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Notch morphology is a risk factor for ACL injury: a systematic review and meta-analysis
  1. Renato Andrade1,2,3,
  2. Sebastiano Vasta4,
  3. Nuno Sevivas2,3,5,6,7,
  4. Rogério Pereira2,3,8,
  5. Ana Leal2,3,9,
  6. Rocco Papalia4,
  7. Hélder Pereira2,3,7,10,11,
  8. João Espregueira-Mendes2,3,6,7,11,12
  1. 1Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, Porto, Portugal
  2. 2Dom Henrique Research Centre, Porto, Portugal
  3. 3Faculty of Sports, University of Porto, Porto, Portugal
  4. 4Orthopaedic and Trauma Department, Campus Biomedico University of Rome, Rome, Italy
  5. 5Orthopaedics Department, Hospital de Braga, Braga, Portugal
  6. 6Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
  7. 7ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
  8. 8Faculty of Health Sciences, University of Fernando Pessoa, Porto, Portugal
  9. 9Mechanical Engineering Department, CMEMS Center for MicroElectroMechanical Systems, University of Minho, Guimarães, Portugal
  10. 10Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal
  11. 113B's Research Group—Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, Guimarães, Portugal
  12. 12Orthopaedics Department, Minho University, Minho, Portugal
  1. Correspondence to Renato da Costa Andrade, Clínica do Dragão, Espregueira-Mendes Sports Centre—FIFA Medical Centre of Excellence, 4350-415, Porto, Portugal; espregueira{at}


Importance Several bone morphological parameters have been identified in the scientific literature as risk factors for sustaining an anterior cruciate ligament (ACL) injury; however, a clear consensus on which are the most predisposing factors is still missing.

Aim This systematic review and meta-analysis aims to investigate the association between bone morphological parameters and the risk of sustaining an ACL injury.

Evidence review We conducted a comprehensive search using PubMed, Cochrane Library, Scopus, CINAHL and SPORTDiscus databases from 2005 until 2015. Two authors independently searched for relevant studies that assessed the association between bone morphology and ACL injury. Other search sources were used for hand-searching additional potential studies and the reference list of recent studies was screened. The methodological quality of the included studies was assessed through an adapted scale for radiological studies. A fixed-effects or random-effects model was used accordingly to estimate the mean differences with 95% CIs regarding the association of ACL injury with intercondylar notch (ICN) width, notch width index (NWI) and tibial slopes.

Findings 23 studies were included for analysis comprising a total of 3452 participants, 1681 with an ACL injury and 1763 with an intact ACL. The ACL-injured individuals had narrower ICN width (p<0.001), smaller NWI (p=0.005) and steeper tibial slope (p<0.001).

Conclusions On the basis of the current scientific literature, narrower ICN widths, smaller NWI and increased tibial slopes put the individual at higher risk of injuring the ACL. Future research should focus on developing indexes for different parameters rather than absolute measurements.

  • Tissue
  • ACL / PCL
  • Bone
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