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Patel SH, Campbell NW, Emenim CE, Farino DO, Damen FW, Rispoli JV, Goergen CJ, Haus JM, Sabbaghi A, Carroll CC. Patellar tendon biomechanical and morphologic properties and their relationship to serum clinical variables in persons with prediabetes and type 2 diabetes. J Orthop Res 2024; 42:1653-1669. [PMID: 38400550 PMCID: PMC11222058 DOI: 10.1002/jor.25816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/08/2024] [Accepted: 01/27/2024] [Indexed: 02/25/2024]
Abstract
Tendon biomechanical properties and fibril organization are altered in patients with diabetes compared to healthy individuals, yet few biomarkers have been associated with in vivo tendon properties. We investigated the relationships between in vivo imaging-based tendon properties, serum variables, and patient characteristics across healthy controls (n = 14, age: 45 ± 5 years, body mass index [BMI]: 24 ± 1, hemoglobin A1c [HbA1c]: 5.3 ± 0.1%), prediabetes (n = 14, age: 54 ± 5 years, BMI: 29 ± 2; HbA1c: 5.7 ± 0.1), and type 2 diabetes (n = 13, age: 55 ± 3 years, BMI: 33 ± 2, HbA1c: 6.7 ± 0.3). We used ultrasound speckle-tracking and measurements from magnetic resonance imaging (MRI) to estimate the patellar tendon in vivo tangent modulus. Analysis of plasma c-peptide, interleukin-1β (IL-1β), IL-6, IL-8, tumor necrosis factor-α (TNF-α), adiponectin, leptin, insulin-like growth factor 1 (IGF-1), and C-reactive protein (CRP) was completed. We built regression models incorporating statistically significant covariates and indicators for the clinically defined groups. We found that tendon cross-sectional area normalized to body weight (BWN CSA) and modulus were lower in patients with type 2 diabetes than in healthy controls (p < 0.05). Our regression analysis revealed that a model that included BMI, leptin, high-density lipoprotein (HDL), low-density lipoprotein (LDL), age, and group explained ~70% of the variability in BWN CSA (R2 = 0.70, p < 0.001). For modulus, including the main effects LDL, groups, HbA1c, age, BMI, cholesterol, IGF-1, c-peptide, leptin, and IL-6, accounted for ~54% of the variability in modulus (R2 = 0.54, p < 0.05). While BWN CSA and modulus were lower in those with diabetes, group was a poor predicter of tendon properties when considering the selected covariates. These data highlight the multifactorial nature of tendon changes with diabetes and suggest that blood variables could be reliable predictors of tendon properties.
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Affiliation(s)
- Shivam H. Patel
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN
| | | | - Chinonso E. Emenim
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN
| | - Dominick O. Farino
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN
| | - Frederick W. Damen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN
| | - Joseph V. Rispoli
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN
| | - Craig J. Goergen
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN
| | - Jacob M. Haus
- School of Kinesiology, University of Michigan, Ann Arbor, MI
| | | | - Chad C. Carroll
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN
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Akatsuka Y, Teramoto A, Murahashi Y, Takahashi K, Imamura R, Takashima H, Watanabe K, Yamashita T. Quantitative assessment of anterior talofibular ligament quality in chronic lateral ankle instability using magnetic resonance imaging T2* value. Skeletal Radiol 2024; 53:733-739. [PMID: 37857750 DOI: 10.1007/s00256-023-04480-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE To determine T2* normal reference values for anterior talofibular ligament (ATFL) and to investigate the feasibility of the quantitative ATFL quality evaluation in chronic lateral ankle instability (CLAI) using T2* values. MATERIALS AND METHODS This study enrolled 15 patients with CLAI and 30 healthy volunteers. The entire ATFL T2* values from the MRI T2* mapping were measured. The prediction equation (variables: age, height, and weight) in a multiple linear regression model was used to calculate the T2* normal reference value in the healthy group. T2* ratio was defined as the ratio of the actual T2* value of the patient's ATFL to the normal reference value for each patient. A Telos device was used to measure the talar tilt angle (TTA) from the stress radiograph. RESULTS T2* values of ATFL in the healthy and CLAI groups were 10.82 ± 1.84 ms and 14.36 ± 4.30 ms, respectively, which are significantly higher in the CLAI group (P < 0.05). The prediction equation of the normal reference T2* value was [14.9 + 0.14 × age (years) - 4.7 × height (m) - 0.03 × weight (kg)] (R2 = 0.65, P < 0.0001). A significant positive correlation was found between the T2* ratio and TTA (r = 0.66, P = 0.007). CONCLUSION MRI T2* values in patients with CLAI were higher than those in healthy participants, and the T2* ratio correlated with TTA, suggesting that T2* values are promising for quantitative assessment of ATFL quality preoperatively.
