Individualized Anterior Cruciate Ligament

Graft Matching
In Vivo Comparison of Cross-sectional Areas
of Hamstring, Patellar, and Quadriceps
Tendon Grafts and ACL Insertion Area
Christoph Offerhaus,*yz MD, Márcio Albers,* MD, Kanto Nagai,* MD, PhD, Justin W. Arner,* MD,
Jürgen Höher,z MD, PhD, Volker Musahl,* MD, and Freddie H. Fu,*§ MD, DSc (Hon), DPs (Hon)
Investigation performed at the Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA

Background: Recent literature correlated anterior cruciate ligament (ACL) reconstruction failure to smaller diameter of the har-
vested hamstring (HS) autograft. However, this approach may be a simplification, as relation of graft size to native ACL size is
not typically assessed and oversized grafts may impart their own complications.
Purpose: To evaluate in vivo data to determine if the commonly used autografts reliably restore native ACL size.
Study Design: Descriptive laboratory study.
Methods: Intraoperative data of the tibial insertion area and HS graft diameter were collected and retrospectively evaluated for 46
patients who underwent ACL reconstruction with HS autografts. Magnetic resonance imaging measurements of the cross-sectional
area (CSA) of the possible patellar tendon (PT) and quadriceps tendon (QT) autografts were also done for each patient. The percen-
tages of tibial insertion site area restored by the 3 possible grafts were then calculated and compared for each individual.
Results: The mean ACL tibial insertion area was 107.2 mm2 (60.5-155.5 mm2). The mean CSAs of PT, HS, and QT were 33.2,
55.3, and 71.4 mm2, respectively. When all grafts were evaluated, the percentage reconstruction of the insertion area varied
from 16.2% to 123.1% on the tibial site and from 25.5% to 176.7% on the femoral site, differing significantly for each graft type
(P \ .05). On average, 32.8% of the tibial insertion area would have been filled with PT, 53.6% by HS, and 69.5% by QT. Based on
previous cadaveric studies indicating that graft size goal should be 50.2% 6 15% of the tibial insertion area, 82.7% of patients in
the HS group were within this range (36.9%, QT; 30.5%, PT), while 65.2% in the PT group were below it and 60.9% in the QT
group were above it.
Conclusion: ACL insertion size and the CSAs of 3 commonly used grafts vary greatly for each patient and are not correlated with
one another. Thus, if the reconstructed ACL size is determined by the harvested autograft size alone, native ACL size may not be
adequately restored. PT grafts tended to undersize the native ACL, while QT might oversize it.
Clinical Relevance: These results may help surgeons in preoperative planning, as magnetic resonance imaging measurements
can be helpful in determining individualized graft choice to adequately restore the native ACL.
Keywords: anterior cruciate ligament; graft size; anatomy; individualized; MRI

Anatomic anterior cruciate ligament (ACL) reconstruction is
the gold standard for athletes who have sustained a complete
ACL tear and are unable to return to play. Superior results
were reported in restoring normal knee kinematics as com-
pared with nonanatomic reconstruction.26,36,44 Furthermore,
there is an increasing awareness of and interest in the indi-
vidual anatomy of each knee requiring surgery.36,47 A
The American Journal of Sports Medicine
1–7
DOI: 10.1177/0363546518786032
Ó 2018 The Author(s)
significant correlation between bony parameters (eg, width
and length of the intercondylar notch) and the size of the
native ACL were found in previous studies, exhibiting that
the ACL midsubstance is naturally and appropriately sized
to fit within the intercondylar notch.21,23,36,37 To avoid
impingement within the notch as well as failure attributed
to a small graft, reconstructing the correct graft size is crucial
but challenging to define.25,30 One proposed principal for ana-
tomic ACL reconstruction is to restore the native femoral and
tibial insertion sites.30,36 The extensive anatomic studies by
Iriuchishima et al21,22 showed a large variation in size and
thickness of potential autografts, and it is unlikely that the

1
2 Offerhaus et al
native ACL insertion area is restored with the commonly
used autografts. Furthermore, restoration of the complete
insertion area may result in a graft that is too large at its
midsubstance to fit within the intercondylar notch, poten-
tially causing pathologic impingement.
Currently, ACL reconstruction is most commonly per-
formed with autografts, and ACL graft size is typically
determined by the harvested graft without consideration
of the size of the native ACL.21,28 Given the lack of a corre-
lation in previous cadaveric studies between the size of the
native ACL and the potential grafts,21 more attention
should be paid in choosing the appropriate graft.
