Radiographic Anatomy of the Native Anterior Cruciate Ligament: a Systematic Review

HSS Journal - Volume 11, Number 2 September, 2015

Jaron P. Sullivan, MD
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY

Shane Cook, MD
Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA

Yubo Gao, PhD
Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA

Brian R. Wolf, MD, MS
Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA


In an attempt to improve the accuracy and reproducibility of tunnel positioning, radiographs are being analyzed in an attempt to recreate the native anatomy of the ACL. Understanding the native ACL radiographic anatomy is an essential prerequisite to understand the relevance of postoperative tunnel position.

We performed a systematic review of the literature to delineate the radiographic location of the native ACL femoral and tibial footprints.

A search was performed in March 2014 in PubMed, the Cochrane Collaboration Library, and EMBASE to identify all studies that evaluated the native anterior cruciate ligament (ACL) anatomy on radiographs. Various measurement methods were used in each study, and averages were obtained of the data from studies with the same measurement methods.

Fifteen papers were identified (which included data on 177 femora and 207 tibiae in total). Evaluation of the femoral footprint using the quadrant method on lateral knee radiographs showed that the average percent distance location of the anteromedial (AM) bundle and posterolateral (PL) bundle was 22.8% (95% confidence interval (CI) 16.59–28.90) and 32.5% (95% CI 27.71–37.26) from the posterior condyle, respectively, and 23.2% (95% CI 19.52–26.94) and 50.0% (95% CI 46.16–53.76) from Blumensaat’s line, respectively. Using the Amis and Jacob method, the tibial footprint on the lateral knee radiograph average percent distances was 35.1% (95% CI 34.46–35.72) for the center of the AM bundle and 47.3% (95% CI 41.69–52.95) for the center of the PL bundle of the ACL. The femoral and tibial ACL footprints on the anteroposterior (AP) views of the knee were not well delineated by these studies.

The information presented in this systematic review offers surgeons another important tool for accurate ACL footprint identification.

This article appears in the HSS Journal: Volume 11, Issue 2.
View the full HSS Journal article at

About the HSS Journal

HSS Journal, an academic peer-reviewed journal published three times a year, February, July and October. The Journal accepts and publishes peer reviewed articles from around the world that contribute to the advancement of the knowledge of musculoskeletal diseases and disorders.


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