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

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.MethodsThe 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.ResultsTwo 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.ConclusionThis 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.Electronic supplementary materialThe online version of this article (doi:10.1007/s00167-014-3146-7) contains supplementary material, which is available to authorized users.

Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator

“…However, the oval femoral tunnel has several disadvantages, compared to the rounded rectangle femoral tunnel. For example, the oval femoral tunnel cannot increase the size of the femoral tunnel without roof impingement, and does not restore the flat tendon bone junction, as described by Smigielski [27] . Therefore, our technique with the rounded rectangle dilator may potentially reduce the graft failure rate of anatomical ACL reconstructions, compared to that of non-anatomical or standard ACL reconstructions.…”

Accurate Positioning of Femoral and Tibial Tunnels in Single Bundle Anterior Cruciate Ligament Reconstruction Using the Indigenously Made Bernard and Hurtle Grid on a Transparency Sheet and C-arm

“…Some recent studies have shown that the ACL is attached as a single footprint on the femoral side (the ribbon concept). 3 To determine the center of the bundle, many people rely on anatomical landmarks. In some studies, it has been shown that even these landmarks are not consistent and may be absent in many patients.…”

Modern Trends in Surgical Treatment of Patients With Acl Ruptures (Literature Review)

“…они выяснили, что после иссечения синови-альной оболочки и фиброзной мембраны форма и структура связки на своем протяжении меня-ются. на удалении 2-3 мм от мест прикрепления связка приобретает плоскую лентовидную форму шириной от 11,43 до 16,18 мм и толщиной от 2,54 до 3,38 мм без видимого подразделения на хорошо известные описанные ранее передне-медиальный и задне-латеральный пучки [20][21][22]. В месте при-крепления связки к бедренной кости, именуемой «footprint», отмечено изменение ее структуры.…”

“…Таким образом, в большом по площади «footprint» пкс на лате-ральной стенке межмыщелковой ямки, имеющим в среднем размеры 18×11 мм, центр прикрепления главного пучка прямых волокон связки располо-жен эксцентрично в его передней части, а именно в относительно узкой зоне тотчас кзади и книзу от центра межмыщелкового гребня [24]. Так как пря-мые волокна несут основную нагрузку и имеют по-ложение, максимально близкое к изометричному, то в практическом плане именно их реконструк-ция и представляет реальное анатомическое одно-пучковое воссоздание пкс [22,24].…”