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Affiliation(s)
- Yoshihiro Akatsuka
- Division of Radiology and Nuclear Medicine, Sapporo Medical University Hospital, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Yasutaka Murahashi
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Katsunori Takahashi
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Rui Imamura
- Division of Radiology and Nuclear Medicine, Sapporo Medical University Hospital, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Hiroyuki Takashima
- Faculty of Health Sciences, Hokkaido University, North-12, West-15, Kita-ku, Sapporo, 060-0812, Japan
| | - Kota Watanabe
- Second Division of Physical Therapy, Sapporo Medical University School of Health Sciences, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
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Anz AW, Jordan SE, Ostrander RV, Branch EA, Denney TS, Cohen A, Andrews JR. Augmentation of ACL Autograft Reconstruction With an Amnion Collagen Matrix Wrap and Bone Marrow Aspirate Concentrate: A Pilot Randomized Controlled Trial With 2-Year Follow-up. Orthop J Sports Med 2023; 11:23259671231210035. [PMID: 38021297 PMCID: PMC10656805 DOI: 10.1177/23259671231210035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 12/01/2023] Open
Abstract
Background It is theorized that the lack of a synovial lining after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) contributes to slow ligamentization and possible graft failure. Whether graft maturation and incorporation can be improved with the use of a scaffold requires investigation. Purpose To evaluate the safety and efficacy of wrapping an ACL autograft with an amnion collagen matrix and injecting bone marrow aspirate concentrate (BMAC), quantify the cellular content of the BMAC samples, and assess 2-year postoperative patient-reported outcomes. Study Design Randomized controlled trial; Level of evidence, 2. Methods A total of 40 patients aged 18 to 35 years who were scheduled to undergo ACLR were enrolled in a prospective single-blinded randomized controlled trial with 2 arms based on graft type: bone-patellar tendon-bone (BTB; n = 20) or hamstring (HS; n = 20). Participants in each arm were randomized into a control group who underwent standard ACLR or an intervention group who had their grafts wrapped with an amnion collagen matrix during graft preparation, after which BMAC was injected under the wrap layers after implantation. Postoperative magnetic resonance imaging (MRI) mapping/processing yielded mean T2* relaxation time and graft volume values at 3, 6, 9, and 12 months. Participants completed the Single Assessment Numeric Evaluation Score, Knee injury and Osteoarthritis Outcome Score, and pain visual analog scale. Statistical linear mixed-effects models were used to quantify the effects over time and the differences between the control and intervention groups. Adverse events were also recorded. Results No significant differences were found at any time point between the intervention and control groups for BTB T2* (95% CI, -1.89 to 0.63; P = .31), BTB graft volume (95% CI, -606 to 876.1; P = .71), HS T2* (95% CI, -2.17 to 0.39; P = .162), or HS graft volume (95% CI, -11,141.1 to 351.5; P = .28). No significant differences were observed between the intervention and control groups of either graft type on any patient-reported outcome measure. No adverse events were reported after a 2-year follow-up. Conclusion In this pilot study, wrapping a graft with an amnion collagen matrix and injecting BMAC appeared safe. MRI T2* values and graft volume of the augmented ACL graft were not significantly different from that of controls, suggesting that the intervention did not result in improved graft maturation. Registration NCT03294759 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Adam W. Anz
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Steve E. Jordan
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Roger V. Ostrander
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Eric A. Branch
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Thomas S. Denney
- Department of Electrical and Computer Engineering, Auburn University, Auburn, Alabama, USA
| | - Achraf Cohen
- Department of Mathematics and Statistics, University of West Florida, Pensacola, Florida, USA
| | - James R. Andrews
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
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Han M, Singh M, Karimi D, Kim JY, Flannery SW, Ecklund K, Murray MM, Fleming BC, Gholipour A, Kiapour AM. LigaNET: A multi-modal deep learning approach to predict the risk of subsequent anterior cruciate ligament injury after surgery. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.25.23293102. [PMID: 37546855 PMCID: PMC10402234 DOI: 10.1101/2023.07.25.23293102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are a common cause of soft tissue injuries in young active individuals, leading to a significant risk of premature joint degeneration. Postoperative management of such injuries, in particular returning patients to athletic activities, is a challenge with immediate and long-term implications including the risk of subsequent injury. In this study, we present LigaNET, a multi-modal deep learning pipeline that predicts the risk of subsequent ACL injury following surgical treatment. Postoperative MRIs (n=1,762) obtained longitudinally between 3 to 24 months after ACL surgery from a cohort of 159 patients along with 11 non-imaging outcomes were used to train and test: 1) a 3D CNN to predict subsequent ACL injury from segmented ACLs, 2) a 3D CNN to predict injury from the whole MRI, 3) a logistic regression classifier predict injury from non-imaging data, and 4) a multi-modal pipeline by fusing the predictions of each classifier. The CNN using the segmented ACL achieved an accuracy of 77.6% and AUROC of 0.84, which was significantly better than the CNN using the whole knee MRI (accuracy: 66.6%, AUROC: 0.70; P<.001) and the non-imaging classifier (accuracy: 70.1%, AUROC: 0.75; P=.039). The fusion of all three classifiers resulted in highest classification performance (accuracy: 80.6%, AUROC: 0.89), which was significantly better than each individual classifier (P<.001). The developed multi-modal approach had similar performance in predicting the risk of subsequent ACL injury from any of the imaging sequences (P>.10). Our results demonstrate that a deep learning approach can achieve high performance in identifying patients at high risk of subsequent ACL injury after surgery and may be used in clinical decision making to improve postoperative management (e.g., safe return to sports) of ACL injured patients.
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Affiliation(s)
- Mo Han
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mallika Singh
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Davood Karimi
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jin-Young Kim
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 1 Hoppin St, Providence RI 02903, USA
| | - BEAR Trial Team
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Kirsten Ecklund
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 1 Hoppin St, Providence RI 02903, USA
| | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Flannery SW, Murray MM, Badger GJ, Ecklund K, Kramer DE, Fleming BC, Kiapour AM. Early MRI-based quantitative outcomes are associated with a positive functional performance trajectory from 6 to 24 months post-ACL surgery. Knee Surg Sports Traumatol Arthrosc 2023; 31:1690-1698. [PMID: 35704062 PMCID: PMC9751233 DOI: 10.1007/s00167-022-07000-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Quantitative magnetic resonance imaging (qMRI) has been used to determine the failure properties of ACL grafts and native ACL repairs and/or restorations. How these properties relate to future clinical, functional, and patient-reported outcomes remain unknown. The study objective was to investigate the relationship between non-contemporaneous qMRI measures and traditional outcome measures following Bridge-Enhanced ACL Restoration (BEAR). It was hypothesized that qMRI parameters at 6 months would be associated with clinical, functional, and/or patient-reported outcomes at 6 months, 24 months, and changes from 6 to 24 months post-surgery. METHODS Data of BEAR patients (n = 65) from a randomized control trial of BEAR versus ACL reconstruction (BEAR II Trial; NCT02664545) were utilized retrospectively for the present analysis. Images were acquired using the Constructive Interference in Steady State (CISS) sequence at 6 months post-surgery. Single-leg hop test ratios, arthrometric knee laxity values, and International Knee Documentation Committee (IKDC) subjective scores were determined at 6 and 24 months post-surgery. The associations between traditional outcomes and MRI measures of normalized signal intensity, mean cross-sectional area (CSA), volume, and estimated failure load of the healing ACL were evaluated based on bivariate correlations and multivariable regression analyses, which considered the potential effects of age, sex, and body mass index. RESULTS CSA (r = 0.44, p = 0.01), volume (r = 0.44, p = 0.01), and estimated failure load (r = 0.48, p = 0.01) at 6 months were predictive of the change in single-leg hop ratio from 6 to 24 months in bivariate analysis. CSA (βstandardized = 0.42, p = 0.01), volume (βstandardized = 0.42, p = 0.01), and estimated failure load (βstandardized = 0.48, p = 0.01) remained significant predictors when considering the demographic variables. No significant associations were observed between MRI variables and either knee laxity or IKDC when adjusting for demographic variables. Signal intensity was also not significant at any timepoint. CONCLUSION The qMRI-based measures of CSA, volume, and estimated failure load were predictive of a positive functional outcome trajectory from 6 to 24 months post-surgery. These variables measured using qMRI at 6 months post-surgery could serve as prospective markers of the functional outcome trajectory from 6 to 24 months post-surgery, aiding in rehabilitation programming and return-to-sport decisions to improve surgical outcomes and reduce the risk of reinjury. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sean W Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M Murray
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Gary J Badger
- Department of Medical Biostatistics, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Kirsten Ecklund
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis E Kramer
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M Kiapour
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.
