1 Orthopedic Department, Arak University of Medical Sciences, Arak, Iran

2 Pathology Department, Arak University of Medical Sciences, Arak, iran

3 bone and joint reconstruction research center, shafa yahian hospital , iran univercity medical science

4 Bone and Joint Reconstruction Research Center, Shafa Yahyaian Hospital, Iran university of Medical Science, Tehran, Iran

5 Valiasr Hospital, Arak University of Medical Sciences, Arak, Iran

6 Radiology Department, Faculty of Medicine, Arak University of Medical Sciences, Arak, Iran


Background: The presence of cruciate ligaments is very important for normal knee kinematics. Knee arthroplasty
prostheses, in which these ligaments are maintained, have better kinematics. The aim of the present study was to
investigate the association between femoral intercondylar notch (FIN) narrowing in radiography and clinical and
histopathologic integrity of anterior cruciate ligament (ACL) in patients undergoing knee replacement surgery.
Methods: FIN index was measured in tunnel view radiography of the knees of 102 candidates of knee replacement
surgery. The anatomical status of ACL was also examined during total knee arthroplasty (TKA). ACL was removed and
sent for histopathologic examination to assess its degeneration rate. The association between the FIN index and the
clinical and histopathological health of ACL was investigated.
Results: Among 102 patients with mean age of 69.73 ± 7.81 years , 39 patients (38.32%) had no or torn ACL, 31
patients (30.39%) had weak ACL, and 32 (31.37%) had normal ACL. There was a significant association between age
and clinical status of ACL during surgery (P=0.017). There was a significant difference in FIN and ACL health status
during surgery between the two groups with an index of more and less than 0.252 (P=0.019 and P=0.019, respectively).
There was no significant difference in the mean total degeneration score (TDS) of ACL between the two groups with FIN
more and less than 0.252 (P=0.816).
Conclusion: There was a significant difference between the age and FIN narrowing (less than 0.252) as well as ACL
clinical status during surgery. FIN narrowing had no significant effect on the severity of ACL degeneration and there was
no significant difference in the severity of degenerative histopathologic changes between healthy and attenuated ACLs.
This indicates that if ACL exists, although apparently attenuated, it has the histologic characteristic of a healthy ligament.
Level of evidence: II


Main Subjects

1. NiemeläInen MJ, MäKelä KT, Robertsson O, W-Dahl
A, Furnes O, Fenstad AM, et al. Different incidences
of knee arthroplasty in the Nordic countries: a
population-based study from the Nordic Arthroplasty
Register Association. Acta Orthop. 2017; 88(2):173-8.
2. Townley CO. Total knee arthroplasty. A personal
retrospective and prospective review. Clin Orthop
Relat Res. 1988; 236(1):8-22.
3. Pritchett JW. Bicruciate-retaining total knee
replacement provides satisfactory function and
implant survivorship at 23 years. Clin Orthop Relat
Res. 2015; 473(7):2327-33.
4. Abdelbadie A, Toreih AA, Radwan MA. ACL status in
arthroplasty patients, why not to preserve? SICOT J.
2018; 4(1):1.
5. Watanabe A, Kanamori A, Ikeda K, Ochiai N.
Histological evaluation and comparison of the
anteromedial and posterolateral bundle of the human
anterior cruciate ligament of the osteoarthritic knee
joint. Knee. 2011; 18(1):47-50.
6. Nowakowski AM, Stangel M, Grupp TM, Valderrabano V.
Investigating the primary stability of the transversal
support tibial plateau concept to retain both cruciate
ligaments during total knee arthroplasty. J Appl
Biomater Funct Mater. 2012; 10(2):127-35.
7. Stiehl JB, Komistek RD, Cloutier JM, Dennis DA. The
cruciate ligaments in total knee arthroplasty: a
kinematic analysis of 2 total knee arthroplasties. J
Arthroplasty. 2000; 15(5):545-50.
8. Sabouret P, Lavoie F, Cloutier JM. Total knee
replacement with retenti on of both cruciate
ligaments: a 22-year follow-up study. Bone Joint J.
2013; 95(7):917-22.
9. Engh GA, Ammeen D. Is an intact anterior cr uciate 

ligament needed in order to have a well-functioning
unicondylar knee replacement? Clin Orthop Relat
Res. 2000; 428(1):170-3.

10. Suggs JF, Li G, Park SE, Steffensmeier S, Rubash
HE, Freiberg AA. Function of the anterior cruciate
ligament after unicompartmental knee arthroplasty:
an in vitro robotic study. J Arthroplasty. 2004;
11. Nakamae A, Ochi M, Deie M, Adachi N, Kanaya
A, Nishimori M, et al. Biomechanical function of
anterior cruciate ligament remnants: how long
do they contribute to knee stability after injury in
patients with complete tears? Arthroscopy. 2010;
12. Bach Jr BR, Warren RF, Wickiewicz TL. The pivot
shift phenomenon: results and description of a
modified clinical test for anterior cruciate ligament
insufficiency. Am J Sports Med. 1988; 16(6):571-6.
13. Butler DL, Noyes FR, Grood ES. Ligamentous
restraints to anterior–posterior drawer in the human
knee. A biomechanical study. J Bone Joint Surg Am.
1980; 62(2):259-70.
14. Hughston JC, Andrews JR, Cross MJ, Moschi A.
Classification of knee ligament instabilities. Part I.
The medial compartment and cruciate ligaments. J
Bone Joint Surg Am. 1976; 58(2):159-72.
15. Andriacchi TP, Galante JO, Fermier RW. The influence
of total knee-replacement design on walking
and stair-climbing. J Bone Joint Surg Am. 1982;
16. Kuroyanagi Y, Mu S, Hamai S, Robb WJ, Banks SA. In
vivo knee kinematics during stair and deep flexion
activities in patients with bicruciate substituting total
knee arthroplasty. J Arthroplasty. 2012; 27(1):122-8.

