Subscribe to RSS
DOI: 10.1055/a-2607-9927
Comparison of Femoral Notch Width, Shape, and Medial Tibial Plateau Concavity in Individuals with and without Anterior Cruciate Ligament Injury
Funding None.

Abstract
Anterior cruciate ligament (ACL) injuries can occur in people of all ages and genders. Women are significantly more likely to experience them, particularly during their adolescent and young adult years. In the current study, we compared the width and shape of the femoral intercondylar notch and depth of the concavity of the medial tibial plateau in individuals with and without ACL injuries.
In this cross-sectional study, 100 participants (50 in the ACL injury group and 50 in the no-ACL injury group) were included. Data on age, gender, shape (categorized as U, A, and Ω), and width (notch width [NW] and notch width index [NWI]) of the femoral intercondylar notch, and the concavity depth of the medial tibial plateau and bicondylar width (BCW) of all participants were obtained from magnetic resonance imaging (MRI) and recorded. All data were analyzed using SPSS version 21, and a significance level of <0.05 was considered.
The prevalence of female gender in the ACL and no-ACL injury groups was 40% and 52%, respectively. The mean NWI and medial tibial plateau depth were significantly higher in the no-ACL injury group compared with the ACL injury group (p < 0.001). The intercondylar notch shape significantly differed between the two groups, with a higher frequency of type A notch in the ACL injury group and U shape in the no-ACL injury group (p < 0.001). Additionally, the mean NW was significantly narrower in the ACL injury group across the ≤30- and >40-year age groups (p < 0.001), although no significant difference was found in the 31- to 40-year age group (p > 0.05). Receiver operating characteristic (ROC) analysis indicated that NWI was the most predictive measure for ACL injuries (area under the curve [AUC] = 0.869), followed by NW (AUC = 0.763). BCW, however, had a lower predictive value (AUC = 0.431).
Due to our findings, narrow NWI and A-shaped femoral intercondylar notch were more prevalent in the ACL injury group than the no-ACL injury group, suggesting a risk factor for ACL injuries.
Ethical Approval
The study was confirmed by the ethical committee of the AJA University of Medical Sciences, Tehran, Iran (IR.AJAUMS.REC.1402.224).
Patient Consent
All subjects gave their informed consent to participate in the study.
Availability of Data and Materials
The datasets used and analyzed in the current study are available from the corresponding author upon reasonable request.
Authors' Contributions
All authors made significant contributions to the work reported. J.K., H.K.M., and N.H. participated in the research design and wrote the first draft. J.K., R.G., and S.F.H. performed the research and analysis. H.K.M., R.G., and S.F.H. participated in data analysis. All authors reviewed and confirmed the final manuscript. All authors agreed that the corresponding author would act on their behalf for any communication about the paper during the submission, peer-review process, and publication.
Publication History
Received: 25 December 2024
Accepted: 13 May 2025
Article published online:
30 May 2025
© 2025. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 An YW. Neurophysiological mechanisms underlying functional knee instability following an anterior cruciate ligament injury. Exerc Sci 2018; 27 (02) 109-117
- 2 Komnos GA, Hantes MH, Kalifis G, Gkekas NK, Hante A, Menetrey J. Anterior cruciate ligament tear: Individualized indications for non-operative management. J Clin Med 2024; 13 (20) 6233
- 3 Raines BT, Naclerio E, Sherman SL. Management of anterior cruciate ligament injury: What's in and what's out?. Indian J Orthop 2017; 51 (05) 563-575
- 4 Parsons JL, Coen SE, Bekker S. Anterior cruciate ligament injury: towards a gendered environmental approach. Br J Sports Med 2021; 55 (17) 984-990
- 5 Kaeding CC, Léger-St-Jean B, Magnussen RA. Epidemiology and diagnosis of anterior cruciate ligament injuries. Clin Sports Med 2017; 36 (01) 1-8
- 6 Buerba RA, Zaffagnini S, Kuroda R, Musahl V. ACL reconstruction in the professional or elite athlete: State of the art. J ISAKOS 2021; 6 (04) 226-236
- 7 Smith HC, Vacek P, Johnson RJ. et al. Risk factors for anterior cruciate ligament injury: a review of the literature - part 1: Neuromuscular and anatomic risk. Sports Health 2012; 4 (01) 69-78
- 8 Huang M, Li Y, Li H, Liao C, Xu H, Luo X. Predictive effects of the intercondylar notch morphology on anterior cruciate ligament injury in males: A magnetic resonance imaging analysis. Medicine (Baltimore) 2020; 99 (10) e19411
- 9 Yellin JL, Parisien RL, Talathi NS, Farooqi AS, Kocher MS, Ganley TJ. Narrow notch width is a risk factor for anterior cruciate ligament injury in the pediatric population: A multicenter study. Arthrosc Sports Med Rehabil 2021; 3 (03) e823-e828
- 10 Andrade R, Vasta S, Sevivas N. et al. Notch morphology is a risk factor for ACL injury: a systematic review and meta-analysis. J ISAKOS 2016; 1 (02) 70-81