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Batista JP, Maestu R, Barbier J, Chahla J, Kunze KN. Propensity for Clinically Meaningful Improvement and Surgical Failure After Anterior Cruciate Ligament Repair. Orthop J Sports Med 2023; 11:23259671221146815. [PMID: 37065184 PMCID: PMC10102942 DOI: 10.1177/23259671221146815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/11/2022] [Indexed: 04/18/2023] Open
Abstract
Background Primary repair of the anterior cruciate ligament (ACL) confers an alternative to ACL reconstruction in appropriately selected patients. Purpose To prospectively assess survivorship and to define the clinically meaningful outcomes after ACL repair. Study Design Case series; Level of evidence, 4. Methods Included were consecutive patients with Sherman grade 1-2 tears who underwent primary ACL repair with or without suture augmentation between 2017 and 2019. Patient-reported outcomes (Lysholm, Tegner, International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score [KOOS] subscales) were collected preoperatively and at 6 months, 1 year, and 2 years postoperatively. The minimal clinically important difference (MCID) was calculated using a distribution-based method, whereas the Patient Acceptable Symptom State (PASS) and substantial clinical benefit (SCB) were calculated using an anchor-based method. Plain radiographs and magnetic resonance imaging (MRI) were obtained at 6 months, 1 year, and 2 years postoperatively. Results A total of 120 patients were included. The overall failure rate was 11.3% at 2 years postoperatively. Changes in outcome scores required to achieve the MCID ranged between 5.1 and 14.3 at 6 months, 4.6 and 8.4 at 1 year, and 4.7 and 11.9 at 2 years postoperatively. Thresholds for PASS achievement ranged between 62.5 and 89 at 6 months, 75 and 89 at 1 year, and 78.6 and 93.2 at 2 years postoperatively. Threshold scores (absolute/change based) for achieving the SCB ranged between 82.8 and 96.4/17.7 and 40.1 at 6 months, between 94.7 and 100/23 and 45 at 1 year, and between 95.3 and 100/29.4 and 45 at 2 years. More patients achieved the MCID and PASS at 1 year compared with 6 months and 2 years. For SCB, this trend was also observed for non-KOOS outcomes, while for KOOS subdomains, more patients achieved the SCB at 2 years. High-intensity signal of the ACL repair (odds ratio [OR], 31.7 [95% CI, 1.5-73.4]; P = .030) and bone contusions on MRI (OR, 4.2 [95% CI, 1.7-25.2]; P = .041) at 1 year postoperatively were independently associated with increased risk of ACL repair failure. Conclusion The rate of clinically meaningful outcome improvement was high early after ACL repair, with the greatest proportion of patients achieving the MCID, PASS, and SCB at 1 year postoperatively. Bone contusions involving the posterolateral tibia and lateral femoral condyle as well as high repair signal intensity at 1 year postoperatively were independent predictors of failure at 2 years postoperatively.
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Affiliation(s)
| | - Rodrigo Maestu
- Centro de Tratamiento de Enfermedades
Articulares, Buenoa Aires, Argentina
| | - Jose Barbier
- Centro Artroscópico Jorge Batista SA,
Buenos Aires, Argentina
| | - Jorge Chahla
- Division of Sports Medicine, Department
of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois,
USA
| | - Kyle N. Kunze
- Department of Orthopedic Surgery,
Hospital for Special Surgery, New York, New York, USA
- Kyle N. Kunze, M.D,
Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th
Street, New York, NY 10021, USA ()
(Twitter: @kylekunzemd)
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Flannery SW, Beveridge JE, Proffen BL, Walsh EG, Kramer DE, Murray MM, Kiapour AM, Fleming BC. Predicting anterior cruciate ligament failure load with T 2* relaxometry and machine learning as a prospective imaging biomarker for revision surgery. Sci Rep 2023; 13:3524. [PMID: 36864112 PMCID: PMC9981601 DOI: 10.1038/s41598-023-30637-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 02/27/2023] [Indexed: 03/04/2023] Open
Abstract
Non-invasive methods to document healing anterior cruciate ligament (ACL) structural properties could potentially identify patients at risk for revision surgery. The objective was to evaluate machine learning models to predict ACL failure load from magnetic resonance images (MRI) and to determine if those predictions were related to revision surgery incidence. It was hypothesized that the optimal model would demonstrate a lower mean absolute error (MAE) than the benchmark linear regression model, and that patients with a lower estimated failure load would have higher revision incidence 2 years post-surgery. Support vector machine, random forest, AdaBoost, XGBoost, and linear regression models were trained using MRI T2* relaxometry and ACL tensile testing data from minipigs (n = 65). The lowest MAE model was used to estimate ACL failure load for surgical patients at 9 months post-surgery (n = 46) and dichotomized into low and high score groups via Youden's J statistic to compare revision incidence. Significance was set at alpha = 0.05. The random forest model decreased the failure load MAE by 55% (Wilcoxon signed-rank test: p = 0.01) versus the benchmark. The low score group had a higher revision incidence (21% vs. 5%; Chi-square test: p = 0.09). ACL structural property estimates via MRI may provide a biomarker for clinical decision making.
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Affiliation(s)
- Sean W Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Coro West, Suite 402, 1 Hoppin St, Providence, RI, 02903, USA
| | - Jillian E Beveridge
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Coro West, Suite 402, 1 Hoppin St, Providence, RI, 02903, USA
| | - Benedikt L Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward G Walsh
- Department of Neuroscience, Division of Biology and Medicine, Brown University, Providence, RI, USA
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ata M Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Coro West, Suite 402, 1 Hoppin St, Providence, RI, 02903, USA.
