Gender Differences of the ACL Insertion Sites

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Abstract

Background. The modern principles of reconstruction of the anterior cruciate ligament (ACL) and well-known surgical techniques do not take into account the peculiarities of the anatomical structure of the female knee. This happens due to insufficient substantiation that these peculiarities could influence the results of the treatment. The purpose of this study was to obtain new data on the structure of the areas of the ACL attachment, taking into consideration patient’s gender and the surgical anatomy. Material and Methods. 40 unpaired “fresh” anatomical preparations of the human female and male knees were studied. After preparation of the knee joints, the morphometry of the distal femoral epiphysis and the proximal tibial epiphysis was carried out by a digital sliding caliper according to 16 parameters. The shape, size, area, and the distance of the ACL attachment center from individual bone structures were assessed. The obtained data were correlated with the gender type of the knee structure. Results. The distal femoral epiphysis of the “female” type knee joint compared with the “male” type revealed the significant differences (p<0.05) in the following parameters: the width of the condyles at the level of the transepicondylar line, the width of the intercondylar fossa, the length and height of the lateral condyle, and the ratio of the condyles width at the level of the transepicondylar line to the height of the lateral condyle. The tibial proximal epiphysis showed the gender differences in the articular surface frontal and sagittal dimensions, the width of the intercondylar eminence and the posterior slope of the tibial epiphysis articular surface. These features determined the different proportions of the female knee structure. The area of the anterior cruciate ligament femoral attachment and its center in the “female” type of structure were located 3 mm distal and 1.5 mm posteriorly (anteriorly and downwardly in arthroscopic imaging). The area of the tibial attachment of the same ligament and its center were localized 2 mm anteriorly in comparison with the “male” type structure. Conclusion. The discovered anatomical differences made it possible to distinguish the “female” and “male” types of the knee structure. The topography of the anterior cruciate ligament attachment areas is gender specific. This should be taken into account in the anatomical reconstruction of the ligament.

About the authors

D. A. Malanin

Volgograd State Medical University; Volgograd Science Medical Center

Email: malanin67@mail.ru
ORCID iD: 0000-0001-7507-0570

Dmitry A. Malanin — Dr. Sci. (Med.), Professor, Head of Department for Traumatology, Orthopaedics and Field Surgery, Volgograd State Medical University; Head of Laboratory for Clinical and Experimental Orthopaedics, Volgograd Medical Research Center

Volgograd

Россия

I. V. Volodin

Volgograd State Medical University; Volgograd Science Medical Center

Author for correspondence.
Email: volodin_ili@mail.ru
ORCID iD: 0000-0002-8037-1674

Ilya V. Volodin — PhD Student of Department for Traumatology, Orthopaedics and Field Surgery, Volgograd State Medical University; Researcher, Volgograd Medical Research Center

Volgograd

Россия

I. A. Suchilin

Volgograd State Medical University; Volgograd Science Medical Center

Email: omnio@mail.ru
ORCID iD: 0000-0001-7375-5365

Ilya A. Suchilin — Cand. Sci. (Med.), Associated Professor, Department of Traumatology, Orthopaedics and Field Surgery, Volgograd State Medical University; Researcher, Volgograd Medical Research Center

Volgograd

Россия

M. V. Demeshchenko

Volgograd State Medical University; Volgograd Science Medical Center

Email: maximus275@yandex.ru
ORCID iD: 0000-0003-1797-2431

Maxim V. Demeshchenko — Cand. Sci. (Med.), Assistant Professor, Department of Traumatology, Orthopaedics and Field Surgery, Volgograd State Medical University; Researcher, Volgograd Medical Research Center