Furthermore, hamstring (HS) autograft diameter can
be manipulated by doubling the grafts. Harvesting of the
patellar tendon (PT) or quadriceps tendon (QT) is typically
done with the same standard procedure, gaining a width of
10 mm regardless of its thickness. However, cadaveric and
magnetic resonance imaging (MRI) studies showed consid-
erable differences in PT and QT thickness among individ-
uals.2,22,32,42 Furthermore, studies found that MRI can
accurately and reliably predict graft sizes of the PT, QT,
and HS.5,46
Previous cadaveric studies evaluated the average size of
ACL insertion areas and diameter of ACL midsubstances
and correlated these with the average size of possible
grafts.20,21,24 But to our knowledge, no study has been pub-
lished that focuses on individualized ACL graft matching
where potential autografts are compared with ACL size
in each patient undergoing ACL reconstruction.
The purpose of this study was to evaluate in vivo data to
determine if commonly used autografts reliably restore native
ACL size. It was hypothesized that the cross-sectional areas
(CSAs) of the PT, HS, and QT vary in each patient and do
not correlate with native ACL insertion area. Furthermore,
the QT will provide the largest diameter, followed by the HS
and PT, with the risk of oversizing the native ACL by the
use of the QT and undersizing it with the PT.
METHODS
A retrospective chart review was performed of 325 patients
who underwent ACLR by the senior author (F.H.F.) from
January 2012 to January 2016. Inclusion criteria were pri-
mary anatomic single-bundle ACL reconstruction with HS
autograft and the availability of intraoperative data of the
ACL tibial insertion area and HS graft diameter, as well as
preoperative MRI. Exclusion criteria were revision sur-
gery, ACL augmentation, concomitant ligament or capsu-
lar injuries, and any use of allografts. Institutional
review board approval was obtained before the start of
this study (PRO12020319).
§
Address correspondence to Freddie H. Fu, MD, DSc (Hon), DPs (Hon), Department of Orthopaedic Surgery, University of Pittsburgh, 3200 South Water
Street, Pittsburgh, PA 15203, USA (email: ffu@upmc.edu).
*Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
y
Department for Trauma, Orthopaedics, Hand, and Reconstructive Surgery, HELIOS-Spital Überlingen, Überlingen, Germany.
z
Sportsclinic Cologne, University of Witten-Herdecke, Cologne, Germany.
One or more of the authors has declared the following potential conflict of interest or source of funding: V.M. has received consulting fees from Smith &
Nephew, education and hospitality payments from Arthrex, and grants from Mid-Atlantic Surgical Systems.
The American Journal of Sports Medicine
Surgical Procedure and Intraoperative Measurements
Individualized single-bundle ACL reconstruction was per-
formed as previously described.36 The tibial stump of the
ACL was cut, facilitating the measurement of the footprint
to obtain the area of the tibial insertion site. Largest length
and width were measured with an arthroscopic ruler
(Trukor Depth Gauge; Smith & Nephew) and multiplied
to obtain the CSA of the insertion site. Required graft size
was then calculated by the formula of an ellipse as described
by Kopf et al.29 The femoral insertion site was measured
according to the ACL remnant on the lateral femoral con-
dyle. The HS was prepared as deemed appropriate by the
surgeon, mostly resulting in a 4-strand semitendinosus
(ST) and gracilis (G) autograft. Graft size was measured
with the aid of a standard graft measurement device (Sizing
Tube; Smith & Nephew). The femoral tunnel was drilled
through an anteromedial portal in the anatomic midbundle
position with the aid of an arthroscopic ruler. The tibial tun-
nel was centered with a line between the margin of the ante-
rior horn of the lateral meniscus and the medial tibial spine.
For comparison with the other potential grafts and native
ACL, the CSA of the implanted HS graft was calculated
with its previously measured diameter.
PT and QT CSA Measurement With MRI
Postoperative MRI measurements of the CSAs of the poten-
tial PT and QT autografts were done for each patient. Two
sports medicine orthopaedic surgeons were blinded to the
intraoperative data and instructed to select the best sagittal
image displaying the maximal thickness of the quadriceps
and patellar tendon. To reveal the most accurate approxi-
mation of the potential autograft’s true CSA, the full thick-
ness of the PT and QT was measured on axial MRI at
a point 15 mm distal (PT) or proximal (QT) from the inferior
(PT) or superior (QT) pole of the patella. The width was
assumed to be 10 mm. Previous studies found that MRI
can accurately and reliably predict graft sizes of the PT,
QT, and HS.5,46 To eliminate error attributed to different
axial and sagittal MRI cuts, the angle between the tendon
and axial image cut orientation was measured on sagittal
MRI to calculate the true perpendicular CSA of the graft
with a cosine function (Figure 1). As HS graft size can be
adapted by doubling the tendons, the intraoperative mea-
surement of the final HS graft diameter for implantation
was used for comparison with the QT and the PT.
The percentages of the tibial and femoral insertion site
area restored by the 3 possible grafts were then compared
per individual.
In a previous cadaveric study, Fujimaki et al10 found
the ACL midsubstance to be 50.2% 6 15% (mean 6 SD)
the size of the tibial insertion area. Based on these
AJSM Vol. XX, No. X, XXXX Individualized ACL Graft Matching 3

TABLE 1
Autograft Measurements

Mean 6 SD Minimum Maximum

Thickness,a mm
Patellar tendon 3.6 6 0.8 2.5 5.8
Quadriceps tendon 7.7 6 1.1 4.3 10.5
Diameterb: hamstrings, mm 8.4 6 0.6 7.0 10.0

a
Magnetic resonance imaging.
b
Intraoperative (final graft).

TABLE 2
Graft Cross-sectional Areas
and Anterior Cruciate Ligament Insertion Sizes
Figure 1. Sample magnetic resonance imaging measurement Mean 6 SD Minimum Maximum
of cross-sectional area (CSA) of potential quadriceps tendon
autograft: The thickness of the quadriceps tendon is mea- Insertion size, mm2
sured on the axial view at a point 15 mm proximal from the Tibial 107.2 6 22.9 60.5 155.5
Femoral insertion size 66.2 6 12.2 45.2 100.5
superior pole of the patella. The width is assumed to be
Autograft, mm2
10 mm. The angle between the tendon and axial image cut ori-
Patellar tendon 33.2 6 7.3 19.6 51.9
entation is measured on the sagittal view to calculate the true Quadriceps tendon 71.4 6 10.5 47.6 97.4
perpendicular CSA of the graft with a cosine (cos) function. Hamstrings 55.3 6 8.0 38.5 78.5

findings, restoring 35% to 65% of the tibial insertion size

TABLE 3
(being equivalent to 85%-115% of the assumed native
Correlation of Autograft CSA
ACL midsubstance) was considered optimal. The number
and Anterior Cruciate Ligament Insertion Sizea
of patients who would have been within this range was
then calculated and the different grafts compared. Insertion Size: CSA Pearson Correlation P Value

Tibial
Statistical Analyses
Patellar tendon –0.07 .646
Quadriceps tendon 0.131 .385
Descriptive statistics, including mean 6 SD and range,
Hamstrings 0.241 .107
were collected for all recorded variables. Measurements
Femoral
were done twice within 3 weeks by 1 observer to analyze Patellar tendon –0.161 .284
intraobserver reliability and once by a second observer to Quadriceps tendon 0.04 .793
evaluate interobserver reliability with the intraclass corre- Hamstrings 0.165 .274
lation coefficient. Pearson coefficient was used to evaluate
a
the correlation between the ACL femoral/tibial insertion No correlation between size of footprint and size of any
area and the CSA of the PT, HS, and QT. Whether grafts observed autograft. CSA, cross-sectional area.
differ in their ability to reconstruct the tibial insertion site
and the ACL size was tested by analysis of variance and 0.96-0.99, P \ .05) reliability demonstrated good test-retest
paired t test. A P value \.05 was considered statistically sig- reliability. Table 1 shows the mean thickness of the PT and
nificant. All statistical analyses were performed with SPSS QT as well as the diameter of the implanted HS graft.
(v 24; IBM Corp). A priori power analysis showed that at Forty-one patients had a doubled ST/G graft (4 strands);
least 46 patients were required to detect a moderate corre- 2 patients, a quadrupled ST graft (4 strands); 1 patient,
lation (0.40), with a power of 0.80 and an alpha error of a tripled ST and doubled G graft (5 strands); and 1 patient,
.05. A minimum of 37 patients were required to compare a doubled ST graft (2 strands). Table 2 presents the mean
the 3 groups with 1-way analysis of variance, with an effect CSA of the 3 possible grafts and femoral and tibial inser-
size of 0.30, a power of 0.80, and an alpha error of .5. tion areas. Range of size is shown for all data to illustrate
the high variation. No significant correlation was observed
between the femoral or tibial ACL insertion size and any of
RESULTS the autograft CSAs (Table 3) or time to surgery.
