Direct versus indirect ACL femoral attachment fibres and their implications on ACL graft placement

Moulton, Samuel G.; Steineman, Brett D.; Donahue, Tammy L. Haut; Fontboté, Cristián A.; Cram, Tyler R.; LaPrade, Robert F.

doi:10.1007/s00167-016-4188-9

Cited by 25 publications

(21 citation statements)

References 17 publications

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“…The differentiation between the two types of ligament insertions into the bone (direct and indirect) has been addressed by several other recent studies. 8 , 9 , 10 , 15 Studies that assessed the ACL demonstrated that the direct insertion, located predominantly in the most central portion of the ligament, played an important role in the mechanical attachment of the ligament to the bone, in contrast to the indirect insertion. 15 , 16 Uncalcified fibrocartilage, present only between the structural layers of the direct insertion, plays an important role in controlling the tension that occurs over the ligament, compatible with that observed in muscle contraction.…”

Section: Discussionmentioning

confidence: 99%

“…From a microscopic standpoint, the insertion of the ligament to the bone has two distinct structures: direct and indirect insertion. 8 , 9 , 10 , 11 These two types of insertion are histologically different. While direct insertion has four histological layers (ligament, non-calcified fibrocartilage, calcified fibrocartilage, and bone), the indirect insertion presents only two (the ligament is inserted directly into the bone, without a clear transition between them).…”

Section: Introductionmentioning

confidence: 99%

“…Recent studies involving microscopic analysis of the anterior cruciate ligament (ACL) have assessed the histological and functional differences between these insertions. 8 , 9 , 10 Regarding PCL, the literature presents conflicting information on the correct position of its femoral insertion; many authors have described different methods of locating the anatomical site of femoral insertion, but few have demonstrated its microscopic anatomy. 5 , 12 , 13 , 14 …”

Section: Introductionmentioning

confidence: 99%

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Histological study of the posterior cruciate ligament femoral insertion

Costa

Mestriner

Amaral

et al. 2018

Revista Brasileira de Ortopedia (English Edition)

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ObjectivesTo describe the microscopic anatomy of the posterior cruciate ligament femoral insertion in order to identify and establish differences between the direct and indirect insertions of this ligament.MethodsTen cadaveric knees were used for this study. The posterior cruciate ligament femoral insertion was observed microscopically. Hematoxylin and eosin staining was performed to observe the morphology of the posterior cruciate ligament insertion. Alcian blue staining was performed to determine the location of the cartilage matrix and better assist in the observation and differentiation between direct and indirect insertions.ResultsThe direct insertion was observed to be a more complex structure than the indirect insertion because it showed four different histological layers (ligament, uncalcified fibrocartilage, calcified fibrocartilage, and bone). Chondrocytes were observed in the uncalcified and calcified fibrocartilage layers. It was observed that the indirect insertion was composed of two layers in which the ligament was anchored directly to the bone by collagen fibers. Indirect insertion was located in the marginal region of the posterior cruciate ligament between the direct insertion and the anterior articular cartilage.ConclusionThrough histological analysis, it was demonstrated that the indirect insertion was adjacent to the anterior articular cartilage and presents a histological pattern where the collagen fibers insert directly into the bone (two-layer insertion). The direct insertion is posterior to the indirect insertion and has four histologically distinct layers.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Histological study of the posterior cruciate ligament femoral insertion

Costa

Mestriner

Amaral

et al. 2018

Revista Brasileira de Ortopedia (English Edition)

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“…Thus conversely, it is possible that the strong AM bundle tibial insertion renders the femoral origin more prone to injuries. Moulton et al () have shown that the ACL femoral enthesis contains a mixture of indirect and direct insertions and Beaulieu et al, () have found systematic reginal differences in collagen fibre attachment angles, however detailed microstructural characterization of the enthesis, especially data regarding to the interdigitation depth and frequency is still lacking. These counter arguments and knowledge gaps present scope for further investigation into the multi‐scalar structural realties of the ACL in relation to its vulnerability to injury.…”

Section: Discussionmentioning

confidence: 99%

Microstructure Variations in the Soft‐Hard Tissue Junction of the Human Anterior Cruciate Ligament

Zhao

Lee

Ackland

et al. 2017

The Anatomical Record

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The role of the sub-bundles in the anterior cruciate ligament (ACL) has been defined, such that the anterior-medial bundle directly resists anterior tibial translation while the posterior lateral bundle is involved in rotational stability. With regards to this biomechanical function, much of the previous work on bundle-specific morphology has been carried out on the macroscale, with much less attention given to the micro-to-ultrastructural scalar levels. This is especially true of the enthesis and its microstructure, a biomechanically significant region that has been largely neglected in the published literature dealing with ACL sub-bundle anatomy. In this study, the human ACL tibial enthesis was investigated at multiple scalar levels using differential interference contrast and scanning electron microscopies with the aim of determining whether the sub-bundle ligament structure, and its known macroscale function, is consistent with its micro-architecture at the ligament-bone junction. The investigation found that different ligament insertion morphologies exist between the two bundles, where the AM bundle has more intense interdigitation with the bone matrix than that of the PL bundle. The results suggest that such structure-function relationships, especially across scalar-levels, provide new insight into the significance of the sub-bundle anatomy of the ACL. Anat Rec, 300:1547-1559, 2017. © 2017 Wiley Periodicals, Inc.

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“…Recent clinical and biomechanical results have shown that the (functional) double-bundle or fanlike shape of a graft tends to more closely restore normal ACL function. 8 Owing to a lower revision rate, reduced graft elongation, and better return to the preinjury level of activity in earlier studies, the BPTB graft plays an important role especially in the young and active patient. 3,[9][10][11]…”

Section: Graft Choicementioning

confidence: 99%

Bone-on-Bone Anatomic Patellar Tendon Graft Anterior Cruciate Ligament Reconstruction: A Reproducible Technique Combining Press-Fit and Extracortical Fixation

Brandl¹,

Ostermann²,

Pauzenberger

et al. 2020

Arthroscopy Techniques

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Scientific interest in optimizing outcomes after anterior cruciate ligament (ACL) reconstruction is ongoing, and some recent developments have focused on graft shape as one of the most important factors of anatomic graft placement. The double-bundle or fanlike structure of the native ACL seems to more closely restore normal function and control of rotational stability of the knee with implant-free or press-fit techniques, creating a favorable situation in terms of direct graft-tunnel healing. The ACL reconstruction technique presented in this article enables safe, reproducible, and anatomic fixation of the patellar tendon autograft, providing the biological and biomechanical benefits of direct bony integration of the ribbonlike boneepatellar tendonebone graft. Because press-fit fixation represents a technically challenging surgical procedure, the goal of the described technique is to enable direct bone-to-bone healing by using secondary extracortical femoral and tibial fixation without the need for a true press-fit situation. Safe and anatomic femoral tunnel drilling is achieved with an outside-in technique (retrograde drilling), hence providing advantages in the routine clinical setting in terms of applicability and time effort. To reduce donor-site morbidity caused by bone block harvesting, refilling of the harvest sites with autologous material is performed.

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Direct versus indirect ACL femoral attachment fibres and their implications on ACL graft placement

Cited by 25 publications

References 17 publications

Histological study of the posterior cruciate ligament femoral insertion

Histological study of the posterior cruciate ligament femoral insertion

Microstructure Variations in the Soft‐Hard Tissue Junction of the Human Anterior Cruciate Ligament

Bone-on-Bone Anatomic Patellar Tendon Graft Anterior Cruciate Ligament Reconstruction: A Reproducible Technique Combining Press-Fit and Extracortical Fixation

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