Anatomical study of anterior cruciate ligament and its effect on reconstruction technique_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LI Feilong , LUO Xiaoji , LIANG Xi , HUANG Wei ,  HU Ning

Department of Orthopedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400042, P.R.China;

Corresponding author：

HU Ning, Email: 1276321387@qq.com

Keywords：

Anterior cruciate ligament; ligament reconstruction; anatomical study

DOI：

10.7507/1002-1892.201708038

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To summarize the current research progress of anterior cruciate ligament (ACL) anatomy, and discuss its effect on the reconstruction technique. Methods The literature concerning ACL anatomy and reconstruction at home and abroad was extensively reviewed and summarized. Results The anatomy and morphology of ACL has gained new recognition in recent years, and the " Ribbon-like” ACL has gradually been paid attention to by researchers. In present researches, it seems the " Ribbon-like” anatomy theory has advantages in theory when compared with the previous anatomy theory. It is more in line with the anatomy and isometric reconstruction. Conclusion The understanding of ACL anatomy guided the development of ACL reconstruction. The " Ribbon-like” ACL anatomy theory is the different understanding of the anatomy theory, which remains controversy. The " Ribbon-like” reconstruction maybe has more advantages in theory, but further study is needed.

Citation： LI Feilong, LUO Xiaoji, LIANG Xi, HUANG Wei, HU Ning. Anatomical study of anterior cruciate ligament and its effect on reconstruction technique. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(3): 377-381. doi: 10.7507/1002-1892.201708038 Copy

