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Purpose:
The objective of this study was to evaluate the dimensions of the femoral intercondylar notch intraoperatively and to determine whether a small intercondylar notch increases the risk of graft failure after individualized anatomic single- or double-bundle anterior cruciate ligament (ACL) reconstruction.
Methods:
A retrospective review of...
Citations
... As a part of this concept, preoperative planning in ACL reconstruction is essential based on each patient's native anatomy to determine single-bundle versus double-bundle ACL reconstruction, graft type and size, tibial and femoral insertion site size, and fixation method [4]. The morphology of the femoral intercondylar notch, which houses the ACL as it travels between the femoral and tibial insertions, has gained particular attention [5]. Although the relationship between the morphology of the intercondylar notch and ACL injury remains controversial, many recent studies have emphasized that the narrow intercondylar notch was a predictive risk factor for ACL injuries for both females and males, children and adults, athletes and non-athletes [6][7][8][9]. ...
Abstract Background Patellar instability (PI) usually combines with morphological abnormalities of femoral condyles that may affect the morphology of the intercondylar notch and anterior cruciate ligament (ACL), which are important in individualized ACL reconstruction. This study aimed to investigate the morphological characteristics of the intercondylar notch and ACL in patients with PI. Methods 80 patients with PI and 160 age- and gender-matched controls from January 2014 to June 2022 were studied. Morphological measurements of the femoral condyles included intercondylar notch height, notch width, medial condylar width, lateral condylar width, bicondylar width, notch width index, notch angle, lateral femoral condyle ratio (LFCR), condyle flexion angle, and posterior tibial slope. Morphological measurements of the ACL included ACL length, inclination angle, and ACL size. The measurements were compared between PI and control groups, and between males and females in PI group. The independent samples t-test was performed to examine differences in continuous variables. The chi-square test was used for comparing categorical variables. Results The intercondylar notch width, bicondylar width, notch width index, and notch angle were significantly smaller, while the LFCR was significantly larger in PI group than those of control group (p 0.05). No sex difference related to the morphology of the ACL was found. Conclusions The patient with PI had a stenotic intercondylar notch and a thin ACL. No significant sex difference in the intercondylar notch stenosis and ACL size was observed. The morphology of the intercondylar notch and ACL should be taken into consideration when planning individualized ACL reconstruction in the presence of PI.
... Theoretically, a small intercondylar notch could create wear of the graft on the lateral femoral condyle during knee extension and internal rotation movements [36]. However, some recent studies on human cadaveric knees [53] and post-operative imaging analysis [42,52,144] demonstrated that, if the graft is correctly placed, impingement should not occur, and therefore the risk for failure is not increased. ...
Anterior cruciate ligament (ACL) tear is one of the most common sport-related injuries and the request for ACL reconstructions is increasing nowadays. Unfortunately, ACL graft failures are reported in up to 34.2% in athletes, representing a traumatic and career-threatening event. It can be convenient to understand the various risk factors for ACL failure, in order to properly inform the patients about the expected outcomes and to minimize the chance of poor results. In literature, a multitude of studies have been performed on the failure risks after ACL reconstruction, but the huge amount of data may generate much confusion.
The aim of this review is to resume the data collected from literature on the risk of graft failure after ACL reconstruction in athletes, focusing on the following three key points: individuate the predisposing factors to ACL reconstruction failure, analyze surgical aspects which may have significant impact on outcomes, highlight the current criteria regarding safe return to sport after ACL reconstruction.
... The femoral intercondylar notch width varies considerably between individuals (Fig. 6). Although traditionally used to determine the desired diameter of the ACL graft during reconstruction, it has recently been shown to be inversely correlated with risk of ACL graft rupture [143,153,154]. This has been demonstrated in biomechanical studies, as more "narrow" intercondylar notches have been shown to result in increased strain on the ACL fibers and impingement during knee range of motion, especially during external rotation and abduction [40,109]. ...
