Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-013-2562-4

KNEE

The concept of individualized anatomic anterior cruciate ligament

(ACL) reconstruction
M. Hofbauer B. Muller C. D. Murawski
C. F. van Eck F. H. Fu

Received: 12 December 2012 / Accepted: 29 May 2013

Springer-Verlag Berlin Heidelberg 2013

Abstract
Purpose To describe the concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction.
Methods The PubMed/Medline database was searched
using keywords pertaining to ACL reconstruction. Relevant articles were reviewed in order to summarize important concepts of individualized surgery in ACL
reconstruction. Surgical experiences with case examples
are also highlighted.
Results Individualized ACL surgery allows for the customization of surgery to each individual patient.
Accounting for graft selection and other characteristics
such as anatomy, lifestyle and activity preferences may
provide the patient with the best potential for a successful
outcome. The surgeon should be comfortable with a variety
of graft harvests and surgical techniques when practicing
individualized surgery.
Conclusion Individualized anatomic ACL reconstruction
is founded on the objective evaluation of functional anatomy and individual characteristics, thereby restoring the
ACL as closely as possible to the native anatomy and
function. The adoption and subsequent use of
M. Hofbauer
B. Muller
C. D. Murawski

C. F. van Eck
F. H. Fu (&)
Department of Orthopaedic Surgery, University of Pittsburgh
Medical Center, 3471 Fifth Avenue Kaufman Building,
Suite 1011, Pittsburgh, PA 15213, USA
e-mail: ffu@upmc.edu
M. Hofbauer
Department of Trauma Surgery, Medical University Vienna,
Vienna, Austria
B. Muller
C. D. Murawski
Department of Orthopaedic Surgery, Academic Medical Center,
Amsterdam, The Netherlands

individualized surgery may facilitate improved clinical as

well as objective outcomes, particularly in the long term.
Level of evidence V.
Keywords Individualized
Anterior cruciate ligament
(ACL)
AnatomyGraft selection

Introduction
Each year, there are approximately 250300,000 anterior
cruciate ligament (ACL) injuries in the United States alone,
with an estimated healthcare cost of about 2 billion dollars
annually [11]. The mainstay of treatment is surgical management with an emphasis on restoring native anatomy and
normal knee kinematics. Over the past decade, increased
attention has been paid to the patients individual anatomy,
resulting in an improved understanding of the ACL structure and function. This has led to a renewed focus of
restoring the native anatomy of the ACL and highlights the
importance of individualized ACL reconstruction [18, 23
25, 35].
The native ACL consist of two distinct functional
bundlesthe anteromedial (AM) and the posterolateral
(PL) bundles. The goal of anatomic ACL reconstruction
is the functional restoration of the ACL to its native
dimensions, collagen orientation and insertion sites [28].
This can be accomplished with the use of either a singleor double-bundle technique, but should be performed
according to the anatomic principle. When reconstructing
the ACL, anatomic characteristics should be considered,
such as insertion site size and intercondylar notch
dimensions [16, 29].
Hence, the concept of individualized anatomic ACL
reconstruction comprises more than the decision to utilize

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either anatomic single- or double-bundle technique. Additional characteristics including graft choice, patients
preferences, lifestyle, and activity level should be taken
into account when planning for individualized anatomic
ACL reconstruction. Beyond this, individualized ACL
reconstruction should take into account diagnosing each
ACL tear individually (i.e. partial or complete tear) and
rehabbing each patient based on his or her graft choice and
activities.
Individualized ACL surgery can be defined as a surgical
procedure that is customized to the patient by accounting
for lifestyle and an objective appreciation of the native
anatomy. The purpose of this paper is to: (1) review the
individual anatomic characteristics (e.g. notch size, graft
size, tibial insertion size) as they pertain to ACL reconstruction; (2) describe the concept of individualized anatomic ACL reconstruction and (3) highlight considerations
for the individual patient to assist surgeons in practicing
and mastering this concept.

