Elsevier

The Knee

Volume 25, Issue 4, August 2018, Pages 531-544
The Knee

Stereophotogrammetric surface anatomy of the anterior cruciate ligament's tibial footprint: Precise osseous structure and distances to arthroscopically-relevant landmarks

https://doi.org/10.1016/j.knee.2018.03.016Get rights and content

Abstract

Background

While femoral tunnel malposition is widely recognized as the main technical error of failed anterior cruciate ligament (ACL) surgery, tibial tunnel malposition is likely underrecognized and underappreciated.

Purpose

To describe more precisely the qualitative and quantitative anatomy of the ACL's tibial attachment in vitro using widely available technology for stereophotogrammetric surface reconstruction, and to test its applicability in vivo.

Methods

Stereophotogrammetric surface reconstruction was obtained from fourteen proximal tibias of cadaver donors. Measurements of areas and distances from the center of the ACL footprint and the footprint of the obtained bundles to selected arthroscopically-relevant anatomic landmarks were carried out using a three-dimensional design software program, and means and 95% confidence intervals were calculated for these measurements. Reference landmarks were tested in three-dimensional models obtained with arthroscopic videos.

Main findings

The osseous footprint of the ACL was described in detail, including its precise elevated limits, size, and shape, with its elevation pattern described as a quarter-turn-staircase-like ridge. Its internal indentations were related to inter-spaces identified as bundle divisions. Distances from the footprint center to arthroscopically relevant landmarks were obtained and compared to its internal structure, yielding a useful X-like landmark pointing to the most accurate placeholder for the ACL footprint's “anatomic” center. Certain structures and reference landmarks described were readily recognized in three-dimensional models from arthroscopic videos.

Conclusions

Stereophotogrammetric surface reconstruction is an accessible technique for the investigation of anatomic structures in vitro, offering a detailed three-dimensional depiction of the ACL's osseous footprint.

Introduction

The most popular surgical techniques available today for reconstructing a torn anterior cruciate ligament (ACL) involve replacing it with a graft. It is critical, therefore, to know the exact position, area, and shape of its footprint, as well as its relationship with neighboring structures.

There are no general standard guidelines and fewer reports on the bony landmarks for anatomic placement of the tibial tunnel, which have been disparately described in recent studies. It is suspected, therefore, that tibial tunnel malposition is likely underrecognized and underappreciated as a cause of failed ACL reconstruction surgery.

The ACL has long been described as a group of fascicles that change in tension and length through the range of motion [1], [2], with the simplest division proposed as an anteromedial (AM) part that tightens with knee flexion, and a posterolateral (PL) part that tightens with knee extension [3], [4], [5], [6].

Norwood & Cross [7] divided the ACL into three functional bundles, a division supported by later studies [8], [9], [10]. The function and footprint of the three bundles have since been further investigated mainly by Japanese researchers [11], [12], [13], [14], who have applied it to surgical repair [12], [15], [16], [17], [18], and their findings have been supported in many mammal species [19], [20], [21]. Support for a three-bundle reconstruction is also given for more “anatomic” and functional ACL restoration [12], [13], [22].

The aim of this work is to describe with detail the qualitative and quantitative anatomy of the ACL's attachment to the proximal tibia, with reference to pertinent surgically identifiable osseous landmarks.

It was hypothesized that widely available technological means for stereophotogrammetric surface reconstruction is capable of offering highly detailed three-dimensional (3D) models. These models should allow for a precise and consistent depiction of the ACL attachment in relation to known (and potentially yet unknown) anatomic landmarks, to help guide future surgical repair and reconstruction protocols.

Section snippets

Specimen collection and preparation

Fourteen adult formaldehyde-preserved tibial plateaux were donated and used in this study under a protocol approved by the research ethics committee of our hospital. Exclusion criteria included previous knee surgery (one patient, arthroscopic debridement in osteoarthritis), and lack of integrity of ligamentous or meniscal structures, verified during dissection. There were five males (three paired, two non-paired) and three females (paired), and the mean age of the cadaveric specimens was 49 

Size

Specimens had an average mediolateral width of 72.4 mm (SD = 4.4), and anteroposterior depth of 50.4 mm (SD = 2.8).

The anterior intercondylar staircase (AIS)

The posterior part of the domed medial aspect of the anterior intercondylar area (AIA) was found as a quarter-turn-staircase-shaped ridge, and referenced as the “anterior intercondylar staircase”.

Two “stairs” were always found (Figure 1): the upper one connected the higher intertubercular ridge posteriorly to the anterior frontal intercondylar ridge anteriorly, following the direction of

Anterior intercondylar staircase

The ACL attachment area has been variously described as an “oblique groove” [24], the posterior part of the medial taller, domed half of the AIA [25], [26], a fossa [27], [28], a depression [4], [29], or a bony prominence [30].

In this study the AIS was found to be of triangular, or of an irregular quadrilateral shape associated with degenerative elevations, with intermediate forms showing a wider and more rounded PA. In Tensho et al. [30], it was described as having oval vs. triangular

Conclusions

Surface reconstruction of the proximal tibia's osseous surface based on careful marking and stereophotogrammetric technique offers a detailed three-dimensional depiction of the ACL's footprint in vitro, including its elevated limits, its internal quarter-turn-staircase-like structure, and indentations corresponding to bundle inter-spaces. Use of 3D design software program for observation and distance measurement help further delimit the actual area of insertion of ACL fibers and its relation to

Acknowledgements

Arthroscopic video and intraoperative feedback of arthroscopic ACL reconstruction were contributed by Lorenzo Castrejón, M.D., and José L. Pereira, M.D., orthopaedic surgeons, specialists in knee arthroscopy, Department of Orthopaedic Surgery and Traumatology. University Hospital Infanta Cristina, Badajoz 06080, Spain.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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