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8
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Flannery SW, Barnes DA, Costa MQ, Menghini D, Kiapour AM, Walsh EG, Kramer DE, Murray MM, Fleming BC. Automated segmentation of the healed anterior cruciate ligament from T 2 * relaxometry MRI scans. J Orthop Res 2023; 41:649-656. [PMID: 35634860 PMCID: PMC9708947 DOI: 10.1002/jor.25390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/16/2022] [Accepted: 05/26/2022] [Indexed: 02/04/2023]
Abstract
Collagen organization of the anterior cruciate ligament (ACL) can be evaluated using T2 * relaxometry. However, T2 * mapping requires manual image segmentation, which is a time-consuming process and prone to inter- and intra- segmenter variability. Automating segmentation would address these challenges. A model previously trained using Constructive Interference in Steady State (CISS) scans was applied to T2 * segmentation via transfer learning. It was hypothesized that there would be no significant differences in the model's segmentation performance between T2 * and CISS, structural measures versus ground truth manual segmentation, and reliability versus independent and retest manual segmentation. Transfer learning was conducted using 54 T2 * scans of the ACL. Segmentation performance was assessed with Dice coefficient, precision, and sensitivity, and structurally with T2 * value, volume, subvolume proportions, and cross-sectional area. Model performance relative to independent manual segmentation and repeated segmentation by the ground truth segmenter (retest) were evaluated on a random subset. Segmentation performance was analyzed with Mann-Whitney U tests, structural measures with Wilcoxon signed-rank tests, and performance relative to manual segmentation with repeated-measures analysis of variance/Tukey tests (α = 0.05). T2 * segmentation performance was not significantly different from CISS on all measures (p > 0.35). No significant differences were detected in structural measures (p > 0.50). Automatic segmentation performed as well as the retest on all segmentation measures, whereas independent segmentations were lower than retest and/or automatic segmentation (p < 0.023). Structural measures were not significantly different between segmenters. The automatic segmentation model performed as well on the T2 * sequence as on CISS and outperformed independent manual segmentation while performing as well as retest segmentation.
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Affiliation(s)
- Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Dominique A. Barnes
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Meggin Q. Costa
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Danilo Menghini
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward G. Walsh
- Department of Neuroscience, Division of Biology and Medicine, Brown University, Providence, RI, USA
| | - Dennis E. Kramer
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
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9
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Barnes DA, Flannery SW, Badger GJ, Yen YM, Micheli LJ, Kramer DE, Fadale PD, Hulstyn MJ, Owens BD, Murray MM, Fleming BC, Kiapour AM. Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration. Am J Sports Med 2023; 51:413-421. [PMID: 36645042 PMCID: PMC9905304 DOI: 10.1177/03635465221142323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.
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Affiliation(s)
- Dominique A. Barnes
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, Larner College of
Medicine, University of Vermont, Burlington, VT, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Lyle J. Micheli
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis E. Kramer
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul D. Fadale
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Michael J. Hulstyn
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Brett D. Owens
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
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10
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Flannery SW, Walsh EG, Sanborn RM, Chrostek CA, Costa MQ, Kaushal SG, Murray MM, Fleming BC, Kiapour AM. Reproducibility and postacquisition correction methods for quantitative magnetic resonance imaging of the anterior cruciate ligament (ACL). J Orthop Res 2022; 40:2908-2913. [PMID: 35266588 PMCID: PMC9463398 DOI: 10.1002/jor.25319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 02/04/2023]
Abstract
Quantitative magnetic resonance imaging has been used to evaluate the structural integrity of knee joint structures. However, variations in acquisition parameters between scanners pose significant challenges. Understanding the effect of small differences in acquisition parameters for quantitative sequences is vital to the validity of cross-institutional studies, and for the harmonization of large, heterogeneous datasets to train machine learning models. The study objective was to assess the reproducibility of T2 * relaxometry and the constructive interference in steady-state sequence (CISS) across scanners, with minimal hardware-necessitated changes to acquisition parameters. It was hypothesized that there would be no significant differences between scanners in anterior cruciate ligament T2 * relaxation times and CISS signal intensities (SI). Secondarily, it was hypothesized that differences could be corrected by rescaling the SI distribution to harmonize between scanners. Seven volunteers were scanned on 3T Prisma and Tim Trio scanners (Siemens). Three correction methods were evaluated for T2 *: inverse echo time scaling, z-scoring, and Nyúl histogram matching. For CISS, scans were normalized to cortical bone, scaled by the background noise ratio, and log-transformed. Before correction, significant mean differences of 6.0 ± 3.2 ms (71.8%; p = 0.02) and 0.49 ± 0.15 units (40.7%; p = 0.02) for T2 * and CISS across scanners were observed, respectively. After rescaling, T2 * differences decreased to 2.6 ± 2.7 ms (23.9%; p = 0.03), 1.3 ± 2.5 ms (10.9%; p = 0.13), and 1.27 ± 3.0 ms (19.6%; p = 0.40) for inverse echo time, z-scoring, and Nyúl, respectively, while CISS decreased to 0.01 ± 0.11 units (4.0%; p = 0.87). These findings suggest that small acquisition parameter differences may lead to large changes in T2 * and SI values that must be reconciled to compare data across magnets.
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Affiliation(s)
- Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Edward G. Walsh
- Department of Neuroscience, Division of Biology and Medicine, Brown University, Providence, RI, USA
| | - Ryan M. Sanborn
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Cynthia A. Chrostek
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Meggin Q. Costa
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Shankar G. Kaushal
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha M. Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M. Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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11
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Shi Q, Wang H, He K, Tao M, Cheng CK. Comparison of the morphology of the anterior cruciate ligament and related bony structures between pigs and humans. Front Vet Sci 2022; 9:1045785. [PMID: 36467640 PMCID: PMC9716283 DOI: 10.3389/fvets.2022.1045785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/03/2022] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Pigs are widely used for clinical research on the anterior cruciate ligament (ACL) because of the similarity of the knee structure to the human knee. But evidence to support the suitability of using porcine samples to guide clinical practices is limited. This study aims to explore the qualitative and quantitative morphological features of the porcine knee and ACL, and to compare these with data on humans reported in literature. METHODS Nineteen porcine knees were used for this study. The bone structures were measured on coronal X-ray images. The length of the ACL was measured using a caliper. The ACL bone insertion sites were marked and measured on a digital photograph. The lengths of the long and short axis of the ACL isthmus were measured on the X-ray microscopy reconstructed images. The outcomes were compared with previously reported data on humans using an abstract independent-samples T test. RESULTS Qualitative observation indicated a similar location, orientation and general morphology of the porcine ACL to human ACLs. The major difference was the location of the ACL tibial insertion with respect to the anterior horn of the lateral meniscus (AHLM). The porcine ACL was split into AM and PL bundles by the AHLM, while the AHLM was adjacent to the anterolateral border of the ACL tibial insertion in human knees. The quantitative comparison showed no significant difference between the human and porcine ACL in terms of the length of the ACL, the width of the femoral condyle and tibial plateau, and the tibial interspinal width. However, the CSA, the lengths of the long and short axis of the ACL isthmus, and the femoral and tibial insertion areas of the porcine ACL were all significantly larger than the reported features in human knees. CONCLUSION The location, orientation and basic morphology of the porcine ACL and knee are similar to humans. However, the two-bundle structure is more distinct in a porcine ACL, and the dimensions of the porcine ACL are generally larger. This study may provide useful information to researchers when assessing the feasibility and limitations of using porcine samples for research on the human ACL and knee.