Percentage reconstruction of the tibial insertion area
Forty-six patients (29 female, 17 male; 21.8 6 8.1 years) varied from 16.2% to 123.1% when all grafts were evalu-
met inclusion criteria and were enrolled in the study. ated. Reconstruction of the femoral insertion site ranged
Time of injury to time of surgery was 166.3 6 147.8 days from 25.5% to 176.7%. Figure 2 demonstrates the percent-
(95% CI = 120.8-211.8). Interrater (0.87, 95% CI = 0.62- age of the tibial insertion site reconstructed with each graft
0.92, P \ .05) and intrarater (rater 1: 0.98, 95% CI = per individual (PT, 32.8% 6 11.8%; HS, 53.6% 6 11.9%;
4 Offerhaus et al
Figure 2. Percentage of the tibial insertion site recon-
structed significantly differs for the 3 examined grafts (P \
.05). The vertical lines mark the optimal size of reconstruction
(50.2% 6 15%) of the tibial insertion size. While the patellar
tendon and quadriceps tendon significantly differ from this
mark (P \ .05), with patellar tendon tending to undersize
and quadriceps tendon tending to oversize, hamstring grafts
are more commonly within this optimal region (P = .36).
QT, 69.5% 6 17.3%), showing significant differences
among the 3 possible grafts (P \ .05). As mentioned previ-
ously, if we consider the graft size goal to be 50.2% 6 15% of
restoration of the tibial insertion size,10 30.5% of patients in
the PT group were within this range (65.2% below, 4.3%
above), 82.7% of the HS (4.3% below, 13.0% above), and
36.9% in the QT group (2.2% below, 60.9% above). Figure
2 summarizes these findings, illustrating that PT and QT
CSAs significantly differ from this ‘‘50% mark’’ (P \ .05),
whereas HS does not diverge much (P = .36).
Figure 3 demonstrates the percentage of the femoral
insertion site reconstructed with the 3 possible grafts per
individual (PT, 52.1% 6 15.9%; HS, 85.8% 6 18.1%; QT,
111.2% 6 25.3%), showing significant differences among
them (P \ .05).
DISCUSSION
The main findings of the present study are that sizes of the
3 possible autografts for ACL reconstruction significantly
differ in each patient and that no correlation is observed
between the CSA of the native ACL and any of the auto-
grafts. No one graft is able to most optimally restore ACL
size in individual patients; therefore, patient-specific
measurements may be done to determine which autograft
may best restore the native CSA of the ACL. To our knowl-
edge, this study is the first to correlate individual in vivo
data of native ACL insertion sizes with the CSAs of possi-
ble HS, PT, and QT autografts. These in vivo data show
The American Journal of Sports Medicine
Patellar Tendon
Quadriceps Tendon
Figure 3. Percentage of the femoral insertion site recon-
structed significantly differs for the 3 examined grafts (P \
.05). The femoral insertion site is smaller than the tibial inser-
tion site, shifting the graph to the right.
that the use of similar standard autograft sizes in each
patient may lead to undersized as well as oversized auto-
grafts in many cases. This finding is highlighted by the
example of 1 patient with a very small insertion site. The
appropriate diameter (6.5 mm) of the graft could already
be achieved by doubling the ST (2 strands) in this case.
As the concept of ACL reconstruction shifted from iso-
metric to anatomic procedures within the past decades,
numerous studies have been performed to evaluate the
native anatomy of the ACL. These studies focused on ana-
tomic graft positioning and tunnel placement as well as
biomechanical testing and graft healing.7-9,17,26,41,47
Although ACL insertion areas have been intensively inves-
tigated,20,21,23,24,37 the literature is limited on the restora-
tion of native ACL size.
The extensive studies by Iriuchishima et al21-24
provided useful data regarding ACL insertion sizes and
commonly used autografts. They showed, in cadaveric dis-
sections, that there is no correlation between the size of
the ACL insertion areas and the mean size of the commonly
used autografts as well as anthropometric data such as
height, weight, and sex of the patient.23 These findings sup-
port the present individual in vivo measurements. The area
of the ACL insertion site in cadavers was 2 to 3 times larger
than the area of the HS or PT graft.22 This was also seen in
the current study. Furthermore, this study evaluated possi-
ble QT autografts, which are even larger and were not pre-
viously considered in the cadaveric studies of Iriuchishima
et al.21 That group concluded that if the reconstructed
ACL size is determined by the harvested autograft size
alone, then the native ACL insertion size is unlikely to be
reproduced. However, Iriuchishima et al21,22 did not provide
data in matching the insertion size and possible grafts in
AJSM Vol. XX, No. X, XXXX
each knee. Furthermore, it is controversial whether restor-
ing the ACL insertion size is desirable, as several studies
showed the native ACL to be ‘‘sandglass’’ or ‘‘bowtie’’
shaped.10,39
The cylindrical autografts used cannot reconstruct this
native ACL shape; therefore, reconstructing the native
ACL midsubstance CSA may be preferable to avoid inter-
condylar roof or posterior cruciate ligament impingement
by a potentially oversized graft. Fujimaki et al10 quantified
the shape of the ACL and its insertions site boundaries
through a range of flexion angles and different loading
states. Using a laser scan, they showed the CSA at the isth-
mus of the ACL to be around half the area of the tibial
insertion site. As mentioned, given these findings, we
assumed the graft size goal to be 50.2% 6 15% of the tibial
insertion area. For several reasons, final analysis of match-
ing was done with the autograft’s relation to the tibial
insertion size, although the femoral insertion site was mea-
sured as well. Intraoperative measurements of the tibial
insertion site are more accurate because the tibial stump
is always preserved. By cutting this stump, exact evalua-
tion of the tibial footprint is possible, while femoral rem-
nants are often difficult to define. Furthermore, the tibial
insertion site can be reliably predicted on MRI imaging.13
By knowing the tibial insertion size, the native ACL size
can be assumed, enabling the surgeon to calculate the opti-
mal graft size.
