Variation in the shape of the tibial insertion site of the anterior cruciate ligament: classification is required

Knee Surg Sports Traumatol Arthrosc. 2017 Aug;25(8):2428-2432. doi: 10.1007/s00167-015-3891-2. Epub 2015 Dec 12.


Purpose: To propose a classification system for the shape of the tibial insertion site (TIS) of the anterior cruciate ligament (ACL) and to demonstrate the intra- and inter-rater agreement of this system. Due to variation in shape and size, different surgical approaches may be feasible to improve reconstruction of the TIS.

Methods: One hundred patients with a mean age of 26 ± 11 years were included. The ACL was cut arthroscopically at the base of the tibial insertion site. Arthroscopic images were taken from the lateral and medial portal. Images were de-identified and duplicated. Two blinded observers classified the tibial insertion site according to a classification system.

Results: The tibial insertion site was classified as type I (elliptical) in 51 knees (51 %), type II (triangular) in 33 knees (33 %) and type III (C-shaped) in 16 knees (16 %). There was good agreement between raters when viewing the insertion site from the lateral portal (κ = 0.65) as well as from the medial portal (κ = 0.66). Intra-rater reliability was good to excellent. Agreement in the description of the insertion site between the medial and lateral portals was good for rater 1 and good for rater 2 (κ = 0.74 and 0.77, respectively).

Conclusion: There is variation in the shape of the ACL TIS. The classification system is a repeatable and reliable tool to summarize the shape of the TIS using three common patterns. For clinical relevance, different shapes may require different types of reconstruction to ensure proper footprint restoration. Consideration of the individual TIS shape is required to prevent iatrogenic damage of adjacent structures like the menisci.

Level of evidence: III.

Keywords: ACL; Anterior cruciate ligament; C-shape; Classification; Elliptical; Insertion site; Shape; Tibial insertion site; Triangular; Variation.

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament / anatomy & histology
  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries / surgery*
  • Anterior Cruciate Ligament Reconstruction / classification*
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Arthroscopy
  • Female
  • Humans
  • Knee Joint / surgery
  • Male
  • Middle Aged
  • Observer Variation
  • Reproducibility of Results
  • Single-Blind Method
  • Tibia / anatomy & histology
  • Tibia / surgery*
  • Young Adult