ACL tibial footprint is elliptical or triangular shaped in healthy young adults (3-T MRI analysis)

Anterior cruciate ligament tibial insertion site is elliptical or triangular shaped in healthy young adults: high-resolution 3-T MRI analysis, Tashiro et al. KSSTA (2018) 26(2):485-490.

Abstract:

Purpose
To clarify the morphology of anterior cruciate ligament (ACL) tibial insertion site in healthy young knees using high-resolution 3-T MRI.

Methods
Subjects were 50 ACL-reconstructed patients with a mean age of 21.4 ± 6.8 years. The contralateral healthy knees were scanned using high-resolution 3-T MRI. The tibial insertion sites of the anteromedial (AM) and posterolateral (PL) bundle fibres, and the ACL attachment on the anterior horn of lateral meniscus (AHLM) were segmented from the MR images, and 3D models were reconstructed to evaluate the morphology. The shape of ACL footprint was qualitatively analysed, and the size of AM and PL attachments and AHLM overlapped area was measured digitally.

Results
Tibial AM and PL bundles were clearly identified in 42 of 50 knees (84.0%). Morphology of the whole ACL tibial insertion site was elliptical in 23 knees (54.8%) and triangular in 19 knees (45.2%), but not classified as C-shape in any knees. However, the AM bundle attachment was of C-shape in 29 knees (69.0%) and band-like in 13 knees (31.0%). Overlap of ACL on AHLM was found in 26 knees (61.9%), and the size of the overlapped area was 4.8 ± 4.7% of the whole ACL insertion site.

Conclusion
3D morphology of the intact ACL tibial insertion site analysed by high-resolution 3-T MRI was elliptical or triangular in healthy young knees. However, the AM bundle insertion site was of C-shape or band-like. A small lateral portion of the ACL was overlapped with the AHLM. As for clinical relevance, these findings should be considered in order to reproduce the native ACL insertion site sufficiently.

Level of evidence
III.

tashiro2017-ACL-footprint-bundles
If PL bundle was eliminated, AM bundle footprint looked C-shape (a) in 29 knees (69.0%) and band-like in 13 knees (31.0%) (b)

Preoperative MRI predicts eligibility for arthroscopic primary ACL repair

ACL-tear-tipe-II

Preoperative magnetic resonance imaging predicts eligibility for arthroscopic primary anterior cruciate ligament repair, by van der List and DiFelice, KSSTA (2018), 26(2):660–671

Abstract:

Purpose
To assess the role of preoperative magnetic resonance imaging (MRI) on the eligibility for arthroscopic primary anterior cruciate ligament (ACL) repair.

Methods
All patients undergoing ACL surgery between 2008 and 2017 were included. Patients underwent arthroscopic primary repair if sufficient tissue length and quality were present, or they underwent single-bundle ACL reconstruction. Preoperative MRI tear locations were graded with the modified Sherman classification: type I (>90% distal remnant length), type II (75–90%), or type III (25–75%). MRI tissue quality was graded as good, fair, or poor. Arthroscopy videos were reviewed for tissue length and quality, and final treatment.

Results
Sixty-three repair patients and 67 reconstruction patients were included. Repair patients had more often type I tears (41 vs. 4%, p < 0.001) and good tissue quality (89 vs. 12%, p < 0.001). Preoperative MRI tear location and tissue quality predicted eligibility for primary repair: 90% of all type I tears and 88% of type II tears with good tissue quality were repaired, while only 23% of type II tears with fair tissue quality, 0% of type II tears with poor tissue quality, and 14% of all type III tears could be repaired. Conclusions This study showed that tear location and tissue quality on preoperative MRI can predict eligibility for arthroscopic primary ACL repair. These findings may guide the orthopaedic surgeon on the preoperative assessment for arthroscopic primary repair of proximal ACL tears. Level of evidence Level IV.

ACL-tear-MRI-repair-flowchart
Flowchart, based on preoperative MRI tear location and tissue quality, shows the percentage of patients that were repaired per tear location and tissue quality

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

The importance of Blumensaat’s line morphology for accurate femoral ACL footprint evaluation using the quadrant method, by Yahagi, Iriuchishima,, Horaguchi, et al. KSSTA (2018) 26(2):455–461.

Morphological variation of the Blumensaat’s line
Following Iriuchishima’s classification*, the morphology of the Blumensaat’s line was classified into straight, small hill, and large hill types.

Straight type
The Blumensaat’s line (intercondylar roof) appeared more or less straight, and the transition from the Blumensaat’s line to the posterior cortex was clearly defined.

Small hill type
A protrusion spanning less than half of the line was observed at the posterior (proximal) part of the Blumensaat’s line.

Large hill type
A protrusion spanning more than half of the line was observed at the proximal part of the the Blumensaat’s line.

*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

iriuchishima-blumensaat-line-morphology
Morphological variations of the Blumensaat’s line. In Iriuchishima’s classification, the morphology of the Blumensaat’s line has three types of variations: straight type, small hill type, and large hill type

Grid placement in the quadrant method
In the same images used for the morphological evaluation of the Blumensaat’s line, four types of quadrant grid placement were evaluated according to the morphological variations of the Blumensaat’s line and the chondral lesion

  • Grid (1) Without consideration of hill existence and not including the chondral lesion. The baseline of the quadrant grid was matched to the anterior part of the Blumensaat’s line. The lower and side line of the grid were tangential to the medial wall of the lateral femoral condyle.
  • Grid (2) Without consideration of hill existence and including the chondral lesion. The base line of the grid was determined as in Grid 1. The lower and side line were tangential to the articular surface.
  • Grid (3) With consideration of hill existence and not including the chondral lesion. The baseline of the grid was the line connecting the anterior edge of the Blumensaat’s line and the top of the hill. The lower and side line of the grid were tangential to the medial wall of the lateral femoral condyle.
  • Grid (4) With consideration of hill existence and including the chondral lesion. The baseline of the grid was determined as in Grid 3. The lower and side line were tangential to the articular surface. The measurement accuracy of the Image J software were, 0.1 mm and 0.1 mm2.
yahagi2017-quadrant-grid-placement
Quadrant grid placement according to the morphological variations of the Blumensaat’s line and the chondral lesion. According to the morphological variations of the Blumensaat’s line and the chondral lesion, quadrant grids 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

3D graft-bending angle measurement and finite-element analysis

3D-FEM-ACL-graft

Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis, by Van Der Bracht et al. KSSTA (2018) 26(2): 508–517.

Abstract:

Purpose
To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft.

Methods
Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12®. 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations.

Results
In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture.

Conclusion
In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture. Clinical relevance: the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively.