Knee Morphological Risk Factors for Anterior Cruciate Ligament Injury: A Systematic Review

Anterior cruciate ligament (ACL) reconstruction incidence has increased substantially in the past 25 years. Recently, there has been a focus on knee morphology as a contributor to ACL injury risk. The purpose of this study was to systematically review the literature to assess the influence of knee morphology on ACL injury.

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, Embase, and MEDLINE were searched in September 2017 for studies reporting on knee morphology and ACL injury. The search was updated in June 2018. The following inclusion criteria were used: English language; full text available; Level-I, II, or III evidence; human studies; and skeletally mature patients.

After systematically screening 6,208 studies, 65 studies met the inclusion/exclusion criteria. Three additional studies were identified in the search update, for a total of 68 studies comprising 5,834 ACL-injured knees. Intercondylar notch stenosis, most commonly defined by an "A-shaped" notch, decreased notch width, or decreased notch width index, was the most commonly reported femoral morphological risk factor for ACL injury. Increased femoral condylar offset ratio (>63%) and decreased condylar radius of curvature also were associated with an increased risk of ACL injury. Increased medial and lateral tibial slopes were the most commonly reported tibial risk factors. A smaller tibial eminence, reduced ACL size, and poor tibiofemoral congruity were also associated with increased injury risk.

Intercondylar notch stenosis, variations in sagittal condylar shape, increased tibial slope, reduced tibial eminence size, poor tibiofemoral congruity, and reduced ACL size are substantial risk factors for ACL injury. In future research, it would be valuable to identify a slope beyond which slope correction should be performed concomitantly with ACL reconstruction, and to determine whether an optimal relationship of notch size to graft size exists. To achieve optimal outcomes, the osseous morphological risk factors should be considered in individualized anatomic ACL reconstructions.

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.