In-vivo three-dimensional MR imaging of the intact anterior cruciate ligament shows a variable insertion pattern of the femoral and tibial footprints

Scheffler, Sven; Maschewski, Katja; Becker, Roland; Asbach, Patrick

doi:10.1007/s00167-018-4939-x

Cited by 18 publications

(26 citation statements)

References 20 publications

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“…In our study orthopedic surgeons were able to determine the same point (femoral footprint) with a mean difference of 2.97 mm between two assessments of 20 scans. A high diversity in the size and shape of the femoral footprint has been reported [ 12 ], and this footprint appears to be ribbon shaped with a length of 16 mm and a width of 8 mm [ 11 , 12 ]. In this light, a mean 3D difference of 2–5 mm can be regarded acceptable.…”

Section: Discussionmentioning

confidence: 99%

Intra-and interobserver reliability of determining the femoral footprint of the torn anterior cruciate ligament on MRI scans

Zee

Sulaihem

Diercks

et al. 2021

BMC Musculoskelet Disord

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Background Re-injury rates following reconstruction of the anterior cruciate ligament (ACL) are significant; in more than 20% of patients a rupture of the graft occurs. One of the main reasons for graft failure is malposition of the femoral tunnel. The femoral origin of the torn ACL can be hard to visualize during arthroscopy, plus many individual variation in femoral origin anatomy exists, which may lead to this malpositioning. To develop a patient specific guide that may resolve this problem, a preoperative MRI is needed to identify the patient specific femoral origin of the ACL. The issue here is that there may be a difference in the reliability of identification of the femoral footprint of the ACL on MRI between different observers with different backgrounds and level of experience. The purpose of this study was to determine the intra- and interobserver reliability of identifying the femoral footprint of the torn ACL on MRI and to compare this between orthopedic surgeons, residents in orthopedic surgery and MSK radiologists. Methods MR images of the knee joint were collected retrospectively from 20 subjects with a confirmed rupture of the ACL. The 2D (coronal, sagittal, transversal) proton-density (PD) images were selected for the segmentation procedure to create 3D models of the femurs. The center of the femoral footprint of the ACL on 20 MRI scans, with visual feedback on 3D models (as reference) was determined twice by eight observers. The intra- and interobserver reliability of determining the center of the femoral footprint on MRI was evaluated. Intraclass correlation coefficients (ICCs) were calculated for the X, Y and Z coordinates separately and for a 3D coordinate. Results The mean 3D distance between the first and second assessment (intraobserver reliability) was 3.82 mm. The mean 3D distance between observers (interobserver reliability) was 8.67 mm. ICCs were excellent (> 0.95), except for those between the assessments of the two MSK radiologists of the Y and Z coordinates (0.890 and 0.800 respectively). Orthopedic surgeons outscored the residents and radiologists in terms of intra- and interobserver agreement. Conclusion Excellent intraobserver reliability was demonstrated (< 4 mm). However the results of the interobserver reliability manifested remarkably less agreement between observers (> 8 mm). An orthopedic background seems to increase both intra- and interobserver reliability. Preoperative planning of the femoral tunnel position in ACL reconstruction remains a surgical decision. Experienced orthopedic surgeons should be consulted when planning for patient specific instrumentation in ACL reconstruction.

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Section: Discussionmentioning

confidence: 99%

Intra-and interobserver reliability of determining the femoral footprint of the torn anterior cruciate ligament on MRI scans

Zee

Sulaihem

Diercks

et al. 2021

BMC Musculoskelet Disord

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“…24 Additional oblique scans in the coronal and axial planes improve visualization of the ACL, and a 3-dimensional MRI sequence might provide more information on the ACL rupture characteristics. 1,12,20,22,25,26 Furthermore, it has been reported that MRI performed with the knee in flexion instead of extension improves accuracy in the diagnosis of partial and complete ACL ruptures in general. Although not investigated, this might improve the accuracy of MRI for classifying the characteristics of complete ACL rupture that were investigated in the present study.…”

Section: Discussionmentioning

confidence: 99%

Standard MRI May Not Predict Specific Acute Anterior Cruciate Ligament Rupture Characteristics

