Skip to main content
SpringerLink
Log in

Bony and soft tissue landmarks of the ACL tibial insertion site: an anatomical study

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

Abstract

Purpose

To identify and describe reliable landmarks for tibial tunnel placement in anatomical ACL reconstruction.

Methods

Eight non-paired cadaveric knees were used. After dissection, the tibial plateaus, menisci and ACL insertions were grossly observed to identify anatomical landmarks and relate them to the ACL insertion site. The specimens were scanned with a laser scanner, and 3-Dimensional images were obtained. Measurements of the ACL tibial insertion were taken. The center of the ACL and its bundles was measured regarding the distance from the medial tibial eminence and intermeniscal ligament.

Results

The medial tibial eminence demonstrated a constant relationship with the ACL tibial insertion site center and its bundles, as well as the intermeniscal ligament. The anterior root of the lateral meniscus had a variable relationship with the ACL tibial insertion. The length of the ACL tibial insertion was 18.1 ± 2.8 mm and the width was 10.7 ± 1.9 mm. The width of the AM bundle was 11.1 ± 2.1 mm and the PL 7.9 ± 2.0 mm. The ACL center was 9.1 ± 1.5 mm posterior to the intermeniscal ligament and 5.7 ± 1.1 mm anterior to a projected line from the apex of the medial tibial eminence. The center of the AM bundle was at 4.6 ± 0.7 mm posterior to the intermeniscal ligament. The center of the PL bundle was 1.4 ± 0.7 mm anterior to the medial tibial eminence.

Conclusion

The medial tibial eminence and the intermeniscal ligament may be used as landmarks to guide the correct tunnel placement in an anatomical ACL reconstruction.

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.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Amis AA, Dawkins GP (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 73(2):260–267

    PubMed  CAS  Google Scholar 

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

    PubMed  Google Scholar 

  3. 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 

  4. Cohen M, Amaro JT, Ejnisman B, Carvalho RT, Nakano KK, Peccin MS, Teixeira R, Laurino CF, Abdalla RJ (2007) Anterior cruciate ligament reconstruction after 10–15 years: association between meniscectomy and osteoarthrosis. Arthroscopy 23(6):629–634

    Article  PubMed  Google Scholar 

  5. Colombet P, Robinson J, Christel P, Franceschi JP, Djian P, Bellier G, Sbihi A (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22(9):984–992

    Article  PubMed  Google Scholar 

  6. Dodds JA, Arnoczky SP (1994) Anatomy of the anterior cruciate ligament: a blueprint for repair and reconstruction. Arthroscopy 10(2):132–139

    Article  PubMed  CAS  Google Scholar 

  7. Duthon VB, Messerli G, Menetrey J (2008) Anterior cruciate ligament reconstruction: indications and techniques. Rev Med Suisse 4(184):2744–2748

    PubMed  Google Scholar 

  8. Edwards A, Bull AM, Amis AA (2008) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament. Part 1: femoral attachment. Knee Surg Sports Traumatol Arthrosc 16(1):29–36

    Article  PubMed  Google Scholar 

  9. 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 

  10. 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 

  11. 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(11):1218–1225

    Article  PubMed  Google Scholar 

  12. Ferretti M, Levicoff EA, Macpherson TA, Moreland MS, Cohen M, Fu FH (2007) The fetal anterior cruciate ligament: an anatomic and histologic study. Arthroscopy 23(3):278–283

    Article  PubMed  Google Scholar 

  13. 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 

  14. Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231

    Article  PubMed  Google Scholar 

  15. Giron F, Cuomo P, Edwards A, Bull AM, Amis AA, Aglietti P (2007) Double-bundle “anatomic” anterior cruciate ligament reconstruction: a cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy 23(1):7–13

    Article  PubMed  Google Scholar 

  16. Harner CD, Baek GH, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL (1999) Quantitative analysis of human cruciate ligament insertions. Arthroscopy 15(7):741–749

