Factors influencing graft impingement on the wall of the intercondylar notch after anatomic double-bundle anterior cruciate ligament reconstruction

Kazuhiko Udagawa, Yasuo Niki, Hiroyuki Enomoto, Yoshiaki Toyama, Yasunori Suda

Research output: Contribution to journalArticlepeer-review

26 Citations (Scopus)


Background: Anatomic placement of the bone tunnel reportedly reduces impingement of the graft with the intercondylar roof, but as a trade-off, the risk of impingement with the lateral wall of the intercondylar notch would increase instead in anatomic doublebundle anterior cruciate ligament (ACL) reconstruction.

Purpose: The 2 grafts for the anteromedial bundle (AMB) and posterolateral bundle (PLB) were separately analyzed for the frequency of and risk factors for graft impingement on the wall of the intercondylar notch.

Study Design: Case control study; Level of evidence, 3

Methods: A total of 51 patients (53 knees) who underwent primary anatomic double-bundle ACL reconstruction were enrolled. Based on the graft orientation plane reconstructed with 3-dimensional imaging software, graft-wall impingement was defined as overlap between the lateral wall of the notch and the line connecting each center of the intra-articular apertures of the femoral and tibial bone tunnels. The rate of wall impingement was assessed for each bundle. Parameters for bone tunnel positioning in the femur and tibia, notch width index, and knee joint rotation angle were compared between patients with and without wall impingement. The most important risk factors for wall impingement were assessed by logistic regression analysis.

Results: Wall impingement for the AMB was observed in 22 knees (42%), whereas no patients exhibited wall impingement for the PLB. Regarding femoral bone tunnel positioning according to the quadrant method, the AMB bone tunnel was placed significantly higher in impingement-positive patients than in impingement-negative patients (P = .03). Regarding tibial tunnel positioning, the tunnel was placed significantly more anteriorly (P = .02) and laterally (P = .02) in the impingement-positive group than in the impingement-negative group. Bone tunnels positioned 48% to 50% from the medial border of the tibia demonstrated a 100% incidence of wall impingement. Based on logistic regression analysis, lateral deviation of the AMB tibial bone tunnel was significantly associated with wall impingement (odds ratio, 1.403; P = .048).

Conclusion: The tibial bone tunnel position in the coronal orientation was most likely associated with wall impingement. Considering that tibial bone tunnels are generally created with the knee in 90- of flexion and move laterally as the knee extends because of screw-home movement, the AMB bone tunnel for the tibia should be positioned as medially as possible within its footprint to minimize the risk of wall impingement after anatomic double-bundle ACL reconstruction.

Original languageEnglish
Pages (from-to)2219-2225
Number of pages7
JournalAmerican Journal of Sports Medicine
Issue number9
Publication statusPublished - 2014 Sept 1


  • anatomic double-bundle reconstruction
  • anterior cruciate ligament
  • bone tunnel positioning
  • wall impingement

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation


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