Volgograd

Россия

References

  1. Schilaty N.D., Bates N.A., Nagelli C., Krych A.J., Hewett T.E. Sex-based differences in knee kinetics with anterior cruciate ligament strain on cadaveric impact simulations. Orthop J Sports Med. 2018;6(3):23-25. doi: 10.1177/2325967118761037.
  2. Griffin L.Y., Agel J., Albohm M.J., Arendt E.A., Dick R.W., Garrett W.E. et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000;8(3):141-150. doi: 10.5435/00124635-200005000-00001.
  3. Hutchinson M.R., Ireland M.L. Knee injuries in female athletes. Sports Med. 1995;19:288-302. doi: 10.2165/00007256-199519040-00006.
  4. Arendt E., Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. Am J Sports Med. 1995;23:694-701. doi: 10.1177/036354659502300611.
  5. Nicholls M., Aspelund T., Ingvarsson T., Briem, K. Nationwide study highlights a second peak in ACL tears for women in their early forties. Knee Surg Sports Traumatol Arthrosc. 2017;26:648-654. doi: 10.1007/s00167-017-4807-0.
  6. Stevenson H., Webster J., Johnson R., Beynnon B. Gender differences in knee injury epidemiology among competitive alpine ski racers. Iowa Orthop J. 1998;18:64-66.
  7. Gwinn D.E., Wilckens J.H., McDevitt E.R., Ross G., Kao T.C. The relative incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy. Am J Sports Med. 2000;28(1):98-102. doi: 10.1177/03635465000280012901.
  8. Schneider A., Si-Mohamed S., Magnussen R.A., Lustig S., Neyret P., Servien E. Tibiofemoral joint congruence is lower in females with ACL injuries than males with ACL injuries. Knee Surg Sports Traumatol Arthrosc. 2018;26:1375-1383. doi: 10.1007/s00167-017-4756-7.
  9. Hewett T.E., Myer G.D., Ford K.R., Heidt R.S., Colosimo A.J., McLean S.G. et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501. doi: 10.1177/0363546504269591.
  10. Snaebjörnsson T., Svantesson E., Sundemo D., Westin O., Sansone M., Engebretsen L. et al. Young age and high BMI are predictors of early revision surgery after primary anterior cruciate ligament reconstruction: a cohort study from the Swedish and Norwegian knee ligament registries based on 30,747 patients. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3583-3591. doi: 10.1007/s00167-019-05487-2.
  11. Iguchi J., Tateuchi H., Taniguchi M., Ichihashi N. The effect of sex and fatigue on lower limb kinematics, kinetics, and muscle activity during unanticipated sidestep cutting. Knee Surg Sports Traumatol Arthrosc. 2014;22(1):41-48. doi: 10.1007/s00167-013-2526-8.
  12. Trigsted S.M., Cook D.B., Pickett K.A., CadmusBertram L., Dunn W.R, Bell D.R. Greater fear of reinjury is related to stiffened jump-landing biomechanics and muscle activation in women after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26:3682-3689. doi: 10.1007/s00167-018-4950-2.
  13. Sigurethsson H.B., Briem K. Cluster analysis successfully identifies clinically meaningful knee valgus moment patterns: frequency of early peaks reflects sex-specific ACL injury incidence. J Exp Orthop. 2019;6(1):37. doi: 10.1186/s40634-019-0205-5.
  14. Hashemi J., Chandrashekar N., Mansouri H., Gill B., Slauterbeck J. R., Schutt R.C. et al. Shallow medial tibial plateau and steep medial and lateral tibial slopes: new risk factors for anterior cruciate ligament injuries. Am J Sports Med. 2010;38(1):54-62. doi: 10.1177/0363546509349055.
  15. Wahl C.J., Westermann R.W., Blaisdell G.Y., Cizik A.M. An association of lateral knee sagittal anatomic factors with noncontact ACL injury: sex or geometry? J Bone Joint Surg Am. 2012;94(3):217-226. doi: 10.2106/JBJS.K.00099.