1.	Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med, 2003, 31(1): 2-11.
2.	Fu FH, Bennett CH, Lattermann C, et al. Current trends in anterior cruciate ligament reconstruction. Part 1: Biology and biomechanics of reconstruction. Am J Sports Med, 1999, 27(6): 821-830.
3.	Harner CD, Giffin JR, Dunteman RC, et al. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect, 2001, 50: 463-474.
4.	Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res, 1975, (106): 216-231.
5.	Sasaki N, Ishibashi Y, Tsuda E, et al. The femoral insertion of the anterior cruciate ligament: discrepancy between macroscopic and histological observations. Arthroscopy, 2012, 28(8): 1135-1146.
6.	Iwahashi T, Shino K, Nakata K, et al. Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography. Arthroscopy, 2010, 26(9 Suppl): S13-20.
7.	Purnell ML, Larson AI, Clancy W. 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, 2008, 36(11): 2083-2090.
8.	Siebold R, Ellert T, Metz S, et al. 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, 2008, 24(5): 585-592.
9.	Tsukada S, Fujishiro H, Watanabe K, et al. Anatomic variations of the lateral intercondylar ridge: relationship to the anterior margin of the anterior cruciate ligament. Am J Sports Med, 2014, 42(5): 1110-1117.
10.	Mochizuki T, Muneta T, Nagase T, et al. Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy, 2006, 22(4): 356-361.
11.	Śmigielski R, Zdanowicz U, Drwiega M, et al. Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3143-3150.
12.	Iriuchishima T, Ryu K, Aizawa S, et al. The difference in centre position in the ACL femoral footprint inclusive and exclusive of the fan-like extension fibres. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 254-259.
13.	Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg (Am), 1985, 67(2): 257-262.
14.	Arnoczky SP. Anatomy of the anterior cruciate ligament. Clin Orthop Relat Res, 1983, (172):19-25.
15.	Ferretti M, Levicoff EA, Macpherson TA, et al. The fetal anterior cruciate ligament: an anatomic and histologic study. Arthroscopy, 2007, 23(3): 278-283.
16.	Colombet P, Robinson J, Christel P, et al. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy, 2006, 22(9): 984-992.
17.	Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of human cruciate ligament insertions. Arthroscopy, 1999, 15(7): 741-749.
18.	Siebold R, Ellert T, Metz S, et al. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy, 2008, 24(2): 154-161.
19.	Tensho K, Shimodaira H, Aoki T, et al. Bony landmarks of the anterior cruciate ligament tibial footprint: A detailed analysis comparing 3-dimensional computed tomography images to visual and histological evaluations. Am J Sports Med, 2014, 42(6): 1433-1440.
20.	Siebold R. Flat ACL anatomy: fact no fiction. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3133-3135.
21.	Siebold R, Schuhmacher P, Fernandez F, et al. Flat midsubstance of the anterior cruciate ligament with tibial " C”-shaped insertion site. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3136-3142.
22.	Śmigielski R, Zdanowicz U, Drwiega M, et al. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J, 2016, 98-B(8):1020-1026.
23.	Oka S, Schuhmacher P, Brehmer A, et al. Histological analysis of the tibial anterior cruciate ligament insertion. Knee Surg Sports Traumatol Arthrosc, 2016, 24(3): 747-753.
24.	Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med, 2005, 33(3): 335-346.
25.	Yasuda K, Kondo E, Ichiyama H, et al. Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy, 2006, 22(3): 240-251.
26.	Araki D, Kuroda R, Kubo S, et al. A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system. Int Orthop, 2011, 35(3): 439-446.
27.	Piasecki DP, Bach BR Jr, Espinoza Orias AA, et al. Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique? Am J Sports Med, 2011, 39(6): 1306-1315.
28.	Murawski CD, Wolf MR, Araki D, et al. Anatomic anterior cruciate ligament reconstruction: current concepts and future perspective. Cartilage, 2013, 4(3 Suppl): 27S-37S.
29.	Yagi M, Kuroda R, Nagamune K, et al. Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res, 2007, 454: 100-107.
30.	Radford WJ, Amis AA. Biomechanics of a double prosthetic ligament in the anterior cruciate deficient knee. J Bone Joint Surg (Br), 1990, 72(6): 1038-1043.
31.	Kondo E, Yasuda K, Azuma H, et al. Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med, 2008, 36(9): 1675-1687.