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12
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Wilms LM, Radke KL, Latz D, Thiel TA, Frenken M, Kamp B, Filler TJ, Nagel AM, Müller-Lutz A, Abrar DB, Nebelung S. UTE-T2* versus conventional T2* mapping to assess posterior cruciate ligament ultrastructure and integrity-an in-situ study. Quant Imaging Med Surg 2022; 12:4190-4201. [PMID: 35919061 PMCID: PMC9338370 DOI: 10.21037/qims-22-251] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/23/2022] [Indexed: 01/01/2023]
Abstract
Background Clinical-standard morphologic magnetic resonance imaging (MRI) is limited in the refined diagnosis of posterior cruciate ligament (PCL) injuries. Quantitative MRI sequences such as ultrashort echo-time (UTE)-T2* mapping or conventional T2* mapping have been theorized to quantify ligament (ultra-) structure and integrity beyond morphology. This study evaluates their diagnostic potential in identifying and differentiating partial and complete PCL injuries in a standardized graded injury model. Methods Ten human cadaveric knee joint specimens were imaged on a clinical 3.0 T MRI scanner using morphologic, conventional T2* mapping, and UTE-T2* mapping sequences before and after standardized arthroscopic partial and complete PCL transection. Following manual segmentation, quantitative T2* and underlying texture features (i.e., energy, homogeneity, and variance) were analyzed for each specimen and PCL condition, both for the entire PCL and its subregions. For statistical analysis, Friedman’s test followed by Dunn’s multiple comparison test was used against the level of significance of P≤0.01. Results For the entire PCL, T2* was significantly increased as a function of injury when acquired with the UTE-T2* sequence [entire PCL: 11.1±3.1 ms (intact); 10.9±4.6 ms (partial); 14.3±4.9 ms (complete); P<0.001], but not when acquired with the conventional T2* sequence [entire PCL: 10.0±3.2 ms (intact); 11.4±6.2 ms (partial); 15.5±7.8 ms (complete); P=0.046]. The PCL subregions and texture variables showed variable changes indicative of injury-associated disorganization. Conclusions In contrast to the conventional T2* mapping, UTE-T2* mapping is more receptive in the detection of structural damage of the PCL and allows quantitative assessment of ligament (ultra-)structure and integrity that may help to improve diagnostic differentiation of distinct injury states. Once further substantiated beyond the in-situ setting, UTE-T2* mapping may refine diagnostic evaluation of PCL injuries and -possibly- monitor ligament healing, ageing, degeneration, and inflammation.
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Affiliation(s)
- Lena Marie Wilms
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany.,Department of Orthopaedics and Trauma Surgery, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | - Karl Ludger Radke
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | - David Latz
- Department of Orthopaedics and Trauma Surgery, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | - Thomas Andreas Thiel
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | - Miriam Frenken
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | - Benedikt Kamp
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | | | - Armin Michael Nagel
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Division of Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anja Müller-Lutz
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | - Daniel Benjamin Abrar
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany
| | - Sven Nebelung
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Dusseldorf, Germany.,Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
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13
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Ligamentization of the reconstructed ACL differs between the intraarticular and intraosseous regions: A quantitative assessment using UTE-T2* mapping. PLoS One 2022; 17:e0271935. [PMID: 35867680 PMCID: PMC9307199 DOI: 10.1371/journal.pone.0271935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/08/2022] [Indexed: 11/20/2022] Open
Abstract
Background The purpose of this study was to prospectively observe the trends of ultrashort echo time (UTE)-T2* values for the intraarticular and intraosseous regions of reconstructed anterior cruciate ligaments from 6 to 12 months after anterior cruciate ligament reconstruction by using UTE-T2* mapping, and to investigate the changes and differences over time in each region. Methods Ten patients underwent UTE-T2* mapping of the operated knee at 6, 9, and 12 months after anterior cruciate ligament reconstruction. The UTE-T2* values of intraarticular and intraosseous regions of reconstructed anterior cruciate ligaments at 6, 9, and 12 months postoperatively were statistically compared. Results The UTE-T2* values of the intraarticular region at 6 months postoperatively were significantly higher than those at 9 and 12 months. There were no significant differences in the UTE-T2* values at 6, 9, and 12 months postoperatively in the intraosseous region. At 6 months postoperatively, the UTE-T2* values of the intraarticular region were significantly higher than those of the intraosseous region. The UTE-T2* values of the intraosseous region at the tibia were significantly lower than those of the other sites at any postoperative time point. Conclusions According to UTE-T2*mapping-based findings, histological maturation of reconstructed ACLs is faster in the intraosseous region than in the intraarticular region. In particular, the intraarticular region is still undergoing rapid histologic changes at 6 months postoperatively, and its tissue structure is less substantial than normal. The findings of this study may provide clues to determine the optimal timing for safe return to sports in terms of ligamentaization of reconstructed ACLs.