17. Trompeter AJ, Gill K, Appleton MA, Palmer SH.
Predicting anterior cruciate ligament integrity
in patients with osteoarthritis. Knee Surg Sports
Traumatol Arthrosc. 2009; 17(6):595-9.
18. Komistek RD, Allain J, Anderson DT, Dennis DA,
Goutallier D. In vivo kinematics for subjects with and
without an anterior cruciate ligament. Clin Orthop
Relat Res. 2002; 404(1):315-25.
19. Schmidt R, Komistek RD, Blaha JD, Penenberg BL,
Maloney WJ. Fluoroscopic analyses of cruciateretaining
and medial pivot knee implants. Clin
Orthop Relat Res. 2003; 410(1):139-47.
20. Cushner FD, La Rosa DF, Vigorita VJ, Scuderi GR, Scott
WN, Insall JN. A quantitative histologic comparison:
ACL degeneration in the osteoarthritic knee. J
Arthroplasty. 2003; 18(6):687-92.
21. Douglas MJ, Hutchison JD, Sutherland AG. Anterior
cruciate ligament integrity in osteoarthritis of the
knee in patients undergoing total knee replacement.
J Orthop Traumatol. 2010; 11(3):149-54.
22. Allain J, Goutallier D, Voisin MC. Macroscopic and
histological assessments of the cruciate ligaments
in arthrosis of the knee. Acta Orthop Scand. 2001;
23. Noyes FR, DeLucas JL, Torvik PJ. Biomechanics of
anterior cruciate ligament failure: an analysis of
strain-rate sensitivity and mechanisms of failure in
primates. J Bone Joint Surg Am. 1974; 56(2):236-53.
24. Levy YD, Hasegawa A, Patil S, Koziol JA, Lotz MK,
D’Lima DD. Histopathological changes in the human
posterior cruciate ligament during aging and
osteoarthritis: correlations with anterior cruciate
ligament and cartilage changes. Ann Rheum Dis.
2013; 72(2):271-7.
25. Mullaji AB, Marawar SV, Simha M, Jindal G. Cruciate
ligaments in arthritic knees: a histologic study
with radiologic correlation. J Arthroplasty. 2008;
26. Hasegawa A, Otsuki S, Pauli C, Miyaki S, Patil S,
Steklov N, et al. Anterior cruciate ligament changes
in the human knee joint in aging and osteoarthritis.
Arthritis Rheum. 2012; 64(3):696-704.
27. Babatunde OM, Danoff JR, Patrick DA, Lee JH, Kazam
JK, Macaulay W. The Combination of the tunnel view
and weight-bearing anteroposterior radiographs
improves the detection of knee arthritis. Arthritis.
2016; 2016(1):9786924.

28. Souryal TO, Moore HA, Evans JP. Bilaterality in
anterior cruciate ligament injuries: associated
intercondylar notch stenosis. Am J Sports Med. 1988;
29. Chen C, Ma YH, Tan XY, Zhang B, Geng B, Jiang J, et al.
Relationship between coronal intercondylar notch
width index and osteoarthritis. Nan Fang Yi Ke Da
Xue Xue Bao. 2015; 35(10):1384-9.
30. Hasegawa A, Nakahara H, Kinoshita M, Asahara H,
Koziol J, Lotz MK. Cellular and extracellular matrix
changes in anterior cruciate ligaments during
human knee aging and osteoarthritis. Arthritis Res
Ther. 2013; 15(1):R29.
31. Stubbs G, Dahlstrom J, Papantoniou P, Cherian
M. Correlation between macroscopic changes
of arthrosis and the posterior cruciate ligament
histology in the osteoarthritic knee. ANZ J Surg.
2005; 75(12):1036-40.
32. Geng B, Wang J, Ma JL, Zhang B, Jiang J, Tan XY, et
al. Narrow intercondylar notch and anterior cruciate
ligament injury in female nonathletes with knee
osteoarthritis aged 41-65 years in plateau region.
Chin Med J. 2016; 129(21):2540-5.
33. Chen C, Ma Y, Geng B, Tan X, Zhang B, Jayswal CK, et al.
Intercondylar notch stenosis of knee osteoarthritis
and relationship between stenosis and osteoarthritis
complicated with anterior cruciate ligament injury:
a study in MRI. Medicine. 2016; 95(17):e3439.
34. Görmeli CA, Görmeli G, Ö􀇆 ztürk BY, Ö􀇆 zdemir Z,
Kahraman AS, Yıldırım O, et al. The effect of the
intercondylar notch width index on anterior
cruciate ligament injuries. Acta Orthop Belg. 2015;
35. Stein V, Li L, Guermazi A, Zhang Y, Kent Kwoh C, Eaton
CB, et al. The relation of femoral notch stenosis to
ACL tears in persons with knee osteoarthritis.
Osteoarthritis Cartilage. 2010; 18(2):192-9.
36. Mont MA, Elmallah RK, Cherian JJ, Banerjee S,
Kapadia BH. Histopathological evaluation of the
anterior cruciate ligament in patients undergoing
primary total knee arthroplasty. J Arthroplasty.
2015; 31(1):284-9.
37. Al-Saeed O, Brown M, Athyal R, Sheikh M. Association
of femoral intercondylar notch morphology, width
index and the risk of anterior cruciate ligament
injury. Knee Surg Sports Traumatol Arthrosc. 2013;