Dynamic 3-Dimensional Mapping of Isometric Anterior Cruciate Ligament Attachment Sites on the Tibia and Femur: Is Anatomic Also Isometric?

Purpose: The purpose of this study was to (1) map the length changes of the medial wall of the lateral femoral condyle (MWLFC) with respect to various points about the tibial anterior cruciate ligament (ACL) footprint to determine the area that demonstrates the least amount of length change through full range of motion and (2) to identify a range of flexion that would be favorable for graft tensioning. Methods: Six fresh-frozen cadaveric knees were obtained from screened individuals with no prior history of arthritis, cancer, surgery, or any ligamentous knee injury. For each knee, 3-dimensional computed tomography point-cloud models were obtained in succession from 0 degrees to 135 degrees. A point grid was placed on the MWLFC and the tibia. Intra-articular length was calculated for each point on the femur to the tibia at all flexion angles and grouped to represent areas for bone tunnels. Normalized length changes were compared. Results: Areas anterior/distal on the MWLFC increased with increasing flexion, and areas proximal/posterior decreased with increasing flexion. The area about the intersection of the lateral intercondylar ridge and the bifurcate ridge was most isometric throughout flexion as no significant change in ligament length was found throughout flexion. The normalized length changes from the central position of the tibia showed no significant difference compared with the anterior or posterior tibial position. Conclusions: No area of the MWLFC is truly isometric through flexion. Femoral tunnel placement slightly anterior to the center of the anteromedial and posterolateral bundles wasmost isometric. Minimal lengthchange occurs between 10 degrees and 40 degrees, whichreflects the range where graft tensioning wasmost often performed. The results of this study provide further support for an anatomic ACL reconstruction. Clinical Relevance: The femoral tunnel location for ACL reconstructionwith the least amount of length change through range of motion should encompass the direct fibers of the ACL.