There is evidence that impingement on the intercondy-
lar wall may weaken the ACL and be a major factor with
its injury.3 In a recent study, Orsi et al35 stated that small
changes in graft size lead to large increases of impinge-
ment force and contact area. This may be one reason why
PT grafts are successful, although, on average, they are
smaller than QT and HS autografts. Certainly, correct
placement of the graft by accurate femoral and tibial tun-
nel drilling is crucial and cannot be overstressed.19,26,35
In recent literature, graft failure was correlated with
smaller HS autograft size.6,31,33,38 However, this may be
an oversimplification, as correlation of graft size to native
ACL size as well as return to sports was not assessed in
these studies and oversizing the ACL might impart its
own complications. These patients may not return to
high-level pivoting sports and therefore may be less likely
to rerupture their ACLs. Indeed, 2 studies showed the
same or slightly better Knee injury and Osteoarthritis Out-
come Scores among patients with bigger autograft diame-
ters, although these results were from multicenter
studies where surgical factors are not controlled.33,38 Fur-
thermore, these results for the HS may not be transferable
to other autografts, as their histological and biomechanical
properties vary.4,15,16
The main limitation of this study is selection bias by
including only patients who underwent ACL reconstruc-
tion with an HS graft; in these cases, the size of the HS
graft was already adapted by using grafts with different
numbers of strands. However, it is common practice to
adapt HS sizes, while the PT and QT are often harvested
in a standard technique with a width of 10 mm regardless
of their thickness. Nevertheless, this study shows that pos-
sible graft sizes significantly differ per individual, with the
Individualized ACL Graft Matching 5
QT being bigger and the PT smaller than the HS on aver-
age. Besides varying in overall size, the tibial insertion site
of the ACL varies in its shape.14 To ensure clinical applica-
bility, insertion size was calculated as an ellipse. Not con-
sidering different shapes of the tibial insertion site is
another limitation of the present study. Although the cur-
rent study evaluates graft size, other characteristics of the
possible autografts are important and not examined here.
As the QT tends to oversize the native ACL midsub-
stance with the risk of consecutive notch impingement,
detailed preoperative MRI planning is important. Harvest-
ing partial-thickness QT, as well as harvesting a smaller
width graft, may help to avoid this problem.11 The results
of this study might provoke concerns about PT grafts for
ACL reconstruction, as they tend to undersize the native
ACL on average. In addition, histology has shown a higher
density of collagen fibrils as well as a higher density of
fibroblasts in the HS and QT as compared with PT grafts,
possibly providing another potential advantage of the HS
and QT in ultimate strength.15,16 In contrast, Noyes
et al34 showed PT grafts to have significantly higher ten-
sile strengths than the HS. However, several outcome
meta-analyses comparing HS and PT autografts did not
reveal any significant clinical difference, but they did
show a trend toward return to higher sports level with
the use of bone–patellar tendon–bone grafts.12,43,45
Different histological properties and direct bone-to-bone
healing might be reasons for the success of PT grafts, as
well as the aforementioned possible avoidance of notch
impingement. Herbort et al18 speculated that the constant
fiber orientation of PT and QT grafts was similar to the orig-
inal ACL structure and therefore provided better rotational
stability as compared with the HS in a cadaveric knee kine-
matics test. This finding again provides insight that consid-
erations more than just graft size alone may be important
but are not yet well defined. Thickness of the PT and QT
also varies greatly among patients and results in different
diameters, as these are typically harvested with a width of
10 mm.2,22,32,42 Literature is lacking in regard to outcome
studies comparing different sizes of PT and QT autografts,
which was already done for HS autografts. Furthermore,
possible differences of the remodeling process between 1-
stranded QT or PT grafts and multiple-stranded HS grafts
should be investigated in future studies.