  16. Hohmann E., Bryant A., Reaburn P., Tetsworth K. Is there a correlation between posterior tibial slope and non-contact anterior cruciate ligament injuries? Knee Surg Sports Traumatol Arthrosc. 2011;19(1):109-114. doi: 10.1007/s00167-011-1547-4.
  17. Brandon M.L., Haynes P.T., Bonamo J.R., Flynn M.I., Barrett G.R., Sherman M.F. The association between posterior–inferior tibial slope and anterior cruciate ligament insufficiency. Arthroscopy. 2006;22(8):894-899. doi: 10.1016/j.arthro.2006.04.098.
  18. Everhart J.S., Chaudhari A.M.W., Flanigan D.C. Creation of a simple distal femur morphology classfication system. J Ortopedic Research. 2016;34(6):924-931. doi: 10.1002/jor.23102.
  19. Hohe J., Ateshian G.A., Reiser M., Englmeier K., Eckstein F. Surface size, curvature analysis, and assessment of knee joint incongruity with MRI in vivo. Magn Reson Med. 2002;47(3):554-561. doi: 10.1002/mrm.10097.
  20. Mahfouz M., Abdel Fatah E.E., Bowers L.S., Scuderi G. Three-dimensional morphology of the knee reveals ethnic differences. Clin Orthop Relat Res. 2012;470(1):172–185. doi: 10.1007/s11999-011-2089-2.
  21. Gillespie R.J., Levine A., Fitzgerald S.J., Kolaczko J., DeMaio M., Marcus R.E. et al. Gender differences in the anatomy of the distal femur. J Bone Joint Surg Br. 2011;93(3):357-363. doi: 10.1302/0301-620X.93B3.24708.
  22. Aldrian S., Valentin P., Wondrasch B., KruscheMandl I., Ostermann R.C., Platzer P. et al. Gender differences following computer-navigated singleand double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014;22:2145-2152. doi: 10.1007/s00167-013-2649-y.
  23. Siebold R., Webster K.E., Feller J.A., Sutherland A.G., Elliott J. Anterior cruciate ligament reconstruction in females: a comparison of hamstring tendon and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2006;14(11):1070-1076. doi: 10.1007/s00167-006-0100-3.
  24. Ryan J., Magnussen R., Cox C., Hurbanek J., Flanigan D., Kaeding C. ACL reconstruction: Do outcomes differ by sex? A systematic review. J Bone Joint Surg Am. 2014;96(6):507-512. doi: 10.2106/JBJS.M.00299.
  25. Tan S.H., Lau B.P., Khin L.W., Lingaraj K. The importance of patient sex in the outcomes of anterior cruciate ligament reconstructions: a systematic review and meta-analysis. Am J Sports Med. 2016;44(1):242-254. doi: 10.1177/0363546515573008.
  26. Paterno M.V., Weed A.M., Hewett T.E. A between sex comparison of anterior-posterior knee laxity after anterior cruciate ligament reconstruction with patellar tendon or hamstrings autograft: a systematic review. Sports Med. 2012;42(2):135-152. doi: 10.2165/11596940-000000000-00000.
  27. Wada M., Tatsuo H., Baba H., Asamoto K., Nojyo Y. Femoral intercondylar notch measurements in osteoarthritic knees. Rheumatology. 1999;38(6),554-558. doi: 10.1093/rheumatology/38.6.554.
  28. Huston L.J., Greenfield M.L., Wojtys E.M. Anterior cruciate ligament injuries in the female athlete. Potential risk factors. Clin Orthop Relat Res. 2000;(372):50-63. doi: 10.1097/00003086-200003000-00007.
  29. Caplan N., Kader D.F. Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. In: Classic Papers in Orthopaedics. London: Springer; 2014. p. 153-155. doi: 10.1007/978-1-4471-5451-8_37.
  30. Sutton K.M., Bullock J.M. Anterior cruciate ligament rupture: differences between males and females. J Am Acad Orthop Surg. 2013;21:41-50. doi: 10.5435/JAAOS-21-01-41.
  31. Herzog M.M., Marshall S.W., Lund J.L., Pate V., Mack C.D., Spang J.T. Incidence of anterior cruciate ligament reconstruction among adolescent females in the United States, 2002 Through 2014. JAMA Pediatr. 2017;171(8):808-810. doi: 10.1001/jamapediatrics.2017.0740.