32.	Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy, 2004, 20(10): 1015-1025.
33.	Ho JY, Gardiner A, Shah V, et al. Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy, 2009, 25(5): 464-472.
34.	Muneta T, Koga H, Morito T, et al. A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction. Arthroscopy, 2006, 22(3): 252-258.
35.	Desai N, Bjrnsson H, Musahl V, et al. Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc, 2014, 22(5): 1009-1023.
36.	Kang HJ, Wang XJ, Wu CJ, et al. Single-bundle modified patellar tendon versus double-bundle tibialis anterior allograft ACL reconstruction: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc, 2015, 23(8): 2244-2249.
37.	Xu Y, Ao YF, Wang JQ, et al. Prospective randomized comparison of anatomic single- and double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2014, 22(2): 308-316.
38.	Abebe ES, Utturkar GM, Taylor DC, et al. The effects of femoral graft placement on in vivo knee kinematics after anterior cruciate ligament reconstruction. J Biomech, 2011, 44(5): 924-929.
39.	Tashman S, Araki D. Effects of anterior cruciate ligament reconstruction on in vivo, dynamic knee function. Clin Sports Med, 2013, 32(1): 47-59.
40.	Chu CR, Williams AA, West RV, et al. Quantitative magnetic resonance imaging UTE-T2* mapping of cartilage and meniscus healing after anatomic anterior cruciate ligament reconstruction. Am J Sports Med, 2014, 42(8): 1847-1856.
41.	Fu FH, van Eck CF, Tashman S, et al. Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 640-648.
42.	Duffee A, Magnussen RA, Pedroza AD, et al. Transtibial ACL femoral tunnel preparation increases odds of repeat ipsilateral knee surgery. J Bone Joint Surg (Am), 2013, 95(22): 2035-2042.
43.	Lubowitz JH. Anatomic ACL reconstruction produces greater graft length change during knee range-of-motion than transtibial technique. Knee Surg Sports Traumatol Arthrosc, 2014, 22(5): 1190-1195.
44.	Artmann M, Wirth CJ. Investigation of the appropriate functional replacement of the anterior cruciate ligament (author’s transl). Z Orthop Grenzgeb, 1974, 112(1): 160-165.
45.	Pearle AD, Shannon FJ, Granchi C, et al. Comparison of 3-dimensional obliquity and anisometric characteristics of anterior cruciate ligament graft positions using surgical navigation. Am J Sports Med, 2008, 36(8): 1534-1541.
46.	Hefzy MS, Grood ES, Noyes FR. Factors affecting the region of most isometric femoral attachments. Part Ⅱ: The anterior cruciate ligament. Am J Sports Med, 1989, 17(2): 208-216.
47.	Markolf KL, Jackson SR, McAllister DR. A comparison of 11 o’clock versus oblique femoral tunnels in the anterior cruciate ligament-reconstructed knee: knee kinematics during a simulated pivot test. Am J Sports Med, 2010, 38(5): 912-917.
48.	Beynnon BD, Uh BS, Johnson RJ, et al. The elongation behavior of the anterior cruciate ligament graft in vivo. A long-term follow-up study. Am J Sports Med, 2001, 29(2):161-166.
49.	Rahr-Wagner L, Thillemann TM, Pedersen AB, et al. Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy, 2013, 29(1): 98-105.
50.	Norimasa N, Stefano Z, Robert G, et al. Controversies in the Technical Aspects of ACL Reconstruction: An Evidence-Based Medicine Approach. Berlin: Springer Berlin Heidelberg, 2017: 217-231.
51.	Clatworthy M PA, Williams A, Lind M. Current concepts: Femoral tunnel placement in ACL reconstruction: Central footprint versus AM bundle. ISAKOS Newsletter, 2015, Ⅱ: 24-31.
52.	Kato Y, Maeyama A, Lertwanich P, et al. Biomechanical comparison of different graft positions for single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2013, 21(4): 816-823.
53.	Amis AA, Jakob RP. Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc, 1998, 6 Suppl 1: S2-12.
54.	Dahlstedt L, Dalén N, Dahlborn M, et al. Value of intercondylar notch plasty: CT studies and peroperative measurements of 127 knees. Acta orthopaedica Scandinavica, 1990, 61(6): 558-561.
55.	Shino K, Mae T, Tachibana Y. Anatomic ACL reconstruction: rectangular tunnel/bone-patellar tendon-bone or triple-bundle/semitendinosus tendon grafting. Journal of Orthopaedic Science, 2015, 20(3): 457-468.
56.	Matsuo T, Mae T, Shino K, et al. Tibiofemoral relationship following anatomic triple-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2014, 22(9): 2128-2135.
57.	Hohmann E. Editorial Commentary: The Ribbon Theory. Another Quantum Leap? The Anterior Cruciate Ligament Is Twisted and in Fact a Flat Structure. Or not? Arthroscopy, 2017, 33(9): 1710-1711.

1. Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med, 2003, 31(1): 2-11.
2. Fu FH, Bennett CH, Lattermann C, et al. Current trends in anterior cruciate ligament reconstruction. Part 1: Biology and biomechanics of reconstruction. Am J Sports Med, 1999, 27(6): 821-830.
3. Harner CD, Giffin JR, Dunteman RC, et al. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect, 2001, 50: 463-474.
4. Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res, 1975, (106): 216-231.
5. Sasaki N, Ishibashi Y, Tsuda E, et al. The femoral insertion of the anterior cruciate ligament: discrepancy between macroscopic and histological observations. Arthroscopy, 2012, 28(8): 1135-1146.
6. Iwahashi T, Shino K, Nakata K, et al. Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography. Arthroscopy, 2010, 26(9 Suppl): S13-20.
7. Purnell ML, Larson AI, Clancy W. 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, 2008, 36(11): 2083-2090.
8. Siebold R, Ellert T, Metz S, et al. 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, 2008, 24(5): 585-592.
9. Tsukada S, Fujishiro H, Watanabe K, et al. Anatomic variations of the lateral intercondylar ridge: relationship to the anterior margin of the anterior cruciate ligament. Am J Sports Med, 2014, 42(5): 1110-1117.
10. Mochizuki T, Muneta T, Nagase T, et al. Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy, 2006, 22(4): 356-361.
11. Śmigielski R, Zdanowicz U, Drwiega M, et al. Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3143-3150.
12. Iriuchishima T, Ryu K, Aizawa S, et al. The difference in centre position in the ACL femoral footprint inclusive and exclusive of the fan-like extension fibres. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 254-259.
13. Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg (Am), 1985, 67(2): 257-262.
14. Arnoczky SP. Anatomy of the anterior cruciate ligament. Clin Orthop Relat Res, 1983, (172):19-25.
15. Ferretti M, Levicoff EA, Macpherson TA, et al. The fetal anterior cruciate ligament: an anatomic and histologic study. Arthroscopy, 2007, 23(3): 278-283.
16. Colombet P, Robinson J, Christel P, et al. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy, 2006, 22(9): 984-992.
17. Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of human cruciate ligament insertions. Arthroscopy, 1999, 15(7): 741-749.
18. Siebold R, Ellert T, Metz S, et al. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy, 2008, 24(2): 154-161.
19. Tensho K, Shimodaira H, Aoki T, et al. Bony landmarks of the anterior cruciate ligament tibial footprint: A detailed analysis comparing 3-dimensional computed tomography images to visual and histological evaluations. Am J Sports Med, 2014, 42(6): 1433-1440.
20. Siebold R. Flat ACL anatomy: fact no fiction. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3133-3135.
21. Siebold R, Schuhmacher P, Fernandez F, et al. Flat midsubstance of the anterior cruciate ligament with tibial " C”-shaped insertion site. Knee Surg Sports Traumatol Arthrosc, 2015, 23(11): 3136-3142.
22. Śmigielski R, Zdanowicz U, Drwiega M, et al. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J, 2016, 98-B(8):1020-1026.
23. Oka S, Schuhmacher P, Brehmer A, et al. Histological analysis of the tibial anterior cruciate ligament insertion. Knee Surg Sports Traumatol Arthrosc, 2016, 24(3): 747-753.
24. Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med, 2005, 33(3): 335-346.
25. Yasuda K, Kondo E, Ichiyama H, et al. Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy, 2006, 22(3): 240-251.
26. Araki D, Kuroda R, Kubo S, et al. A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system. Int Orthop, 2011, 35(3): 439-446.
27. Piasecki DP, Bach BR Jr, Espinoza Orias AA, et al. Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique? Am J Sports Med, 2011, 39(6): 1306-1315.
28. Murawski CD, Wolf MR, Araki D, et al. Anatomic anterior cruciate ligament reconstruction: current concepts and future perspective. Cartilage, 2013, 4(3 Suppl): 27S-37S.
29. Yagi M, Kuroda R, Nagamune K, et al. Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res, 2007, 454: 100-107.
30. Radford WJ, Amis AA. Biomechanics of a double prosthetic ligament in the anterior cruciate deficient knee. J Bone Joint Surg (Br), 1990, 72(6): 1038-1043.
31. Kondo E, Yasuda K, Azuma H, et al. Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med, 2008, 36(9): 1675-1687.
32. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy, 2004, 20(10): 1015-1025.
33. Ho JY, Gardiner A, Shah V, et al. Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy, 2009, 25(5): 464-472.