A trend within the orthopedic community is rejection of the belief that “one size fits all.” Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient’s anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.
Level of evidence
V.
... Many studies have reported that knees, in which ACL tear occur, have common morphological characteristics [4][5][6][7]. On the femoral side, the intercondylar notch shape is related with the occurrence of ACL injury [8,9]. On the tibial side, the articular geometry of the tibia plateau has been studied in detail [6,[9][10][11]. ...
... On the femoral side, the intercondylar notch shape is related with the occurrence of ACL injury [8,9]. On the tibial side, the articular geometry of the tibia plateau has been studied in detail [6,[9][10][11]. Tibial posterior slope has been revealed to be related with the occurrence of ACL injury [7,[10][11][12]. The tibial eminence is near and close to the ACL, it is possible that the size or volume of it influence the trend and tension of ACL. ...
Anterior cruciate ligament (ACL) is a primary stabilizer of the knee and constrains joint motion, and its injury is very common in clinic. There are many studies on the risk factors of ACL injury such as the ACL diameter, intercondylar notch width index (NWI), sagittal condylar shape, tibial posterior slope, tibia eminence size and so on. Large amount of research data has confirmed that all above are closely related to ACL injury. Among them the morphological characteristics of femoral condyle and tibial plateau are closely related to ACL injury. For example the tibial eminence, which is the hot topic of recent research. Whether or how does it relate to ACL injury has draw much interest of researchers. Since the tibial eminence and the ACL are both located in the intercondylar notch and adjacent to each other, we hypothesize the size of the tibial eminence may relate to the rupture of ACL. For there is report have found that reduced medial tibial eminence was associated with ACL injury, we suggest a hypothesis that enlarged tibia eminence may be a protective factor of ACL.
... Regarding FNw, it has been reported that in patients with a notch diameter of less than 12 mm, anatomic ACL SBr without notchplasty is recommended for preserving as much of the patient's native anatomy as possible [2,10]. However, other studies support that small FNw do not appear to be a risk factor for higher rates of graft failure after anatomic and individualised ACL reconstruction [34]. ...
Purpose: To evaluate the rate of anatomic restrictions on MR imaging which may prevent anterior cruciate ligament (ACL) double-bundle reconstruction (DBr) technique. The hypothesis was that some patients may not meet the criteria for this procedure. Material and Methods: From November 2013 to June 2016, 680 consecutive knee magnetic resonance (MR) imaging studies, from 656 patients (322 males and 334 females; age range 2-85 years; mean age 44.5 years; SD ± 18.8) were retrospectively reviewed. Exclusion criteria included: (i) pres-Original Article Feasibility of a double-bundle anterior cruciate ligament reconstruction can be predicted by anthropometric and skeletal parameters: An MR imaging study, p. 21-28 VOLUME 3 | ISSUE 4 22 H R J ence of non-anatomic parameters (open physes, severe osteoarthritic changes, multiligamentous injuries), (ii) previous ACL reconstruction and (iii) incomplete MR imaging examination. Following the exclusion of 128 patients (139 MR imaging studies), 528 patients (541 MR imaging studies) comprised the study group. The femoral notch width (FNw) was measured on coronal T1-w whereas the ACL tibial insertion site (TIS) length was measured on sagittal fat-suppressed proton density MR images. A TIS length and an FNw of less than 14 mm and 12 mm respectively were regarded abnormal. Results: Ninety-eight patients (18.5%) proved to be improper candidates for DBr technique. Ninety of them (91.8%) were not suitable due to short TIS length, 8 (8.2%) due to narrow FNw and 2 (2%) due to coexistence of both the above anatomic limitations. The number of female patients showing anatomic restrictions was significantly higher compared to that of male patients (p<0.00001). Conclusions: A significant number of patients do not meet the criteria for DBr technique due to anatomic restrictions. MR imaging can identify them pre-operatively and prevent failure of a demanding procedure. Level of evidence: III, retrospective comparative study
... 1,2 Although research into the techniques and options for suitable grafts has been a focus in the literature, the failure rates continue to persist at a rate reported between 0% and 15.3%. [3][4][5][6][7][8][9][10][11][12] Moreover, as the incidence of ACL reconstruction procedures increases, the number of revision surgeries has concurrently risen. 5 Recent literature concerning failure of revision ACL reconstruction has revealed rates ranging from 8% to 25%, with an increased incidence in the young, active population. ...
