150 · DOI
  26. [27]Kennedy JC Weinberg HW Wilson AS The anatomy and function of the anterior cruciate ligament. As determined by clinical and morphological studies J Bone Joint Surg Am 1974 56 2 223 235 4452683
  27. [28]Kopf S Musahl V Tashman S Szczodry M Shen W Fu FH A systematic review of the femoral origin and tibial insertion morphology of the ACL Knee Surg Sports Traumatol Arthrosc 2009 17 3 213 219 10.1007/s00167-008-0709-5 19139847 · DOI
  28. [29]Luites JW Wymenga AB Blankevoort L Kooloos JG 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 2007 15 12 1422 1431 10.1007/s00167-007-0402-0 17899008 PMC2082657 · DOI
  29. [30]Mochizuki T Fujishiro H Nimura A Mahakkanukrauh P Yasuda K Muneta T Akita K Anatomic and histologic analysis of the mid-substance and fan-like extension fibres of the anterior cruciate ligament during knee motion, with special reference to the femoral attachment Knee Surg Sports Traumatol Arthrosc 2014 22 2 336 344 10.1007/s00167-013-2404-4 23344119 · DOI
  30. [31]Mochizuki T Muneta T Nagase T Shirasawa S Akita KI Sekiya I Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction Arthroscopy 2006 22 4 356 361 10.1016/j.arthro.2005.09.020 16581446 · DOI
  31. [32]Mott HW Semitendinosus anatomic reconstruction for cruciate ligament insufficiency Clin Orthop Relat Res 1983 172 90 92 6822010
  32. [33]Muneta T Sekiya I Yagishita K Ogiuchi T Yamamoto H Shinomiya K Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with endobuttons: operative technique and preliminary results Arthroscopy 1999 15 6 618 624 10.1053/ar.1999.v15.0150611 10495178 · DOI
  33. [34]Muneta T Takakuda K Yamamoto H 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 1997 25 1 69 72 10.1177/036354659702500113 9006695 · DOI
  34. [35]Norwood LA Cross MJ Anterior cruciate ligament: functional anatomy of its bundles in rotatory instabilities Am J Sports Med 1979 7 1 23 26 10.1177/036354657900700106 420384 · DOI
  35. [36]Odensten M Gillquist J Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction J Bone Joint Surg Am 1985 67 2 257 262 3968118
  36. [37]Otsubo H Shino K Suzuki D Kamiya T Suzuki T Watanabe K Fujimiya M Iwahashi T Yamashita T The arrangement and the attachment areas of three ACL bundles Knee Surg Sports Traumatol Arthrosc 2012 20 1 127 134 10.1007/s00167-011-1576-z 21695467 · DOI
  37. [38]Papachristou G Sourlas J Magnissalis E Plessas S Papachristou K ACL reconstruction and the implication of its tibial attachment for stability of the joint: anthropometric and biomechanical study Int Orthop 2007 31 4 465 470 10.1007/s00264-006-0213-9 16944142 PMC2267636 · DOI
  38. [39]Petersen W Tillmann B Anatomie und Funktion des vorderen Kreuzbandes Orthopade 2002 31 8 710 718 10.1007/s00132-002-0330-0 12426749 · DOI
  39. [40]Pujol N Queinnec S Boisrenoult P Maqdes A Beaufils P Anatomy of the anterior cruciate ligament related to hamstring tendon grafts. A cadaveric study Knee 2013 20 6 511 514 10.1016/j.knee.2012.10.006 23157968 · DOI
  40. [41]Purnell ML Larson AI Clancy W 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 2008 36 11 2083 2090 10.1177/0363546508319896 18663150 · DOI
  41. [42]Sasaki N Ishibashi Y Tsuda E Yamamoto Y Maeda S Mizukami H Toh S Yagihashi S Tonosaki Y The femoral insertion of the anterior cruciate ligament: discrepancy between macroscopic and histological observations Arthroscopy 2012 28 8 1135 1146 10.1016/j.arthro.2011.12.021 22440794 · DOI
  42. [43]Shino K Suzuki T Iwahashi T Mae T Nakamura N Nakata K Nakagawa S The resident’s ridge as an arthroscopic landmark for anatomical femoral tunnel drilling in ACL reconstruction Knee Surg Sports Traumatol Arthrosc 2010 18 9 1164 1168 10.1007/s00167-009-0979-6 19915823 · DOI · Paper page
  43. [44]Siebold R The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction Knee Surg Sports Traumatol Arthrosc 2011 19 5 699 706 10.1007/s00167-010-1376-x 21222101 · DOI
  44. [45]Siebold R Ellert T Metz S Metz J 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 2008 24 5 585 592 10.1016/j.arthro.2007.12.008 18442692 · DOI
  45. [46]Siebold R Schuhmacher P Restoration of the tibial ACL footprint area and geometry using the modified insertion site table Knee Surg Sports Traumatol Arthrosc 2012 20 9 1845 1849 10.1007/s00167-012-1899-4 22314861 · DOI
  46. [47]Staeubli HU Adam O Becker W Burgkart R Anterior cruciate ligament and intercondylar notch in the coronal oblique plane: anatomy complemented by magnetic resonance imaging in cruciate ligament-intact knees Arthroscopy 1999 15 4 349 359 10.1016/S0749-8063(99)70051-4 10355709 · DOI
  47. [48]Weiler A Hoffmann RF Bail HJ Rehm O Sudkamp NP Tendon healing in a bone tunnel. Part II: histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep Arthroscopy 2002 18 2 124 135 10.1053/jars.2002.30657 11830805 · DOI
  48. [49]Welsh RP Knee joint structure and function Clin Orthop Relat Res 1980 147 7 14 7371319
  49. [50]Yasuda K Kondo E Ichiyama H Kitamura N Tanabe Y Tohyama H Minami A Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts Arthroscopy 2004 20 10 1015 1025 10.1016/j.arthro.2004.08.010 15592229 · DOI
  50. [51]Yasuda K van Eck CF Hoshino Y Fu FH Tashman S Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 1: basic science Am J Sports Med 2011 39 8 1789 1799 10.1177/0363546511402659 21596902 · DOI
  51. [52]Zantop T Petersen W Fu FH Anatomy of the anterior cruciate ligament Oper Tech Orthop 2005 15 1 20 28 10.1053/j.oto.2004.11.011 · DOI