- 11 Bedi A, Chen T, Santner TJ. et al. Changes in dynamic medial tibiofemoral contact mechanics and kinematics after injury of the anterior cruciate ligament: A cadaveric model. Proc Inst Mech Eng H 2013; 227 (09) 1027-1037
- 12 Bae BS, Yoo S, Lee SH. Ramp lesion in anterior cruciate ligament injury: A review of the anatomy, biomechanics, epidemiology, and diagnosis. Knee Surg Relat Res 2023; 35 (01) 23
- 13 Hash II TW. Magnetic resonance imaging of the knee. Sports Health 2013; 5 (01) 78-107
- 14 Xu B, Zhang H, Li B, Wang W. Comparison of magnetic resonance imaging for patients with acute and chronic anterior cruciate ligament tears. Medicine (Baltimore) 2018; 97 (10) e0001
- 15 Zhao M, Zhou Y, Chang J. et al. The accuracy of MRI in the diagnosis of anterior cruciate ligament injury. Ann Transl Med 2020; 8 (24) 1657
- 16 Hirtler L, Röhrich S, Kainberger F. The femoral intercondylar notch during life: An anatomic redefinition with patterns predisposing to cruciate ligament impingement. AJR Am J Roentgenol 2016; 207 (04) 836-845
- 17 Ball S, Stephen JM, El-Daou H, Williams A, Amis AA. The medial ligaments and the ACL restrain anteromedial laxity of the knee. Knee Surg Sports Traumatol Arthrosc 2020; 28 (12) 3700-3708
- 18 Evans J, Mabrouk A. Anterior Cruciate Ligament Knee Injury. In: StatPearls [Internet]. StatPearls Publishing; 2023
- 19 Maheshwari S, Thomas J, Kuber R. et al. Evaluation of bony femoral morphological parameters in anterior cruciate ligament injury using magnetic resonance imaging: A retrospective unmatched case-control study. Cureus 2024; 16 (03) e55463
- 20 Akcaalan S, Kavaklilar A, Caglar C, Ugurlu M, Dogan M, Akkaya M. Investigation of morphometric factors associated with adolescent ACL rupture. Orthop J Sports Med 2023; 11 (09) 23 259671231194928
- 21 Gupta R, Jhatiwal S, Kapoor A, Kaur R, Soni A, Singhal A. Narrow notch width and low anterior cruciate ligament volume are risk factors for anterior cruciate ligament injury: A magnetic resonance imaging-based study. HSS J 2022; 18 (03) 376-384
- 22 Cheung EC, Boguszewski DV, Joshi NB, Wang D, McAllister DR. Anatomic factors that may predispose female athletes to anterior cruciate ligament injury. Curr Sports Med Rep 2015; 14 (05) 368-372
- 23 Wittstein J, Vinson E, Garrett W. Comparison between sexes of bone contusions and meniscal tear patterns in noncontact anterior cruciate ligament injuries. Am J Sports Med 2014; 42 (06) 1401-1407
- 24 Chia L, De Oliveira Silva D, Whalan M. et al. Non-contact anterior cruciate ligament injury epidemiology in team-ball sports: A systematic review with meta-analysis by sex, age, sport, participation level, and exposure type. Sports Med 2022; 52 (10) 2447-2467
- 25 Cho Y, Lee S, Lee YS, Lee MC. Gender disparity in anterior cruciate ligament injuries. Arthrosc Orthop Sport Med. 2014; 1 (02) 65-74
- 26 Stracciolini A, Stein CJ, Zurakowski D, Meehan III WP, Myer GD, Micheli LJ. Anterior cruciate ligament injuries in pediatric athletes presenting to sports medicine clinic: a comparison of males and females through growth and development. Sports Health 2015; 7 (02) 130-136
- 27 Steffensmeier AM, Lamont SM, Metoyer G, DiPaolo Z, Froehle AW. Relationship between age at adult height and knee mechanics during a drop vertical jump in men. Orthop J Sports Med 2020; 8 (08) 2325967120944912
- 28 Grindem H, Engebretsen L, Axe M, Snyder-Mackler L, Risberg MA. Activity and functional readiness, not age, are the critical factors for second anterior cruciate ligament injury - the Delaware-Oslo ACL cohort study. Br J Sports Med 2020; 54 (18) 1099-1102
- 29 Best MJ, Zikria BA, Wilckens JH. Anterior cruciate ligament injuries in the older athlete. Sports Health 2021; 13 (03) 285-289
- 30 Salzler MJ, Chang J, Richmond J. Management of anterior cruciate ligament injuries in adults aged >40 years. J Am Acad Orthop Surg 2018; 26 (16) 553-561 . Accessed May 19, 2025 at: https://journals.lww.com/jaaos/fulltext/2018/08150/management_of_anterior_cruciate_ligament_injuries.1.aspx
- 31 Loeser RF. Age-related changes in the musculoskeletal system and the development of osteoarthritis. Clin Geriatr Med 2010; 26 (03) 371-386
- 32 Kızılgöz V, Sivrioğlu AK, Ulusoy GR, Aydın H, Karayol SS, Menderes U. Analysis of the risk factors for anterior cruciate ligament injury: an investigation of structural tendencies. Clin Imaging 2018; 50: 20-30
- 33 Fahim SM, Dhawan T, Jagadeesh N, Ashwathnarayan YP. The relationship of anterior cruciate ligament injuries with MRI based calculation of femoral notch width, notch width index, notch shape - A randomized control study. J Clin Orthop Trauma 2021; 17: 5-10
- 34 Basukala B, Joshi A, Pradhan I. The effect of the intercondylar notch shape and notch width index on anterior cruciate ligament injuries. J Nepal Health Res Counc 2020; 17 (04) 532-536
- 35 Görmeli CA, Görmeli G, Öztürk BY. et al. The effect of the intercondylar notch width index on anterior cruciate ligament injuries: a study on groups with unilateral and bilateral ACL injury. Acta Orthop Belg 2015; 81 (02) 240-244