Radiographic tibial tubercle morphology as a predictor of anterior cruciate ligament injury

Purpose Few studies have assessed the link between tibial tubercle (TT) morphology and anterior cruciate ligament (ACL) injury, and most focus only on the TT–trochlear groove (TT–TG) distance. This study aimed to examine the relationship between ACL injury, TT morphology, and posterior tibial slope (PTS) by comprehensively evaluating TT-related radiological parameters. Methods Radiological images of 100 patients who underwent isolated ACL reconstruction for non-contact injury between 2016 and 2022 and 100 demographically matched controls with no relevant abnormalities on knee MRI were retrospectively analyzed. Thirteen radiological parameters were measured and compared, including PTS; TT torsion (TTT); TT-rotational angle (TT-RA); plateau axis–tuberosity axis (PA-TA); TT-TG; TT–PCL distance and ratio; TT lateralization (TTL) distance and ratio; TT height (TTH); and TT angle (TTA). Associations between these parameters and ACL injury, as well as interparameter correlations, were evaluated using t-tests, logistic regression, ROC analysis, and Pearson correlation. Results Mean TTT, TT-RA and PA-TA values were significantly lower in the ACL injury group (5.68° vs 8.34°, p < .001; 7.96° vs 12.09°, p < .001; 8.41° vs 11.58°, p < .001). Conversely, TT-TG, PTS and TTH were higher (10.69 mm vs 8.17 mm, p < .001; 12.84° vs 10.61°, p < .001; 11.69 mm vs 10.02 mm, p < .001). Logistic regression showed TTT (OR = −0.849), TT-RA (OR = −0.822), TT-TG (OR = 1.298), PTS (OR = 1.177), and TTH (OR = 1.327) independently associated with ACL injury. Conclusion In isolated ACL injury patients, TT torsion was lower and TT prominence higher. TT morphology assessment may help personalize ACL reconstruction, identify high-risk individuals, and support future clinical and biomechanical research on ACL injury susceptibility.