  32. McNair P.J., Wood G.A., Marshall R.N. Stiffness of the hamstring muscles and its relationship to function in anterior cruciate ligament deficient individuals. Clin Biomech (Bristol, Avon). 1992;7(3):131-137. doi: 10.1016/0268-0033(92)90027-2.
  33. Alenton-Geli E., Myer G.D., Silvers H.J. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg. Sports Traumatol. Arthrosc. 2009;17(7):705-729. doi: 10.1007/s00167-009-0813-1.
  34. LaPrade R.F., Burnett Q.M. Femoral intercondylar notch stenosis and correlation to anterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1994;22(2):198-202. doi: 10.1177/036354659402200208.
  35. Bouras T., Fennema P., Burke S., Bosman H. Stenotic intercondylar notch type is correlated with anterior cruciate ligament injury in female patients using magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1252-1257. doi: 10.1007/s00167-017-4625-4.
  36. Kumar B., Lenert P. Joint hypermobility syndrome: recognizing a commonly overlooked cause of chronic pain. Am J Med. 2017;130(6):640-647. doi: 10.1016/j.amjmed.2017.02.013.
  37. Lind M., Menhert F., Pedersen A.B. The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc. 2009;17:117-124. doi: 10.1007/s00167-008-0654-3.
  38. Capogna B.M., Mahure S.A., Mollon B., Duenes M.L., Rokito A.S. Young age, female gender, Caucasian race, and workers’ compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;(28):2213-2223. doi: 10.1007/s00167-019-05798-4.
  39. Ouanezar H., Blakeney W.G., Fernandes L.R., Borade A., Latrobe C., Temponi E.F. et al. Clinical outcomes of single anteromedial bundle biologic augmentation technique for anterior cruciate ligament reconstruction with consideration of tibial remnant size. Arthroscopy. 2018;34(3):714-722. doi: 10.1016/j.arthro.2017.08.309.
  40. Yasen S.K., Borton Z.M., Eyre-Brook A.I., Palmer H.C., Cotterill S.T., Risebury M.J. et al. Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction. Knee. 2017;24(1):55-62. doi: 10.1016/j.knee.2016.09.007.
  41. Tachibana Y., Shino K., Mae T., Iuchi R., Take Y., Nakagawa S. Anatomical rectangular tunnels identified with the arthroscopic landmarks result in excellent outcomes in ACL reconstruction with a BTB graft. Knee Surg Sports Traumatol Arthrosc. 2019;27:2680-2690. doi: 10.1007/s00167-018-5300-0.
  42. Rothrauff B.B., Jorge A., de Sa D., Kay J., Fu F.H., Musahl V. Anatomic ACL reconstruction reduces risk of post-traumatic osteoarthritis: a systematic review with minimum 10-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2019;28:1072-1084. doi: 10.1007/s00167-019-05665-2.
  43. Achtnich A., Ranuccio F., Willinger L., Pogorzelski J., Imhoff A.B., Braun S. et al. High incidence of partially anatomic tunnel placement in primary single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26:462-467. doi: 10.1007/s00167-017-4555-1.
  44. Greene K.A. Gender-specfic design in total knee arthroplasty. J Arthroplasty. 2007;22:27-31. doi: 10.1016/j.arth.2007.05.019.
  45. Yoshioka Y., Siu D., Cooke T.D. The anatomy and functional axes of the femur. J Bone Joint Surg Am. 1987;69(6):873-880.
  46. Iriuchishima T., Ryu K., Aizawa S., Fu F.H. Proportional evaluation of anterior cruciate ligament footprint size and knee bony morphology. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3157-3162. doi: 10.1007/s00167-014-3139-6.
