Purpose: The purpose of this study was to analyze the femoral insertions of the anteromedial
(AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) and to
develop arthroscopic orientation models for double-bundle (DB) bone tunnel placement.
Methods: The femoral insertions of the AM and PL bundles were dissected in 50 human cadaveric
knees, documented on digital photographs, and quantified with a digital image analysis
system. Results: The insertion areas of both bundles were significantly larger in men (53 mm2 for AM and 45 mm2 for PL) than in women (39 mm2 for AM and 39 mm2 for PL), and the average ACL insertion area was significantly larger in left knees
than in right knees. According to the “femoral center angle model,” the centers of
the AM and PL bundles were horizontally aligned when the femoral shaft axis was lifted
12° from the horizontal plane or when the knee was flexed to 102°. In this position
the center of the AM bundle was 3 to 4 mm “lower” (arthroscopic terminology) to the
over-the-top position, and the distance of the PL bundle to the “shallow” articular
cartilage of the lateral femoral condyle was 6 mm. According to the “modified femoral
clock wall model,” the average centers of the AM and PL bundles were both aligned
at 1 o'clock for a left knee and at 11 o'clock for a right knee in 102° of knee flexion.
Conclusions: The average femoral insertion areas of the ACL and the AM and PL bundles were significantly
larger in men compared with women and in left knees compared with right knees. According
to the femoral center angle model, the AM and PL insertions are aligned horizontally
in an average of 102° of knee flexion, resulting in one commuted time for the AM and
PL bundles in the modified femoral clock wall model. Both models support reproducible
and reliable arthroscopic AM and PL bone tunnel placement. With regard to a mean anatomic
anteroposterior length of the femoral ACL insertion of 14 to 15 mm, adequate DB bone
tunnel placement should be possible in most cases. Clinical Relevance: This study provides an anatomic description of the femoral AM and PL insertions including
gender differences, landmarks, and arthroscopic orientation models for DB bone tunnel
placement.
Key Words
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Footnotes
The authors report no conflict of interest.
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© 2008 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