Anatomic and biomechanical considerations

A detailed knowledge of the anatomy and biomechanical
function of the native ACL is essential for the purpose
of individualized anatomic ACL reconstruction. Numerous studies have confirmed that the ACL consists of two
functional bundles, named according to the relative
position of the tibial insertion site: the AM bundle and
the PL bundle [9, 26]. Both bundles show a synergistic
yet distinct biomechanical function at different knee
flexion angles. The AM bundle is the primary restraint
against anteriorposterior translation and becomes tight
in flexion, whereas the PL bundle is tight in full
extension and is primarily responsible for allowing
rotation [6, 21].
In addition, distinct knowledge of anatomic landmarks
of the femoral and tibial insertion sites (e.g. anterior horn
of the lateral meniscus) is essential to ensure anatomic
placement of the bone tunnels. As non-anatomic femoral
tunnel position has been shown to be the most common
cause of graft failure, two bony landmarks on the lateral
wall of the intercondylar notch are of utmost importance
[8]. The lateral intercondylar ridge, or residents ridge,
represents the anterior border of the femoral AM- and PLbundle insertion sites when the knee is flexed to 90 [7].
The lateral bifurcate ridge, which appears in 80 % of cases
separates the origins of the AM and PL-bundle insertion
sites and runs perpendicular to the lateral intercondylar
ridge [7]. Especially in chronic cases where the bundle
remnants may not be visible, knowledge of these landmarks is crucial to placing the ACL graft within the anatomic footprint [31].

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The concept of anatomic ACL reconstruction

Anatomic ACL reconstruction is a concept rather than a
technique and can best be described based according to the
following four principles. The first principle is to restore
both functional bundles of the ACL, the AM and PL
bundle. The second principle is that the graft needs to be
placed anatomically, with the tibial and femoral tunnel
apertures placed within the native ACL insertion sites. To
ensure similar functional properties as the native bundles
have, the third principle is to tension each bundle in
accordance with the native tensioning patterns from full
knee extension through flexion. The fourth and final principle is to customize the surgery for each individual patient
by considering the variation in anatomic characteristics,
activity level, lifestyle and personal preferences. These
characteristics should be used to determine the ultimate
procedure of choice.
Anatomic ACL reconstruction aims to restore as much
of the native insertion site as possible. Kopf et al. [16]
studied variation in tibial insertion site length and showed a
broad range of measurements with the majority between 14
and 18 mm in the sagittal plane. This information is crucial, as it may affect the type of reconstruction (i.e. singleor double-bundle) that can be performed. Patients with a
smaller insertion site (\14 mm) may be better served with
an anatomic single-bundle ACL reconstruction [28]. With a
tibial insertion site of \14 mm, drilling two separate tunnels may not be technically safe because of the inability to
maintain a 2-mm bone bridge between the tunnels while
not placing the tunnels outside the native insertion site.
Patients with a larger insertion site ([14 mm), however,
may have an insertion site that is insufficiently restored
with a single-bundle reconstruction [15] (Fig. 1). However,
deciding which technique should be utilized is not based
solely on the measurements of the native tibial insertion
site; cofactors such as the intercondylar notch size must
also be taken into account, especially when the size of the
tibial insertion site length ranges between 14 and 18 mm. A
small notch width (\12 mm) may not allow for placement
and drilling of the tunnels at the native insertion site
without damaging the medial femoral condyle, while a
shallow notch (\12 mm) may potentially lead to graft
impingement (Fig. 2). Consequently, the final decision as
to which type of reconstruction will be performed can only
be made intraoperatively.

Physical examination
An accurate diagnosis of ACL injury includes a comprehensive history with details of the specific injury mechanism, the patients goals and expectations, as well activities

Knee Surg Sports Traumatol Arthrosc

Fig. 1 Pre-operative MRI
measurement of the right knee
(sagittal view) demonstrates
variation in size of the tibial
insertion site. a ACL tibial
insertion site of 12.6 mm and
b ACL tibial insertion site of
22.5 mm. The range of tibial
insertion site measurements is
925 mm

Fig. 2 Arthroscopic view

through the central portal
demonstrates variation in the
size of the intercondylar notch.
a notch size of 24 mm; b notch
size of 10 mm; c notch height of
16 mm and d notch height of
10 mm. The size of the notch
width range from 9 to 21 mm,
the range of notch height
measurements from 10 to
28 mm

of daily living, sports activity level and personal preferences regarding graft choice as each may influence the final
graft choice. Especially in case of a partial ACL tear (i.e.
one torn bundle), the mechanism of injury may help the
surgeon to distinguish which bundle has failed; the AM
bundle is frequently torn during high-energy trauma, while
the PL bundle is more likely to be torn with more rotational
mechanisms [34]. A thorough physical examination, comparing the affected knee to the contralateral non-injured

knee, is necessary to provide an estimate of the patients

normal knee function and laxity. The grade of laxity can
vary according to the rupture pattern (complete vs. partial).