34. Muneta T, Koga H, Morito T, et al. A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction. Arthroscopy, 2006, 22(3): 252-258.
35. Desai N, Bjrnsson H, Musahl V, et al. Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc, 2014, 22(5): 1009-1023.
36. Kang HJ, Wang XJ, Wu CJ, et al. Single-bundle modified patellar tendon versus double-bundle tibialis anterior allograft ACL reconstruction: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc, 2015, 23(8): 2244-2249.
37. Xu Y, Ao YF, Wang JQ, et al. Prospective randomized comparison of anatomic single- and double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2014, 22(2): 308-316.
38. Abebe ES, Utturkar GM, Taylor DC, et al. The effects of femoral graft placement on in vivo knee kinematics after anterior cruciate ligament reconstruction. J Biomech, 2011, 44(5): 924-929.
39. Tashman S, Araki D. Effects of anterior cruciate ligament reconstruction on in vivo, dynamic knee function. Clin Sports Med, 2013, 32(1): 47-59.
40. Chu CR, Williams AA, West RV, et al. Quantitative magnetic resonance imaging UTE-T2* mapping of cartilage and meniscus healing after anatomic anterior cruciate ligament reconstruction. Am J Sports Med, 2014, 42(8): 1847-1856.
41. Fu FH, van Eck CF, Tashman S, et al. Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc, 2015, 23(3): 640-648.
42. Duffee A, Magnussen RA, Pedroza AD, et al. Transtibial ACL femoral tunnel preparation increases odds of repeat ipsilateral knee surgery. J Bone Joint Surg (Am), 2013, 95(22): 2035-2042.
43. Lubowitz JH. Anatomic ACL reconstruction produces greater graft length change during knee range-of-motion than transtibial technique. Knee Surg Sports Traumatol Arthrosc, 2014, 22(5): 1190-1195.
44. Artmann M, Wirth CJ. Investigation of the appropriate functional replacement of the anterior cruciate ligament (author’s transl). Z Orthop Grenzgeb, 1974, 112(1): 160-165.
45. Pearle AD, Shannon FJ, Granchi C, et al. Comparison of 3-dimensional obliquity and anisometric characteristics of anterior cruciate ligament graft positions using surgical navigation. Am J Sports Med, 2008, 36(8): 1534-1541.
46. Hefzy MS, Grood ES, Noyes FR. Factors affecting the region of most isometric femoral attachments. Part Ⅱ: The anterior cruciate ligament. Am J Sports Med, 1989, 17(2): 208-216.
47. Markolf KL, Jackson SR, McAllister DR. A comparison of 11 o’clock versus oblique femoral tunnels in the anterior cruciate ligament-reconstructed knee: knee kinematics during a simulated pivot test. Am J Sports Med, 2010, 38(5): 912-917.
48. Beynnon BD, Uh BS, Johnson RJ, et al. The elongation behavior of the anterior cruciate ligament graft in vivo. A long-term follow-up study. Am J Sports Med, 2001, 29(2):161-166.
49. Rahr-Wagner L, Thillemann TM, Pedersen AB, et al. Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy, 2013, 29(1): 98-105.
50. Norimasa N, Stefano Z, Robert G, et al. Controversies in the Technical Aspects of ACL Reconstruction: An Evidence-Based Medicine Approach. Berlin: Springer Berlin Heidelberg, 2017: 217-231.
51. Clatworthy M PA, Williams A, Lind M. Current concepts: Femoral tunnel placement in ACL reconstruction: Central footprint versus AM bundle. ISAKOS Newsletter, 2015, Ⅱ: 24-31.
52. Kato Y, Maeyama A, Lertwanich P, et al. Biomechanical comparison of different graft positions for single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2013, 21(4): 816-823.
53. Amis AA, Jakob RP. Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc, 1998, 6 Suppl 1: S2-12.
54. Dahlstedt L, Dalén N, Dahlborn M, et al. Value of intercondylar notch plasty: CT studies and peroperative measurements of 127 knees. Acta orthopaedica Scandinavica, 1990, 61(6): 558-561.
55. Shino K, Mae T, Tachibana Y. Anatomic ACL reconstruction: rectangular tunnel/bone-patellar tendon-bone or triple-bundle/semitendinosus tendon grafting. Journal of Orthopaedic Science, 2015, 20(3): 457-468.
56. Matsuo T, Mae T, Shino K, et al. Tibiofemoral relationship following anatomic triple-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2014, 22(9): 2128-2135.
57. Hohmann E. Editorial Commentary: The Ribbon Theory. Another Quantum Leap? The Anterior Cruciate Ligament Is Twisted and in Fact a Flat Structure. Or not? Arthroscopy, 2017, 33(9): 1710-1711.

Chinese Journal of Reparative and Reconstructive Surgery

Anatomical study of anterior cruciate ligament and its effect on reconstruction technique

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