Purpose:
To present the mid- to long-term clinical and radiographic outcomes of a series of patients who underwent revision anterior cruciate ligament (ACL) reconstruction with doubled gracilis and semitendinosus (DGST) autograft and a lateral extra-articular tenodesis (LET).
Methods:
Patients who underwent revision ACL reconstruction with DGST and LET by a single surgeon between January 1997 and December 2013 were included. Revision was indicated by ACL failure noted on magnetic resonance imaging, persistent clinical instability, or laxity on clinical exam. Patients were evaluated preoperatively and at latest follow-up by an independent board-certified orthopaedic surgeon. Outcomes included Lachman and pivot shift tests, validated clinical and patient reported outcomes scores, and radiographic analysis. The presence of previous meniscectomy or chondral injury was recorded intraoperatively.
Results:
A total of 118/132 potential patients (89.4%) was available for follow-up at a mean 10.6 years (3-19 years) postoperatively. Lachman and pivot shift examinations as well as the side-to-side difference on an KT-1000 arthrometer demonstrated significant improvement at latest follow-up (P < .05) versus preoperative evaluation. Severe degenerative disease was present in 25% of patients on radiograph and correlated with worsened clinical outcomes. Previous meniscectomy was the only risk factor analyzed that correlated with worsened radiographic grade. No patients had a graft tear based on clinical and/or magnetic resonance imaging evaluation, but 9 (7.6%) failed based on a side-to-side difference of >5 mm on the KT-1000, a grade ≥2+ on pivot shift, or report of continued instability.
Conclusions:
Revision ACL reconstruction with DGST and LET at mid- to long-term follow-up provides continued improvement in clinical and radiological outcomes from preoperative assessment. Meniscectomy was the only factor related to worsened radiological grades and clinical outcomes.
Level of evidence:
Level IV, case series.
... Nevertheless, no univocal data is supporting this hypothesis, and the addition of notchplasty to reduce the reinjury risk is not supported. [10][11][12][13][14] Conversely, most literature agrees upon the utility of notchplasty in the management of arthrofibrosis and cases of chronic instability or revision ACLR, whereas the intercondylar notch may be characterized by the presence of osteophytes. 3,[15][16][17][18] We designed this article with the aim to summarize the current literature evidence concerning the effects of notchplasty on the clinical outcome of primary ACLR. ...
Purpose Notchplasty is a complementary surgical procedure often performed during anterior cruciate ligament reconstruction (ACLR) with the aim to widen the intercondylar notch and to avoid graft impingement. The aim of this review was to analyze the current literature evidence concerning the effects of notchplasty on clinical outcome after primary ACLR.
Methods Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE were used to search English language studies, from January 1990 to July 2015, concerning the effects of the notchplasty on ACLR, using the following keywords: “ACL” OR “anterior cruciate ligament” OR “ACL reconstruction” OR “anterior cruciate ligament reconstruction” AND “notch” OR “notchplasty” OR “intercondylar notch”. Randomized and nonrandomized trials, case series, technical notes, biomechanical studies and radiological study were included.
Results At the final screening 16 studies were included. Despite widely used, the usefulness of notchplasty during ACLR remains unclear. Some concerns emerged regarding potential harmful effects of notchplasty, mostly related to the knee biomechanics and postoperative blood loss. Notchplasty can be useful in the treatment of arthrofibrosis and in presence of bony spurs of the notch both in primary and revision surgery. However, the level of evidence of available literature is poor and there is a strong need for randomized controlled trials investigating the role of notchplasty on ACLR.
