Area of the tibial insertion site of the anterior cruciate ligament as a predictor for graft size

Knee Surg Sports Traumatol Arthrosc. 2017 May;25(5):1576-1582. doi: 10.1007/s00167-016-4295-7. Epub 2016 Aug 19.


Purpose: To determine the distribution of different sizes of the area of the tibial insertion site among the population and to evaluate whether preoperative MRI measurements correlate with intraoperative findings to enable preoperative planning of the required graft size to cover the tibial insertion site sufficiently. The hypothesis was that the area of the tibial insertion site varies among individuals and that there is good agreement between MRI and intraoperative measurements.

Methods: Intraoperative measurements of the tibial insertion site were taken on 117 patients. Three measurements were taken in each plane building a grid to cover the tibial insertion site as closely as possible. The mean of the three measurements in each plane was used for determination of the area. Two orthopaedic surgeons, who were blinded to the intraoperative measurements, took magnetic resonance imaging (MRI) measurements of the area of the tibial insertion site at two different time points.

Results: The intraoperative measured mean area was 123.8 ± 21.5 mm2. The mean area was 132.8 ± 15.7 mm2 (rater 1) and 136.7 ± 15.4 mm2 (rater 2) when determined using MRI. The size of the area was approximately normally distributed. Inter-rater (0.89; 95 % CI 0.84, 0.92; p < 0.001) and intrarater reliability (rater 1: 0.97; 95 % CI 0.95, 0.98; p < 0.001; rater 2: 0.95; 95 % CI 0.92, 0.96; p < 0.001) demonstrated excellent test-retest reliability. There was good agreement between MRI and intraoperative measurement of tibial insertion site area (ICCs rater 1: 0.80; 95 % CI 0.71, 0.87; p < 0.001; rater 2: 0.87; 95 % CI 0.81, 0.91; p < 0.001).

Conclusion: The tibial insertion site varies in size and shape. Preoperative determination of the area using MRI is repeatable and enables planning of graft choice and size to optimally cover the tibial insertion site.

Level of evidence: III.

Keywords: ACL; Anatomy; Anterior cruciate ligament; Graft size; Individualized; Tibial insertion site.

MeSH terms

  • Adolescent
  • Adult
  • Anatomic Variation
  • Anterior Cruciate Ligament / anatomy & histology*
  • Anterior Cruciate Ligament / surgery
  • Anterior Cruciate Ligament Injuries / surgery
  • Anterior Cruciate Ligament Reconstruction*
  • Female
  • Femur / surgery
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Reproducibility of Results
  • Tibia / anatomy & histology*
  • Tibia / surgery*
  • Transplants
  • Young Adult