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14
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Jerban S, Hananouchi T, Ma Y, Namiranian B, Dorthe EW, Wong JH, Shojaeiadib N, Wu M, Du J, D’Lima D, Chung CB, Chang EY. Correlation between the elastic modulus of anterior cruciate ligament (ACL) and quantitative ultrashort echo time (UTE) magnetic resonance imaging. J Orthop Res 2022; 40:2330-2339. [PMID: 35092077 PMCID: PMC9332184 DOI: 10.1002/jor.25266] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/11/2021] [Accepted: 01/06/2022] [Indexed: 02/04/2023]
Abstract
Conventional magnetic resonance imaging (MRI) often acquires no signal in anterior cruciate ligament (ACL) due to the short apparent transverse relaxation time of ACL. Ultrashort echo time (UTE) MRI is capable of imaging ACL with high signal which enables quantitative ACL assessment. This study aimed to investigate the correlations of the mechanical and microstructural properties of human ACL specimens with quantitative three-dimensional UTE Cones (3D-UTE-Cones) MRI measures. ACL specimens were harvested from cadaveric knee joints of 13 (50.9 ± 21.1 years old, 11 males and 2 female) donors. Specimens were scanned using a series of quantitative 3D-UTE-Cones T2 * (UTE-T2 *), T1 (UTE-T1 ), Adiabatic T1ρ (UTE-Adiab-T1ρ ), and magnetization transfer (UTE-MT) sequences in a wrist coil on a clinical 3T scanner. ACL elastic modulus was measured using a uniaxial tensile mechanical test. Histomorphometry analysis was performed to measure the average fascicle specific surface, fascicle size, and number of cells per unit area. Spearman's rank correlations of UTE-MRI biomarkers with mechanical and histomorphometry measures were investigated. The elastic modulus of ACL showed significant moderate correlations with UTE-Adiab-T1ρ (R = -0.59, p = 0.01), macromolecular fraction from MT modeling (R = 0.54, p = 0.01), magnetization transfer ratio (R = 0.53, p = 0.01), UTE-T2* (R = -0.53, p = 0.01), and average fascicle specific surface (R = 0.54, p = 0.01). UTE-MRI showed nonsignificant correlations with histomorphometry measures. UTE-MRI biomarkers may be useful noninvasive tools for the ACL mechanical assessment.
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Affiliation(s)
- Saeed Jerban
- Department of Radiology, University of California San
Diego, San Diego, CA 92093, USA,Corresponding author: Darryl
D’Lima, Shiley Center for Orthopedic Research and Education at
Scripps Clinic, La Jolla, CA 92037, USA, ,
Phone: +1 858 554 7011, Fax: +1 858 554 7011; Eric Y. Chang,
Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Drive,
San Diego, CA 92161, USA, , Phone: +1 858 246
2248, Fax: +1 888 960 5922;Saeed Jerban, Department of Radiology,
University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA,
, Phone: +1 858 246 2248, Fax: +1 888 960
5922
| | - Takehito Hananouchi
- Department of Mechanical Engineering, Osaka Sangyo
University, Daito, Osaka, Japan
| | - Yajun Ma
- Department of Radiology, University of California San
Diego, San Diego, CA 92093, USA
| | - Behnam Namiranian
- Department of Radiology, University of California San
Diego, San Diego, CA 92093, USA
| | - Erik W. Dorthe
- Shiley Center for Orthopedic Research and Education at
Scripps Clinic, La Jolla, CA 92037, USA
| | - Jonathan H. Wong
- Research Service, VA San Diego Healthcare System, San
Diego, CA 92161, USA
| | | | - Mei Wu
- Department of Radiology, University of California San
Diego, San Diego, CA 92093, USA
| | - Jiang Du
- Department of Radiology, University of California San
Diego, San Diego, CA 92093, USA
| | - Darryl D’Lima
- Department of Mechanical Engineering, Osaka Sangyo
University, Daito, Osaka, Japan,Corresponding author: Darryl
D’Lima, Shiley Center for Orthopedic Research and Education at
Scripps Clinic, La Jolla, CA 92037, USA, ,
Phone: +1 858 554 7011, Fax: +1 858 554 7011; Eric Y. Chang,
Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Drive,
San Diego, CA 92161, USA, , Phone: +1 858 246
2248, Fax: +1 888 960 5922;Saeed Jerban, Department of Radiology,
University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA,
, Phone: +1 858 246 2248, Fax: +1 888 960
5922
| | - Christine B. Chung
- Department of Radiology, University of California San
Diego, San Diego, CA 92093, USA
| | - Eric Y. Chang
- Department of Radiology, University of California San
Diego, San Diego, CA 92093, USA,Research Service, VA San Diego Healthcare System, San
Diego, CA 92161, USA,Corresponding author: Darryl
D’Lima, Shiley Center for Orthopedic Research and Education at
Scripps Clinic, La Jolla, CA 92037, USA, ,
Phone: +1 858 554 7011, Fax: +1 858 554 7011; Eric Y. Chang,
Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Drive,
San Diego, CA 92161, USA, , Phone: +1 858 246
2248, Fax: +1 888 960 5922;Saeed Jerban, Department of Radiology,
University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA,
, Phone: +1 858 246 2248, Fax: +1 888 960
5922
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15
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Barnett SC, Murray MM, Flannery SW, Menghini D, Fleming BC, Kiapour AM, Proffen B, Sant N, Portilla G, Sanborn R, Freiberger C, Henderson R, Ecklund K, Yen YM, Kramer D, Micheli L. ACL Size, but Not Signal Intensity, Is Influenced by Sex, Body Size, and Knee Anatomy. Orthop J Sports Med 2022; 9:23259671211063836. [PMID: 34988237 PMCID: PMC8721387 DOI: 10.1177/23259671211063836] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Little is known about sex-based differences in anterior cruciate ligament (ACL) tissue quality in vivo or the association of ACL size (ie, volume) and tissue quality (ie, normalized signal intensity on magnetic resonance imaging [MRI]) with knee anatomy. Hypothesis: We hypothesized that (1) women have smaller ACLs and greater ACL normalized signal intensity compared with men, and (2) ACL size and normalized signal intensity are associated with age, activity levels, body mass index (BMI), bicondylar width, intercondylar notch width, and posterior slope of the lateral tibial plateau. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Knee MRI scans of 108 unique ACL-intact knees (19.7 ± 5.5 years, 62 women) were used to quantify the ACL signal intensity (normalized to cortical bone), ligament volume, mean cross-sectional area, and length. Independent t tests were used to compare the MRI-based ACL parameters between sexes. Univariate and multivariate linear regression analyses were used to investigate the associations between normalized signal intensity and size with age, activity levels, BMI, bicondylar width, notch width, and posterior slope of the lateral tibial plateau. Results: Compared with men, women had significantly smaller mean ACL volume (men vs women: 2028 ± 472 vs 1591 ± 405 mm3), cross-sectional area (49.4 ± 9.6 vs 41.5 ± 8.6 mm2), and length (40.8 ± 2.8 vs 38.1 ± 3.1 mm) (P < .001 for all), even after adjusting for BMI and bicondylar width. There was no difference in MRI signal intensity between men and women (1.15 ± 0.24 vs 1.12 ± 0.24, respectively; P = .555). BMI, bicondylar width, and intercondylar notch width were independently associated with a larger ACL (R2 > 0.16, P < .001). Younger age and steeper lateral tibial slope were independently associated with shorter ACL length (R2 > 0.03, P < .04). The combination of BMI and bicondylar width was predictive of ACL volume and mean cross-sectional area (R2 < 0.3). The combination of BMI, bicondylar width, and lateral tibial slope was predictive of ACL length (R2 = 0.39). Neither quantified patient characteristics nor anatomic variables were associated with signal intensity. Conclusion: Men had larger ACLs compared with women even after adjusting for BMI and knee size (bicondylar width). No sex difference was observed in signal intensity, suggesting no difference in tissue quality. The association of the intercondylar notch width and lateral tibial slope with ACL size suggests that the influence of these anatomic features on ACL injury risk may be partially explained by their effect on ACL size. Registration: NCT02292004 and NCT02664545 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Samuel C Barnett