The present study shows that the CSA of potential auto-
grafts varies greatly among patients, which should be consid-
ered in preoperative planning. Given the aforementioned
clinical and biomechanical studies,3,6,10,35,37,38 it is desirable
to avoid under- and oversizing of the autograft to prevent
its failure. Particularly when the PT or QT is considered as
a possible transplant, its thickness should be measured and
possible CSA calculated preoperatively, as options to adapt
the resulting graft size are limited as compared with HS
autografts. Another study from our institution13 showed
that the tibial insertion site can be reliably predicted on
MRI and, by this, the native ACL size can be assumed. Based
on the results of both studies, preoperative individualized
graft matching is possible. Nevertheless, native ACL size
should not be a surgeon’s only concern in graft choice. Con-
comitant injuries to the capsule and other ligaments are
6 Offerhaus et al
also significant risk factors for postoperative graft fail-
ure.1,27,40 As Ahn and Lee1 showed grade 2 medial collateral
ligament injuries to be a highly significant risk factor for
postoperative knee laxity, there is controversy regarding
the morbidity of harvesting HS tendons with a concomitant
medial knee injury. Furthermore, athletes in high valgus
stress sports such as judo may benefit by preserving their
HS tendons.
CONCLUSION
The CSAs of 3 commonly used grafts vary greatly in each
patient and are not correlated with native ACL insertion
size. Thus, if the reconstructed ACL size is determined
by the harvested autograft size alone, the native ACL
size may not be adequately restored. PT grafts tend to
undersize the native ACL, while QT might oversize the
native ACL. To adequately restore the native ACL, preop-
erative MRI measurements are helpful in determining
individualized graft choice.
ACKNOWLEDGMENT
The authors thank Dr Richard Debski and Eric Hamrin
Senorski for their constructive criticism in this research
project. C.O. gratefully acknowledges the AGA (German
Speaking Association of Arthroscopy and Joint Surgery)
for funding his fellowship at the University of Pittsburgh
Medical Center.
REFERENCES
1. Ahn JH, Lee SH. Risk factors for knee instability after anterior cruci-
ate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc.
2016;24(9):2936-2942.
2. Basso O, Johnson DP, Amis AA. The anatomy of the patellar tendon.
Knee Surg Sports Traumatol Arthrosc. 2001;9(1):2-5.
3. Boden BP, Griffin LY, Garrett WE Jr. Etiology and prevention of non-
contact ACL injury. Phys Sportsmed. 2000;28(4):53-60.
4. Boniello MR, Schwingler PM, Bonner JM, Robinson SP, Cotter A,
Bonner KF. Impact of hamstring graft diameter on tendon strength:
a biomechanical study. Arthroscopy. 2015;31(6):1084-1090.
5. Chan KW, Kaplan K, Ong CC, Walsh MG, Schweitzer ME, Sherman
OH. Using magnetic resonance imaging to determine preoperative
autograft sizes in anterior cruciate ligament reconstruction. Bull
NYU Hosp Jt Dis. 2012;70(4):241-245.
6. Conte EJ, Hyatt AE, Gatt CJ Jr, Dhawan A. Hamstring autograft size
can be predicted and is a potential risk factor for anterior cruciate lig-
ament reconstruction failure. Arthroscopy. 2014;30(7):882-890.
7. Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J,
Schneider T. Femoral bone tunnel placement using the transtibial
tunnel or the anteromedial portal in ACL reconstruction: a radio-
graphic evaluation. Knee Surg Sports Traumatol Arthrosc. 2009;
17(3):220-227.
8. Duquin TR, Wind WM, Fineberg MS, Smolinski RJ, Buyea CM. Cur-
rent trends in anterior cruciate ligament reconstruction. J Knee
Surg. 2009;22(1):7-12.
9. Flandry F, Hommel G. Normal anatomy and biomechanics of the
knee. Sports Med Arthrosc. 2011;19(2):82-92.
The American Journal of Sports Medicine
10. Fujimaki Y, Thorhauer E, Sasaki Y, Smolinski P, Tashman S, Fu FH.
Quantitative in situ analysis of the anterior cruciate ligament: length,
midsubstance cross-sectional area, and insertion site areas. Am J
Sports Med. 2016;44(1):118-125.
11. Fulkerson JP, Langeland R. An alternative cruciate reconstruction
graft: the central quadriceps tendon. Arthroscopy. 1995;11(2):252-
254.
12. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction
of the anterior cruciate ligament: meta-analysis of patellar tendon
versus hamstring tendon autograft. Arthroscopy. 2005;21(7):791-803.
13. Guenther D, Irarrazaval S, Albers M, et al. Area of the tibial insertion
site of the anterior cruciate ligament as a predictor for graft size.
Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1576-1582.
14. Guenther D, Irarrazaval S, Nishizawa Y, et al. Variation in the shape of the
tibial insertion site of the anterior cruciate ligament: classification is
required. Knee Surg Sports Traumatol Arthrosc. 2017;25(8):2428-2432.
15. Hadjicostas PT, Soucacos PN, Berger I, Koleganova N, Paessler HH.
Comparative analysis of the morphologic structure of quadriceps and
patellar tendon: a descriptive laboratory study. Arthroscopy. 2007;
23(7):744-750.
16. Hadjicostas PT, Soucacos PN, Paessler HH, Koleganova N, Berger I.
Morphologic and histologic comparison between the patella and
hamstring tendons grafts: a descriptive and anatomic study. Arthros-
copy. 2007;23(7):751-756.
17. Herbort M, Lenschow S, Fu FH, Petersen W, Zantop T. ACL mis-
match reconstructions: influence of different tunnel placement strat-
egies in single-bundle ACL reconstructions on the knee kinematics.
Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1551-1558.
18. Herbort M, Tecklenburg K, Zantop T, et al. Single-bundle anterior
cruciate ligament reconstruction: a biomechanical cadaveric study
of a rectangular quadriceps and bone–patellar tendon–bone graft
configuration versus a round hamstring graft. Arthroscopy. 2013;
29(12):1981-1990.
19. Iriuchishima T, Horaguchi T, Kubomura T, Morimoto Y, Fu FH. Eval-
uation of the intercondylar roof impingement after anatomical
double-bundle anterior cruciate ligament reconstruction using 3D-
CT. Knee Surg Sports Traumatol Arthrosc. 2011;19(4):674-679.
20. Iriuchishima T, Ryu K, Aizawa S, Fu FH. Size correlation between the
tibial anterior cruciate ligament footprint and the tibia plateau. Knee
Surg Sports Traumatol Arthrosc. 2015;23(4):1147-1152.
21. Iriuchishima T, Ryu K, Yorifuji H, Aizawa S, Fu FH. Commonly used
ACL autograft areas do not correlate with the size of the ACL foot-
print or the femoral condyle. Knee Surg Sports Traumatol Arthrosc.
2014;22(7):1573-1579.
22. Iriuchishima T, Shirakura K, Yorifuji H, Aizawa S, Fu FH. Size compar-
ison of ACL footprint and reconstructed auto graft. Knee Surg Sports
Traumatol Arthrosc. 2013;21(4):797-803.
23. Iriuchishima T, Shirakura K, Yorifuji H, Aizawa S, Murakami T, Fu FH.
ACL footprint size is correlated with the height and area of the lateral
wall of femoral intercondylar notch. Knee Surg Sports Traumatol
Arthrosc. 2013;21(4):789-796.
24. Iriuchishima T, Yorifuji H, Aizawa S, Tajika Y, Murakami T, Fu FH.
Evaluation of ACL mid-substance cross-sectional area for recon-
structed autograft selection. Knee Surg Sports Traumatol Arthrosc.
2014;22(1):207-213.
25. Jagodzinski M, Richter GM, Passler HH. Biomechanical analysis of
knee hyperextension and of the impingement of the anterior cruciate
ligament: a cinematographic MRI study with impact on tibial tunnel
positioning in anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc. 2000;8(1):11-19.
26. Karlsson J, Irrgang JJ, van Eck CF, Samuelsson K, Mejia HA, Fu FH.
Anatomic single- and double-bundle anterior cruciate ligament
reconstruction, part 2: clinical application of surgical technique. Am
J Sports Med. 2011;39(9):2016-2026.
27. Kittl C, El-Daou H, Athwal KK, et al. The role of the anterolateral
structures and the ACL in controlling laxity of the intact and ACL-
deficient knee. Am J Sports Med. 2016;44(2):345-354.
28. Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T. Prospective clinical
comparisons of anatomic double-bundle versus single-bundle
AJSM Vol. XX, No. X, XXXX
anterior cruciate ligament reconstruction procedures in 328 consec-
utive patients. Am J Sports Med. 2008;36(9):1675-1687.
29. Kopf S, Martin DE, Tashman S, Fu FH. Effect of tibial drill angles on
bone tunnel aperture during anterior cruciate ligament reconstruc-
tion. J Bone Joint Surg Am. 2010;92(4):871-881.
