title: Reliability of estimates of ACL attachment locations in 3-dimensional knee reconstruction based on routine clinical MRI in pediatric patients.
abstract: BACKGROUND
  Current techniques of anterior cruciate ligament (ACL) reconstruction focus on the placement of femoral and tibial tunnels at anatomic ACL attachments, which can be difficult to identify intraoperatively.
  
  
  OBJECTIVE
  To determine whether the 3-dimensional (3D) center of ACL attachments can be reliably detected from routine magnetic resonance imaging (MRI) in patients with intact ACLs and whether the reliability of this technique changes if the ACL is torn.
  
  
  METHODS
  Cohort study (diagnosis); Level of evidence, 3.
  
  
  METHODS
  A computer technique was developed in which users identify points along ACL attachments on routine clinical MRI of preoperative knees. These attachments are then displayed on a 3D MRI reconstruction, which can be used as a visual guide for the surgeon during arthroscopic surgery. Thirty-seven pediatric patients (age range, 10-17 years) with ACL tears and 37 controls with intact ACLs were examined. Two blinded observers identified cruciate ligament attachments on routine clinical 1.5-T MRI of knees. From the resulting 3D model, the location of the center of each ligament attachment site and its area were calculated and reliability assessed.
  
  
  RESULTS
  Mean interobserver variation of the centers of ACL attachments for the intact versus torn ACL was 1.7 ± 0.9 mm versus 1.8 ± 1.1 mm (femoral) and 1.4 ± 0.9 mm versus 1.7 ± 1.0 mm (tibial), respectively (P > .05). The 95% confidence interval for the center location was at most 4 mm. The identified ACL attachment areas were more variable, with interobserver reliability ranging from fair to excellent by the intraclass correlation coefficient. Overlap of ligament areas between observers for the intact versus torn ACL was 70% ± 15% versus 73% ± 12% (femoral) and 79% ± 9% versus 78% ± 10% (tibial), respectively (P > .05). In all cases, intraobserver reliability was superior to interobserver reliability.
  
  
  CONCLUSIONS
  The 3D locations of ACL tibial and femoral attachment centers were identified from routine clinical MRI with variability averaging less than 2 mm between 2 observers. The margin of error was at most 4 mm, representing the thickness of a single axial MRI slice, whether the ACL was intact or torn. Remnant tissue at attachments allows a reliable assessment even of torn ligaments. Identification of the ligament attachment areas was more user dependent than was identification of the attachment centers.
authors.affiliation: Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Vimarsha Gopal
authors.initials: VG
authors.lastname: Swami
authors.forename: June
authors.initials: J
authors.lastname: Cheng-Baron
authors.forename: Catherine
authors.initials: C
authors.lastname: Hui
authors.forename: Richard
authors.initials: R
authors.lastname: Thompson
authors.forename: Jacob Lester
authors.initials: JL
authors.lastname: Jaremko
mesh_terms: D000293:Adolescent; D016118:Anterior Cruciate Ligament / Q000033:anatomy & histology* / Q000601:surgery; D000070598:Anterior Cruciate Ligament Injuries; D059549:Anterior Cruciate Ligament Reconstruction; D001182:Arthroscopy; D002648:Child; D005260:Female; D005269:Femur / Q000033:anatomy & histology; D006801:Humans; D021621:Imaging, Three-Dimensional; D008279:Magnetic Resonance Imaging; D008297:Male; D015588:Observer Variation; D016037:Single-Blind Method; D012984:Software; D013977:Tibia / Q000033:anatomy & histology; D013997:Time Factors
keywords: 3D MRI; ACL; MRI; anatomy; anterior cruciate ligament reconstruction; pediatric