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sean W Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Danilo Menghini
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ata M Kiapour
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt Proffen
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Sant
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Portilla
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan Sanborn
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Freiberger
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael Henderson
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis Kramer
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle Micheli
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Flannery SW, Kiapour AM, Edgar DJ, Murray MM, Beveridge JE, Fleming BC. A transfer learning approach for automatic segmentation of the surgically treated anterior cruciate ligament. J Orthop Res 2022; 40:277-284. [PMID: 33458865 PMCID: PMC8285460 DOI: 10.1002/jor.24984] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/17/2020] [Accepted: 01/11/2021] [Indexed: 02/04/2023]
Abstract
Quantitative magnetic resonance imaging enables quantitative assessment of the healing anterior cruciate ligament or graft post-surgery, but its use is constrained by the need for time consuming manual image segmentation. The goal of this study was to validate a deep learning model for automatic segmentation of repaired and reconstructed anterior cruciate ligaments. We hypothesized that (1) a deep learning model would segment repaired ligaments and grafts with comparable anatomical similarity to intact ligaments, and (2) automatically derived quantitative features (i.e., signal intensity and volume) would not be significantly different from those obtained by manual segmentation. Constructive Interference in Steady State sequences were acquired of ACL repairs (n = 238) and grafts (n = 120). A previously validated model for intact ACLs was retrained on both surgical groups using transfer learning. Anatomical performance was measured with Dice coefficient, sensitivity, and precision. Quantitative features were compared to ground truth manual segmentation. Automatic segmentation of both surgical groups resulted in decreased anatomical performance compared to intact ACL automatic segmentation (repairs/grafts: Dice coefficient = .80/.78, precision = .79/.78, sensitivity = .82/.80), but neither decrease was statistically significant (Kruskal-Wallis: Dice coefficient p = .02, precision p = .09, sensitivity p = .17; Dunn post-hoc test for Dice coefficient: repairs/grafts p = .054/.051). There were no significant differences in quantitative features between the ground truth and automatic segmentation of repairs/grafts (0.82/2.7% signal intensity difference, p = .57/.26; 1.7/2.7% volume difference, p = .68/.72). The anatomical similarity performance and statistical similarities of quantitative features supports the use of this automated segmentation model in quantitative magnetic resonance imaging pipelines, which will accelerate research and provide a step towards clinical applicability.
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Affiliation(s)
- Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M. Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - David J. Edgar
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M. Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jillian E. Beveridge
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA,Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
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17
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Kiapour AM, Flannery SW, Murray MM, Miller PE, Fleming BC, Sant N, Portilla G, Sanborn R, Freiberger C, Henderson R, Barnett S, Ecklund K, Yen YM, Kramer DE, Micheli LJ, Fleming BC. Regional Differences in Anterior Cruciate Ligament Signal Intensity After Surgical Treatment. Am J Sports Med 2021; 49:3833-3841. [PMID: 34668789 PMCID: PMC8829819 DOI: 10.1177/03635465211047554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Magnetic resonance-based measurements of signal intensity have been used to track healing of surgically treated anterior cruciate ligaments (ACLs). However, it is unknown how the signal intensity values in different regions of the ligament or graft change during healing. HYPOTHESES (1) Normalized signal intensity of the healing graft or repaired ACL is heterogeneous; (2) temporal changes in normalized signal intensity values differ among the tibial, middle, and femoral regions; and (3) there are no differences in regional normalized signal intensity values 2 years postoperatively among grafts, repaired ACLs, and contralateral native ACLs. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Magnetic resonance imaging scans were analyzed from patients in a trial comparing ACL reconstruction (n = 35) with bridge-enhanced ACL repair (n = 65). The ACLs were segmented from images acquired at 6, 12, and 24 months postoperatively and were partitioned into 3 sections along the longitudinal axis (femoral, middle, and tibial). Linear mixed modeling was used to compare location-specific differences in normalized ligament signal intensity among time points (6, 12, and 24 months) and groups (ACL reconstruction, repair, and contralateral native ACL). RESULTS For grafts, the middle region had a higher mean normalized signal intensity when compared with the femoral region at all time points (P < .01) but compared with the tibial region only at 6 months (P < .01). For repaired ACLs, the middle region had a higher mean normalized signal intensity versus the femoral region at all time points (P < .01) but versus the tibial region only at 6 and 12 months (P < .04). From 6 to 24 months, the grafts showed the greatest reduction in normalized signal intensity in the femoral and middle regions (vs tibial regions; P < .01), while there were no regional differences in repaired ACLs. At 2 years after surgery, repaired ACLs had a lower normalized signal intensity in the tibial region as compared with reconstructed grafts and contralateral native ACLs (P < .01). CONCLUSION The results suggest that graft remodeling is location specific. Repaired ACLs were more homogeneous, with lower or comparable normalized signal intensity values at 2 years as compared with the contralateral native ACL and reconstructed grafts.