    Article  PubMed  CAS  Google Scholar 

  17. 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 

  18. Jackson DW, Gasser SI (1994) Tibial tunnel placement in ACL reconstruction. Arthroscopy 10:124–131

    Article  PubMed  CAS  Google Scholar 

  19. Kato Y, Ingham SJ, Kramer S, Smolinski P, Saito A, Fu FH (2010) Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surg Sports Traumatol Arthrosc 18(1):2–10

    Article  PubMed  Google Scholar 

  20. Kopf S, Forsythe B, Wong AK, Tashman S, Anderst W, Irrgang JJ, Fu FH (2010) Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. J Bone Joint Surg Am 92(6):1427–1431

    Article  PubMed  Google Scholar 

  21. McGuire DA, Hendricks SD, Sanders HM (1997) The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion. Arthroscopy 13(4):465–473

    Article  PubMed  CAS  Google Scholar 

  22. Mochizuki T, Muneta T, Nagase T, Shirasawa S, Akita KI, Sekiya I (2006) Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy 22(4):356–361

    Article  PubMed  Google Scholar 

  23. Morgan CD, Kalman VR, Grawl DM (1995) Definitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy 11(3):275–288

    Article  PubMed  CAS  Google Scholar 

  24. Norwood LA, Cross MJ (1979) Anterior cruciate ligament: functional anatomy of its bundles in rotator instabilities. Am J Sports Med 7(1):23–26

    Article  PubMed  CAS  Google Scholar 

  25. Odensten M, Gillquist J (1985) Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 67(2):257–262

    PubMed  CAS  Google Scholar 

  26. Petersen W, Zantop T (2007) Anatomy of the anterior cruciate ligament with regard to its two bundles. Clin Orthop Relat Res 454:35–47

    Article  PubMed  Google Scholar 

  27. Purnell ML, Larson AI, Clancy W (2008) 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 36(11):2083–2090

    Article  PubMed  Google Scholar 

  28. Sakane M, Fox RJ, Woo SL, Livesay GA, Li G, Fu FH (1997) In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res 15(2):285–293

    Article  PubMed  CAS  Google Scholar 

  29. Siebold R, Ellert T, Metz S, Metz 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(5):585–592

    Article  PubMed  Google Scholar 

  30. 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(2):154–161

    Article  PubMed  Google Scholar 

  31. Tállay 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(8):741–746

    Article  PubMed  Google Scholar 

  32. Van Eck CF, Lesniak BP, Schreiber VM, Fu FH (2010) Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy 26(2):258–268

    Article  PubMed  Google Scholar 

  33. Yunes M, Richmond JC, Engels EA, Pinczewski LA (2001) Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: a meta-analysis. Arthroscopy 17(3):248–257

    Article  PubMed  Google Scholar 

  34. Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH (2006) Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc 14(10):982–992

    Article  PubMed  Google Scholar 

  35. 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 

Download references

Acknowledgments

The support of the Albert B. Ferguson, Jr. MD Orthopaedic Fund of The Pittsburgh Foundation is gratefully acknowledged.

Conflict of interest

The senior author (FF) receives a research/education grant from Smith & Nephew.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, School of Medicine, Federal University of São Paulo, UNIFESP, São Paulo, Brazil

    Mario Ferretti, Daniel Doca & Moises Cohen

  2. Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, 1010 Kaufmann Building, Pittsburgh, PA, 15213, USA

    Sheila M. Ingham & Freddie H. Fu

Authors
  1. Mario Ferretti
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel Doca
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sheila M. Ingham
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Moises Cohen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Freddie H. Fu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Freddie H. Fu.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ferretti, M., Doca, D., Ingham, S.M. et al. Bony and soft tissue landmarks of the ACL tibial insertion site: an anatomical study. Knee Surg Sports Traumatol Arthrosc 20, 62–68 (2012). https://doi.org/10.1007/s00167-011-1592-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-011-1592-z

Keywords

Search

Navigation