Anatomic study related to the anterior cruciate ligament (ACL) reconstruction surgery has been developed in accordance with the progress of imaging technology. Advances in imaging techniques, especially the move from two-dimensional (2D) to three-dimensional (3D) image analysis, substantially contribute to anatomic understanding and its application to advanced ACL reconstruction surgery. This paper introduces previous research about image analysis of the ACL anatomy and its application to ACL reconstruction surgery. Crucial bony landmarks for the accurate placement of the ACL graft can be identified by 3D imaging technique. Additionally, 3D-CT analysis of the ACL insertion site anatomy provides better and more consistent evaluation than conventional “clock-face” reference and roentgenologic quadrant method. Since the human anatomy has a complex three-dimensional structure, further anatomic research using three-dimensional imaging analysis and its clinical application by navigation system or other technologies is warranted for the improvement of the ACL reconstruction. 1. Introduction Recent progress of the anterior cruciate ligament (ACL) reconstruction procedure and related research largely stems from the increased attention to the restoration of the original anatomy. An accurate evaluation of the native anatomy is critical for achieving anatomic ACL reconstruction. Clinical outcome could be imperfect when the graft placement is not located at an anatomic position [1, 2]. Also, conventional transtibial ACL reconstruction, which often locates the graft away from anatomic location [3], leads to abnormal biomechanical behavior and in vivo knee kinematics [4–6], which could influence long-term knee joint health [7, 8]. On the other hand, the anatomical ACL reconstruction procedure, either single-bundle or double-bundle technique, could provide better knee kinematics than nonanatomic reconstruction [9–11] and promising clinical results [12–20]. Appropriate anatomic evaluation of the native ACL for each individual patient can provide critical information for planning ACL reconstruction in an anatomic fashion, while postoperative evaluation of the reconstructed ACL graft location could predict the prognosis after the surgery and give valuable feedback to surgeons. In theory, a conventional two-dimensional assessment cannot fully recognize the three-dimensional structure of the original anatomy. Therefore, three-dimensional imaging analysis of the knee has been progressively developed over the last few years [21, 22]. The purpose of this paper is to introduce
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