30. Kropf EJ, Shen W, van Eck CF, Musahl V, Irrgang JJ, Fu FH. ACL-
PCL and intercondylar notch impingement: magnetic resonance
imaging of native and double-bundle ACL-reconstructed knees.
Knee Surg Sports Traumatol Arthrosc. 2013;21(3):720-725.
31. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett
WE. Graft size and patient age are predictors of early revision after
anterior cruciate ligament reconstruction with hamstring autograft.
Arthroscopy. 2012;28(4):526-531.
32. Malliaras P, Cook J. Changes in anteroposterior patellar tendon
diameter support a continuum of pathological changes. Br J Sports
Med. 2011;45(13):1048-1051.
33. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of ham-
string autograft size on patient-reported outcomes and risk of revi-
sion after anterior cruciate ligament reconstruction: a Multicenter
Orthopaedic Outcomes Network (MOON) Cohort Study. Arthros-
copy. 2013;29(12):1948-1953.
34. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechan-
ical analysis of human ligament grafts used in knee-ligament repairs
and reconstructions. J Bone Joint Surg Am. 1984;66(3):344-352.
35. Orsi AD, Canavan PK, Vaziri A, Goebel R, Kapasi OA, Nayeb-
Hashemi H. The effects of graft size and insertion site location during
anterior cruciate ligament reconstruction on intercondylar notch
impingement. Knee. 2017;24(3):525-535.
36. Rahnemai-Azar AA, Sabzevari S, Irarrazaval S, Chao T, Fu FH. Ana-
tomical individualized ACL reconstruction. Arch Bone Joint Surg.
2016;4(4):291-297.
37. Scheffel PT, Henninger HB, Burks RT. Relationship of the intercondy-
lar roof and the tibial footprint of the ACL: implications for ACL recon-
struction. Am J Sports Med. 2013;41(2):396-401.
38. Snaebjornsson T, Hamrin Senorski E, Ayeni OR, et al. Graft diameter
as a predictor for revision anterior cruciate ligament reconstruction
and KOOS and EQ-5D values: a cohort study from the Swedish
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Individualized ACL Graft Matching 7
National Knee Ligament Register based on 2240 patients. Am J
Sports Med. 2017;45(9):2092-2097.
39. Sohn KM, Lee MJ, Hong H, Yoon YC, Park CD, Wang JH. The bow
tie shape of the anterior cruciate ligament as visualized by high-
resolution magnetic resonance imaging. Am J Sports Med. 2017;
45(8):1881-1887.
40. Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA.
Posteromedial meniscocapsular lesions increase tibiofemoral joint
laxity with anterior cruciate ligament deficiency, and their repair
reduces laxity. Am J Sports Med. 2016;44(2):400-408.
41. Weiler A, Peine R, Pashmineh-Azar A, Abel C, Südkamp NP, Hoff-
mann RF. Tendon healing in a bone tunnel: part I. Biomechanical
results after biodegradable interference fit fixation in a model of ante-
rior cruciate ligament reconstruction in sheep. Arthroscopy. 2002;
18(2):113-123.
42. Xerogeanes JW, Mitchell PM, Karasev PA, Kolesov IA, Romine SE.
Anatomic and morphological evaluation of the quadriceps tendon
using 3-dimensional magnetic resonance imaging reconstruction:
applications for anterior cruciate ligament autograft choice and pro-
curement. Am J Sports Med. 2013;41(10):2392-2399.
43. Xie X, Liu X, Chen Z, Yu Y, Peng S, Li Q. A meta-analysis of bone–
patellar tendon–bone autograft versus four-strand hamstring tendon
autograft for anterior cruciate ligament reconstruction. Knee. 2015;
22(2):100-110.
44. Yasuda K, van Eck CF, Hoshino Y, Fu FH, Tashman S. Anatomic
single- and double-bundle anterior cruciate ligament reconstruction,
part 1: basic science. Am J Sports Med. 2011;39(8):1789-1799.
45. Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus
hamstring tendons in anterior cruciate ligament reconstruction:
a meta-analysis. Arthroscopy. 2001;17(3):248-257.
46. Zakko P, van Eck CF, Guenther D, Irrgang JJ, Fu FH. Can we predict
the size of frequently used autografts in ACL reconstruction? Knee
Surg Sports Traumatol Arthrosc. 2017;25(12):3704-3710.
47. Zantop T, Herbort M, Raschke MJ, Fu FH, Petersen W. The role of
the anteromedial and posterolateral bundles of the anterior cruciate
ligament in anterior tibial translation and internal rotation. Am J
Sports Med. 2007;35(2):223-227.