Editorial Commentary: Outcomes After Anterior Cruciate Ligament Reconstruction Are Defined by Individual Anatomy, Including Both Soft Tissue and Bone Morphology: It’s All Important

Abstract

Well-designed studies add to our understanding of the anatomy, biology, biomechanics, and outcomes of the anterior cruciate ligament (ACL) following injury. Despite improvements in ACL treatment, we are still unable to exactly restore the individually unique function of the native ACL due to the complexity of knee physiology. The ACL is a dynamic structure with a rich neurovascular supply, distinct bundles, and 3-dimensional architecture that function in synergy with the bony morphology to facilitate healthy knee kinematics. Furthermore, the ACL exhibits a wide range of natural, anatomic variation. Since anatomic ACL reconstruction has been defined as functional restoration of the ACL to its native dimensions and collagen orientation, in addition to restoring the native footprint, it is important to restore the native size of the ACL, as the size of the tibial insertion site can vary by a factor of 3 from patient to patient. Moreover, variations in ACL soft tissue reflect differences in bony morphology. Bony morphology influences the static and dynamic biomechanics of the knee. Several bony morphologic factors influence the outcomes following ACL reconstruction, including posterior tibial slope, femoral condylar offset ratio, and notch shape. Morphologic differences that reflect pathologic states, such as the lateral notch sign and posterolateral plateau fracture, have been shown to be associated with greater grade instability. To respect the unique nature of each patient during surgical treatment, it is necessary to perform an individualized, anatomic, and value-based ACL reconstruction.

The relationship between lateral femoral condyle ratio measured by MRI and anterior cruciate ligament injury

“…The combination of the three risk factors was most predictive for ACL injury. The prediction model may help clinicians to identify patients at high risk for ACL injury or rerupture who could benefit from a more precise and personalized risk assessment, surgical indication decision, additional extra-capsular reconstruction, adjustment of graft selection, modification of surgical techniques ( Choi et al, 2023 ; Pfeiffer, 2023 ), prediction of postoperative outcomes and individualized precision rehabilitation therapy ( Fu et al, 2021 ). However, how the three risk factors studied here could influence the biomechanical responses of the knee joint remains worthy of further study.…”

Current trends in the anterior cruciate ligament part 1: biology and biomechanics

“…Biology and biomechanics are the basic guiding principles in orthopedic operative management. In the case of the anterior cruciate ligament (ACL), understanding individual anatomy [36, 132, 161], the biology of the ligament [88, 97], healing properties in response to injury [104], and the differences in knee biomechanics of the intact and deficient state [12, 159] are paramount to developing methods of ACL reconstruction (ACL‐R) that most closely restore natural knee function [38]. Increasing interests in the biologic and biomechanical properties have driven increased research on how biology and biomechanics of the ACL influence reconstruction and outcomes.…”