Hoogeslag

Buitenhuis

Brouwer

et al. 2021

Orthopaedic Journal of Sports Medicine

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Background: There has been renewed interest in the concept of anterior cruciate ligament (ACL) suture repair (ACLSR). Morphologic characteristics of the ruptured ACL remnant play a role in deciding whether a patient is eligible for ACLSR. However, no classification of these characteristics of ACL rupture on magnetic resonance imaging (MRI) scans has yet been compared with intraoperative findings in the context of ACLSR. Purpose: To investigate the value of using preoperative MRI to predict specific characteristics of acute complete ACL rupture. Study Design: Cohort study (diagnostic); Level of evidence, 2. Methods: A total of 25 patients were included. Two radiologists classified ACL rupture location and pattern on preoperative 1.5-T MRI scans with a standard sequence; the results were compared with the corresponding findings at arthroscopy conducted by a single surgeon. The agreement between the MRI and surgical findings was calculated using Cohen κ values. Furthermore, the reliability coefficients of the MRI classifications within and between radiologists were calculated. Results: The agreement between MRI classification and arthroscopic findings for ACL rupture location was slight (Cohen κ, 0.016 [radiologist 1] and 0.087 [radiologist 2]), and for ACL rupture pattern, this was poor to slight (Cohen κ, <0 and 0.074). The intraobserver reliability of MRI classification for ACL rupture location was moderate for radiologist 1 and slight for radiologist 2 (Cohen κ, 0.526 and 0.061, respectively), and for ACL rupture pattern, this was slight for radiologist 1 and 2 (Cohen κ, 0.051 and 0.093, respectively). The interobserver reliability of MRI classification for ACL rupture location and pattern was slight between radiologists (Cohen κ, 0.172 and 0.040, respectively). Conclusion: In the current study, we found poor to slight agreement between MRI classification and arthroscopic findings of specific ACL rupture characteristics. In addition, the intra- and interobserver reliability for MRI classification of the ACL rupture characteristics was slight to moderate.

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“…During the past few years, an effort has been made to understand the precise anatomy of the ACL footprints on the tibial and femoral sides by using 3D MRI and computed tomography scans to improve tunnel position and, eventually, clinical outcomes. 1,12,14,24,31 –33 In a cadaveric study by Han et al, 12 it was demonstrated that 3D MRI localization of the femoral and tibial footprints of the ACL is comparable with open dissection. Using the same 3D MRI technique, Hart et al 14 evaluated the tunnel positions that were created by 4 different orthopaedic sport surgeons for a series of patients in comparison with the native ACL footprint of the patients.…”

Section: Discussionmentioning

confidence: 99%

Three-Dimensional Magnetic Resonance Imaging for Guiding Tibial and Femoral Tunnel Position in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

Marwan

Böttcher

Laverdière

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: Femoral and tibial tunnel malposition for anterior cruciate ligament (ACL) reconstruction (ACLR) is correlated with higher failure rate. Regardless of the surgical technique used to create ACL tunnels, significant mismatches between the native and reconstructed footprints exist. Purpose: To compare the position of tunnels created by a standard technique with the ones created based on preoperative 3-dimensional magnetic resonance imaging (3D MRI) measurements of the ACL anatomic footprint. Study Design: Controlled laboratory study. Methods: Using 3D MRI, the native ACL footprints were identified. Tunnels were created on 16 knees (8 cadavers) arthroscopically. On one knee of a matched pair, the tunnels were created based on 3D MRI measurements that were provided to the surgeon (roadmapped technique), while on the contralateral knee, the tunnels were created based on a standard anatomic ACLR technique. The technique was randomly assigned per set of knees. Postoperatively, the positions of the tunnels were measured using 3D MRI. Results: On the tibial side, the median distance between the center of the native and reconstructed ACL footprints in relation to the root of the anterior horn of the lateral meniscus medially was 1.7 ± 2.2 mm and 1.9 ± 2.8 mm for the standard and roadmapped techniques, respectively ( P = .442), while the median anteroposterior distance was 3.4 ± 2.4 mm and 2.5 ± 2.5 mm for the standard and roadmapped techniques, respectively ( P = .161). On the femoral side, the median distance in relation to the apex of the deep cartilage (ADC) distally was 0.9 ± 2.8 mm and 1.3 ± 2.1 mm for the standard and roadmapped techniques, respectively ( P = .195), while the median distance anteriorly from the ADC was 1.2 ± 1.3 mm and 4.6 ± 4.5 mm for the standard and roadmapped techniques, respectively ( P = .007). Conclusion: Providing precise radiological measurements of the ACL footprints does not improve the surgeon’s ability to position the tunnels. Future studies should continue to attempt to provide tools to improve the tunnel position in ACLR. Clinical Relevance: This cadaveric study indicates that despite the use of 3D MRI in understanding the ACL anatomy, re-creating the native ACL footprints remains a challenge.

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In-vivo three-dimensional MR imaging of the intact anterior cruciate ligament shows a variable insertion pattern of the femoral and tibial footprints

Abstract: 3D imaging of the ACL footprints reveals a distinct difference in insertion site morphology and fiber bundle orientation between the femoral and tibial footprint. This questions the concept of strict anatomical separation of the ACL into an anteromedial and posterolateral bundle.

Cited by 18 publications

References 20 publications

Intra-and interobserver reliability of determining the femoral footprint of the torn anterior cruciate ligament on MRI scans

Intra-and interobserver reliability of determining the femoral footprint of the torn anterior cruciate ligament on MRI scans

Standard MRI May Not Predict Specific Acute Anterior Cruciate Ligament Rupture Characteristics

Three-Dimensional Magnetic Resonance Imaging for Guiding Tibial and Femoral Tunnel Position in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

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