Preoperative imaging
A standard radiographic knee series, including weight
bearing 45 flexion posterioranterior (PA) views, 45

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Knee Surg Sports Traumatol Arthrosc

flexion lateral views and Merchant views for patellar

evaluation should always be obtained to evaluate the bony
morphology and potential osseous pathologies. For revision cases, anatomic tunnel location can be evaluated on
the weight bearing 45 flexion PA views by using a method
described by Illingworth et al. [14]. In this study, it was
found that femoral tunnel angles of \32.7 were typically
associated with non-anatomic femoral tunnel placement.
The inter-tester and intra-tester reliabilities (ICC) for
measurement of the femoral tunnel angle on standard
radiographs has been evaluated and was excellent at 0.976
and 0.988, respectively.
High-resolution magnetic resonance imaging (MRI) is
the gold standard for pre-operative evaluation of ligamentous, meniscal or chondral injuries. Although the ACL can
be visualized with T1- or T2-weighted images on standard views in the coronal and sagittal planes, a clear
discrimination between the AM and PL bundles may be
difficult. Therefore, obtaining special MR imaging in the
oblique coronal and oblique sagittal planes may enhance
visualization [2]. These views are acquired by cutting MRI
sections in the same anatomic alignment as the ACL,
which allows for a clear and predictable recognition of
partial ACL tears.
Additionally, findings and special measurements from
these MR images can be used to help guide the pre-surgical
planning with regard to the most appropriate surgical
technique and graft choice. To objectify anatomic characteristics in a pre-surgical setting already, measurements on
MR images of the sagittal plane should include tibial
insertion site length (normal range 925 mm), ACL

inclination angle (normal range 4357), ACL length

(normal range 2545 mm) and thickness of the quadriceps
and patellar tendons (Fig. 3).

Individualized graft selection

Individualized ACL reconstruction requires surgeons to be
comfortable with harvesting and using a variety of graft
options, including the hamstrings, bone-patellar tendonbone (BPTB) and quadriceps tendon autografts. Sometimes, allograft is also an option (e.g. too small autograft
size intraoperatively or older patients) and should be
available. The ideal graft should fit the native insertion
site size, provide biomechanical stability and biological
tunnel incorporation, as well as facilitate the return of
neuromuscular control. Many studies have been performed
comparing different graft choices, and it has been established that each graft has its respective advantages and
disadvantages [4, 10, 20]. In this regard, the focus should
be placed on individualizing the graft selection to each
patient, while taking multiple factors into consideration,
such as tissue availability, prior surgery, patient preference,
activity level and sport of choice as well as anatomic
factors, such as the native ACL insertion site size and notch
anatomy. Graft size should also be an important consideration in individualized ACL surgery. In this regard,
surgeons should take care to ensure that a sufficient amount
of graft is provided to the patient relative to the size of their
native insertion site. For example, one study by Magnussen
et al. [19] demonstrated high graft failure rates in patients

Fig. 3 Pre-operative MRI measurement of the right knee (sagittal view) demonstrates a an ACL insertion site of 15.3 mm, b an inclination angle
of 50 and c an ACL length of 27 mm

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Knee Surg Sports Traumatol Arthrosc