  47. Gali J.C., Camargo D.B., Oliveira F.A.M., Pereira R.H.N., Silva P.A.C.D. Descriptive anatomy of the anterior cruciate ligament femoral insertion. Rev Bras Ortop. 2018;53(4):421-426. doi: 10.1016/j.rboe.2018.05.004.
  48. Kopf S., Pombo M.W., Szczodry M., Irrgang J., Fu F.H. Size variability of the human anterior cruciate ligament insertion sites. Am J Sports Med. 2011;39(1):108-113. doi: 10.1177/0363546510377399.
  49. Gali J.C., Del Giglio D.B., Patriarcha L.F., Cruz B.A.P., Gali Filho J.C. Correlation bettween Individual Anthropometric Characteristics and Anterior Cruciate Ligament Tibial Fovea Measurements. Rev Bras Ortop (Sao Paulo). 2020;55(1):88-94. doi: 10.1055/s-0039-1700816.
  50. Park Y.B., Song Y.S., Kim S.C., Park Y.G., Ha C.W. The size of tibial footprint of anterior cruciate ligament and association with physical characteristics in Asian females. Arch Orthop Trauma Surg. 2015;135(7):985-992. doi: 10.1007/s00402-015-2229-3.
  51. Siebold R., Webster K.E., Feller J.A., Sutherland A.G., Elliott J. Anterior cruciate ligament reconstruction in females: a comparison of hamstring tendon and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2006;14:1070-1076. doi: 10.1007/s00167-006-0100-3.
  52. Tan S.H.S., Lau B.P.H., Krishna L. Outcomes of Anterior Cruciate Ligament Reconstruction in Females Using Patellar-Tendon-Bone versus Hamstring Autografts: A Systematic Review and Meta-Analysis. J Knee Surg. 2019;32(8):770-787. doi: 10.1055/s-0038-1669916.
  53. Kautzner J., Kos P., Hanus M., Trc T., Havlas V. A comparison of ACL reconstruction using patellar tendon versus hamstring autograft in female patients: a prospective randomised study. Int Orthop. 2015;39(1):125-130. doi: 10.1007/s00264-014-2495-7.
  54. Noojin F.K., Barrett G.R., Hartzog C.W., Nash C.R. Clinical comparison of intraarticular anterior cruciate ligament reconstruction using autogenous semitendinosus and gracilis tendons in men versus women. Am J Sports Med. 2000;28(6):783-789. doi: 10.1177/03635465000280060301.
  55. Ageberg E., Forssblad M., Herbertsson P., Roos E.M. Sex differences in patient-reported outcomes after anterior cruciate ligament reconstruction: data from the Swedish knee ligament register. Am J Sports Med. 2010;38(7):1334-1342. doi: 10.1177/0363546510361218.
  56. Aldrian S., Valentin P., Wondrasch B., Krusche-Mandl I., Ostermann R.C., Platzer P. et al. Gender differences following computer-navigated single- and doublebundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014;22:2145-2152. doi: 10.1007/s00167-013-2649-y.
  57. Gobbi A., Domzalski M., Pascual J. Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts. Knee Surg Sports Traumatol Arthrosc. 2004;12:534-539. doi: 10.1007/s00167-003-0486-0.
  58. Paterno M.V., Huang B., Thomas S., Hewett T.E., Schmitt L.C. Clinical factors that predict a second ACL injury after ACL reconstruction and return to sport: preliminary development of a clinical decision algorithm. Orthop J Sports Med. 2017;5(12):1-7. doi: 10.1177/2325967117745279.
  59. Ferrari J.D., Bach B.R., Bush-Joseph C.A., Wang T., Bojchuk J. Anterior cruciate ligament reconstruction in men and women: An outcome analysis comparing gender. Arthroscopy. 2001;17(6):588-596. doi: 10.1053/jars.2001.24686.
  60. Magnussen R.A., Trojani C., Granan L.P., Neyret P., Colombet P., Engebretsen L. et al. Patient demographics and surgical characteristics in ACL revision: a comparison of French, Norwegian, and North American cohorts. Knee Surg Sports Traumatol Arthrosc. 2015;23:2339-2348. doi: 10.1007/s00167-015-3835-x.

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