Conclusion We suggest being aware of potential complications following notchplasty during ACLR before deciding to perform notchplasty in primary ACLR, reserving it for the surgical management of arthrofibrosis, treatment of notch osteophytosis and revision ACLR.
Level of Evidence Level IV, systematic review of level II-IV studies.
... The relationship between narrow notch width and increased ACL injury risk has been confirmed not just in young patients with acute ACL tears, but also in older patients with knee arthritis (37). In general, an NWI of <0.27 or an absolute notch width of <15 mm is considered a significant risk factor for ACL injury (38). ...
... A narrow NWI (o0.27) can be considered a risk factor for ACL injury as well as can an IN width less than 15 mm. 24 The shape of IN varies and occurs in different formats (A, U, W, or mixed 25 ). The A shape appears to increase the potential ACL injury rate. ...
... The A shape appears to increase the potential ACL injury rate. 24,25 IN bone conformation has been found to be similar) to ours. 26 In another anatomy study that evaluated 6 animal species (cow, goat, sheep, dog, rabbit, and pig), only the cow presented a NWI similar to that of humans. ...
... The remaining animals showed a narrower IN. 27 In humans, females present a smaller femur with a narrower IN and smaller cross-sectional area. 24 Males exhibits a larger femoral bicondylar width with more space for the ACL below the IN. 28 In pigs, significant differences between knees in males and females were observed with bone morphology similar to that of humans. ...
Bone morphology is related to static and dynamic parameters during anterior cruciate ligament (ACL) kinematics and can affect injury mechanism patterns, gait analysis, biomechanical properties, and surgical references for ligament reconstructions. It does not only depend on mechanical factors but also reflects a developmental program with many other factor involved, including nutrition and hormones, especially those involved in the calcium metabolism. Although Wolff׳s law continues to be a dominant paradigm in Orthopaedics, in the past 15 years enormous advances have been made that have improved our understanding of how individual bones achieve their internal and external structure. Transition from the quadrupedal mode of locomotion to bipedalism compelled changes in the femur morphology and the modern human knee has an extensive history of modifications produced by natural selection acting on its function in habitually upright walking and running. The human ACL is a band-like structure of dense connective tissues that binds the femur to the tibia. The femoral ACL attachment is located on the posterior aspect of the medial surface of the lateral femoral condyle and is composed of both direct and indirect fibers; the central part of the insertion is constructed in the manner described by the classical 4-phase architecture (direct insertion), whereas the posterior margin of the insertion is composed of a 2-phase architecture more typical of indirect insertions. The knowledge of anatomy, comparative anatomy, evolution, and natural selection allows us to have a more profound understanding of the interaction between form and function; after all, as Theodosius Dobzhansky has stated, Nothing in biology makes sense except in the light of Evolution.
... Wolf, in a study published in KSSTA in 2015, shows that a lower intercondylar notch dimension does not provide higher risk for graft failure after anatomical ACL restoration. 44 Based on these results, the use of notchplasty is not recommended. The meta-analysis published by Desai et al. in 2014 found that anatomical double-bundle is better compared to single-bundle in terms of re-establishment of knee kinetics and primary anteroposterior laxity. ...
The treatment for anterior cruciate ligament (ACL) deficient knee consists in its surgical reconstruction. There are several available and validated techniques, but there are still numerous questions to be answered concerning the best approach in terms of stability, functional outcome, and avoiding further damage in the knee. This paper sought to analyze the studies published in the literature comparing the outcomes of ACL restoration with single-bundle versus double-bundle techniques. The results demonstrate that even if biomechanical studies find an increased steadiness with double-bundle ACL reconstruction, there seems to be no clinical or functional benefit compared with single-bundle reconstruction.