aged 20 or less when a hamstring autograft \8 mm in

diameter was utilized.
For example, a BPTB provides benefits like bone-tobone healing and ease of harvest, but donor site morbidity
can be a concern, particularly in patients with kneeling
demands. Recently, Hamstrings grafts made of the Semitendinosus and Gracilis tendons have gained popularity
because of ease of harvest and reduced donor site morbidity in comparison to BPTB. However, the size of the
graft is hard to predict pre-operatively and a smaller graft
size may not be adequate for patients with a larger native
insertion site size. Recently, cross-sectional areas of the
hamstring tendons in MR images have been utilized to
estimate the sizes of hamstring grafts prior to ACL
reconstruction [5]. In contrast, the quadriceps tendon
autograft may be up to twice the diameter of BPTB and is
an attractive option in that the size is predictable with
preoperative MRI measurement (Fig. 4). Furthermore, it
can be harvested with or without a bone plug, used for both
single and double-bundle ACL reconstruction, and has less
reported donor site morbidity than BPTB. Nonetheless, a
separate incision over the anterior distal thigh is required,
which should be considered if cosmesis is a priority.
Allograft tissue offers the benefits associated with no donor
site morbidity, less operating time and a greater variety of
graft source choices. Disadvantages include the inherent
potential for disease transmission, higher cost and a higher
risk of re-rupture in younger, more active patients [30].
Therefore, the use of allografts should be reserved for older
and less active individuals or in revision cases with limited
alternatives.

Surgical technique
Visualization of both the tibial and femoral native
insertion site is of great importance in performing anatomic ACL reconstruction. Therefore, a three-portal
approach has been shown to provide the best visualization of the tibial insertion site and the medial wall of the
lateral femoral condyle. In this regard, a high or
superior lateral portal (LP) is created above Hoffas fat
pad, followed by a central (CP) and medial portal (MP),
both of which are created under spinal needle guidance
as position may vary based on the patients individual
notch orientation. The three-portal approach has been
described previously in detail [3].
Diagnostic arthroscopy is then performed to confirm and
examine the rupture pattern of the ACL and to evaluate for
concomitant intra-articular pathologies. The remnants of
the native ACL should be probed in order to assess a
possible single-bundle rupture, for which a single-bundle
augmentation reconstruction can be considered.
Viewing from the LP and CP, measurements are
obtained of the tibial and femoral native insertion site
length, mid-width and individual bundle-widths with an
arthroscopic bendable ruler (Smith & Nephew Endoscopy,
Andover, Massachusetts) (Fig. 5). Measurements of the
intercondylar notch, documenting width at the base, the
middle and the apex, as well as the height on the medial
and lateral side, are then taken. After all measurements
are documented, the decision whether to perform anatomic single- or double-bundle ACL reconstruction can be
made.

Fig. 4 Sagittal view of magnetic resonance imaging (MRI) visibly displaying a a quad diameter size of 6.2 mm and b a quad diameter size of
10.5 mm

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Knee Surg Sports Traumatol Arthrosc

Fig. 5 Arthroscopic view
through the MP. Measurements
of the a tibial insertion site size
(length) and b width, as well as
the femoral insertion site length
(c) and height (d) are made with
an arthroscopic ruler

Case examples

Case #2

Individualizing ACL reconstruction requires knowledge of

the anatomy, lifestyle, profession and overall preferences
of the patient. Following are several example cases illustrating an individualized approach to decision making in
ACL reconstruction.

A 26-year-old division I college football player presents to

the clinic with an MRI that demonstrated a complete rupture of the ACL; this was confirmed with physical examination. The MRI revealed a tibial insertion site of
18.7 mm, an ACL length of 31 mm and inclination angle
of 47.
In cases where the tibial insertion site is [18 mm in
size, double-bundle reconstruction is preferred. However,
intraoperative measurements found a knee notch width of
\12 mm at the widest point. A double-bundle reconstruction is therefore contraindicated in this case, as the femoral
tunnels typically cannot be created without causing iatrogenic injury to the medial femoral condyle while drilling.
At this point, a single-bundle autograft is considered;
allograft is not advisable in a young and athletic patient due
to a longer healing time and potentially higher re-rupture
rate. As for autograft, all options (i.e. hamstrings, patellar
and quadriceps tendons) are available, but caution should
be exercised when not knowing the size of the hamstrings
until after harvest. A hamstrings harvest that is not of
adequate size to reproduce the native insertion site will
require an allograft supplement.

Case #1
A 20-year-old female collegiate sprinter presents to the
clinic during the off season after injuring her knee during a
pick-up basketball game. A subsequent MRI scan demonstrates a complete rupture of the ACL, with a tibial insertion site size of 13.4 mm, an ACL length of 31 mm and
inclination angle of 43.
Intra-operatively, the tibial insertion site size was
confirmed with an arthroscopic ruler to be approximately
13 mm. The notch width was measured to be of sufficient size to accommodate a single- or double-bundle
reconstruction. However, as a tibial insertion site size of
\14 mm is considered a contraindication to doublebundle reconstruction. Thus, a single-bundle reconstruction is recommended. The use of allograft is not recommended in a young and active patient, nor is the use
of hamstrings autograft in a sprinter where they are
essential in the forward propulsion force. In this case,
either BPTB or quadriceps tendon autografts are viable
graft choices.