Cited by

Sorted by citations

Authors
Śmigielski, R., Zdanowicz, U., Drwięga, M., Ciszek, B., Ciszkowska-Łysoń, B., & Siebold, R.
Affiliations
  • Medical University of Warsaw (PL)
  • Heidelberg University (DE)
ORCID
Venue
Knee Surgery, Sports Traumatology, Arthroscopy
Publisher
Wiley
Published
2014-06-28
Volume
23
Issue
11
Pages
3143-3150
ISSN
  • 0942-2056 (ISSN-L)
  • 1433-7347
DOI
10.1007/s00167-014-3146-7
PMC
PMC4611008
OpenAlex
W2170044261
Cited by
238
References
1
Citations by year
2026: 14 · 2025: 14 · 2024: 19 · 2023: 21 · 2022: 16 · 2021: 15 · 2020: 18 · 2019: 18 · 2018: 38 · 2017: 27 · 2016: 24 · 2015: 12 · 2014: 1
FWCI
21.17
Type
journal article
Language
en
Open access
Licence
Locations
  • Knee Surgery Sports Traumatology Arthroscopy (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Tendon Structure and Treatment
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Foot and Ankle Surgery
Keywords
anterior cruciate ligament, femoral insertion, ligament thickness, ligament reconstruction, graft selection, cadaveric anatomy
MeSH terms
Adult, Aged, Cadaver, Female, Femur, Humans, Knee, Male, Middle Aged, Anterior Cruciate Ligament

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