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Case #3
A 19-year-old collegiate male wrestler is diagnosed with an
ACL tear and concomitant bucket handle medial meniscus

Knee Surg Sports Traumatol Arthrosc

tear. An MRI revealed a tibial insertion site length of

17.3 mm, an ACL length of 34 mm and inclination angle
of 47.
A tibial insertion site size between 14 and 18 mm can
facilitate either a single- or double-bundle reconstruction.
Intraoperatively, the tibial insertion site length was confirmed with an arthroscopic ruler. The notch width was also
measured and deemed of sufficient size to allow a singleor double-bundle reconstruction. Turning to graft choice,
allograft is once again not a primary consideration due to
the athletes young age and higher re-rupture rate. BPTB
autograft is also ruled out, as the kneeling demands of
wrestling can cause the patient significant pain and discomfort after surgery. Therefore, quadriceps and hamstrings autografts are the most appropriate choices, with
caution placed on the hamstrings if a double-bundle
reconstruction is chosen; for it may be too small for an
insertion site of approximately 17 mm or larger.

customizing the surgical approach based on the native ACL

insertion site size, no difference was found between anatomic single-bundle- and anatomic double-bundle ACL
reconstruction [12]. Consequently, it was suggested that
patients with a different ACL size might require a different
ACL reconstruction procedures. However, the question
remains whether a single-bundle ACL reconstruction procedure, in cases of ACL insertion sites of [16 mm, would
lead to similar good outcomes to double-bundle reconstruction which still remains unclear.
Recent studies have demonstrated that smaller grafts
increase the risk of failure after ACL reconstruction; bigger
grafts, however, may theoretically lead to overstuffing of
the notch and subsequently to impingement [17, 19, 22].
This dilemma is one of many examples that underline the
importance of an individualized approach that takes a
multitude of parameters into consideration in order to
provide patients with the best potential for a successful
outcome and to prevent from complications.

Discussion
Conclusion
The most important aspect of this article is that individualized ACL surgery should focus on the double-bundle
concept and encompasses technical considerations (i.e.
single- or double-bundle), individualized graft selection as
well as considerations regarding personal lifestyle and
activity preferences.
Over the past decade, double-bundle ACL reconstruction has gained popularity since biomechanical studies
suggested that it restores knee kinematics closer to normal
as compared to traditional single-bundle ACL reconstruction [32, 33]. Several prospective randomized controlled
trials have been published that compared double-bundle
with single-bundle ACL reconstruction. Some studies
reported better outcomes for the double-bundle procedure
in terms of subjective outcome, anterior or rotational stability, while some studies did not find any differences [1,
11, 27]. However, there is a large variation within the
techniques that have been described (anatomic and nonanatomic tunnel placement), and none of these studies did
use an individualized approach to decide whether to perform single- or double-bundle reconstruction.
Recently, Hussein et al. [13] performed a prospective
randomized trial of 281 patients and compared three different reconstruction techniques. The authors reported that
anatomic double-bundle ACL reconstruction was superior
to both conventional single-bundle ACL reconstruction and
anatomic single-bundle ACL reconstruction. However, for
this study, a non-individualized approach was used, since
the randomization process did not allow for individual
considerations. In a follow-up study, the authors did not
randomize, but rather individualized and showed that when

In contrast to conventional reconstruction techniques for

ACL ruptures and the philosophy that one size fits all,
individualized ACL surgery allows for the customization
of surgery to each individual patient, accounting for graft
selection and other characteristics such as anatomy, lifestyle and activity preferences. Recently, evidence has been
mounting that individualized anatomic ACL reconstruction
leads to better knee kinematics and satisfactory clinical
outcomes. Ultimately, the adoption and subsequent use of
individualized surgery may facilitate improved clinical as
well as objective outcomes, particularly in the long term,
by restoring the anatomy of the ACL to as closely as
possible to the native knee.

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