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Affiliation(s)
- Ata M. Kiapour
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Martha M. Murray
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Patricia E. Miller
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | | | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Nicholas Sant
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Portilla
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan Sanborn
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Freiberger
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael Henderson
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Barnett
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Boston Children's Hospital Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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18
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Ranmuthu CDS, MacKay JW, Crowe VA, Kaggie JD, Kessler DA, McDonnell SM. Quantitative analysis of the ACL and PCL using T1rho and T2 relaxation time mapping: an exploratory, cross-sectional comparison between OA and healthy control knees. BMC Musculoskelet Disord 2021; 22:916. [PMID: 34717593 PMCID: PMC8556921 DOI: 10.1186/s12891-021-04755-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/28/2021] [Indexed: 12/18/2022] Open
Abstract
Background Quantitative magnetic resonance imaging (MRI) methods such as T1rho and T2 mapping are sensitive to changes in tissue composition, however their use in cruciate ligament assessment has been limited to studies of asymptomatic populations or patients with posterior cruciate ligament tears only. The aim of this preliminary study was to compare T1rho and T2 relaxation times of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) between subjects with mild-to-moderate knee osteoarthritis (OA) and healthy controls. Methods A single knee of 15 patients with mild-to-moderate knee OA (Kellgren-Lawrence grades 2–3) and of 6 age-matched controls was imaged using a 3.0 T MRI. Three-dimensional (3D) fat-saturated spoiled gradient recalled-echo images were acquired for morphological assessment and T1ρ- and T2-prepared pseudo-steady-state 3D fast spin echo images for compositional assessment of the cruciate ligaments. Manual segmentation of whole ACL and PCL, as well as proximal / middle / distal thirds of both ligaments was carried out by two readers using ITK-SNAP and mean relaxation times were recorded. Variation between thirds of the ligament were assessed using repeated measures ANOVAs and differences in these variations between groups using a Kruskal-Wallis test. Inter- and intra-rater reliability were assessed using intraclass correlation coefficients (ICCs). Results In OA knees, both T1rho and T2 values were significantly higher in the distal ACL when compared to the rest of the ligament with the greatest differences in T1rho (e.g. distal mean = 54.5 ms, proximal = 47.0 ms, p < 0.001). The variation of T2 values within the PCL was lower in OA knees (OA: distal vs middle vs proximal mean = 28.5 ms vs 29.1 ms vs 28.7 ms, p = 0.748; Control: distal vs middle vs proximal mean = 26.4 ms vs 32.7 ms vs 33.3 ms, p = 0.009). ICCs were excellent for the majority of variables. Conclusion T1rho and T2 mapping of the cruciate ligaments is feasible and reliable. Changes within ligaments associated with OA may not be homogeneous. This study is an important step forward in developing a non-invasive, radiological biomarker to assess the ligaments in diseased human populations in-vivo. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04755-y.
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Affiliation(s)
- Chanuka D S Ranmuthu
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0SP, UK. .,, London, UK.
| | - James W MacKay
- Department of Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK.,Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7UY, UK
| | - Victoria A Crowe
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Joshua D Kaggie
- Department of Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Dimitri A Kessler
- Department of Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Stephen M McDonnell
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
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19
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Murray MM. Optimizing outcomes of ACL surgery-Is autograft reconstruction the only reasonable option? J Orthop Res 2021; 39:1843-1850. [PMID: 34191344 PMCID: PMC8387392 DOI: 10.1002/jor.25128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/25/2021] [Indexed: 02/04/2023]
Abstract
Anterior cruciate ligament (ACL) injuries occur at a high frequency in the United States with approximately 400,000 ACL reconstructions being performed each year. While ACL reconstruction is our current gold standard of treatment, it does not restore joint motion, or prevent the premature development of posttraumatic osteoarthritis (PTOA) in many patients. Thus, new treatments for an ACL injury, which are less invasive and minimize patient morbidity, including cartilage damage, are highly desirable. We have used a tissue-engineered approach to stimulate ligament healing, to improve upon current treatment options. In this review, we describe and discuss our work moving a tissue engineering strategy from the concept to bench, preclinical, clinical trials and ultimately FDA 510(k) de Novo approval, providing clinicians and patients with a viable alternative to ACL reconstruction.
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Affiliation(s)
- Martha M. Murray
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital Harvard Medical School Boston Massachusetts USA
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20
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Van Dyck P, Froeling M, Heusdens CHW, Sijbers J, Ribbens A, Billiet T. Diffusion tensor imaging of the anterior cruciate ligament following primary repair with internal bracing: A longitudinal study. J Orthop Res 2021; 39:1318-1330. [PMID: 32270563 DOI: 10.1002/jor.24684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/17/2020] [Accepted: 03/28/2020] [Indexed: 02/04/2023]
Abstract
Diffusion tensor imaging (DTI) provides information about tissue microstructure and its degree of organization by quantifying water diffusion. We aimed to monitor longitudinal changes in DTI parameters (fractional isotropy, FA; mean diffusivity, MD; axial diffusivity, AD; radial diffusivity, RD) of the anterior cruciate ligament (ACL) following primary repair with internal bracing (IBLA). Fourteen patients undergoing IBLA were enrolled prospectively and scheduled for clinical follow-up, including instrumented laxity testing, and DTI at 3, 6, 12, and 24 months postoperatively. DTI was also performed in seven healthy subjects. Fiber tractography was used for 3D segmentation of the whole ACL volume, from which median DTI parameters were calculated. The posterior cruciate ligament (PCL) served as a control. Longitudinal DTI changes were assessed using a linear mixed model, and repeated measures correlations were calculated between DTI parameters and clinical laxity tests. At follow-up, thirteen patients had a stable knee and one patient sustained an ACL rerupture after 12 months postoperatively. The ACL repair showed a significant decrease of FA within the first 12 months after surgery, followed by stable FA values thereafter, while ACL diffusivities decreased over time returning towards normal values at 24 months postoperatively. For PCL there were no significant DTI changes over time. There was a significant correlation between ACL FA and laxity tests (r = -0.42, P = .017). This study has shown the potential of DTI to longitudinally monitor diffusion changes in the ACL following IBLA. The DTI findings suggest that healing of the ACL repair is incomplete at 24 months postoperatively.
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Affiliation(s)
- Pieter Van Dyck
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Martijn Froeling
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jan Sijbers
- Imec-Vision Lab, Department of Physics, University of Antwerp, Wilrijk, Belgium
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21
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Yao S, Fu BSC, Yung PSH. Graft healing after anterior cruciate ligament reconstruction (ACLR). ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 25:8-15. [PMID: 34094881 PMCID: PMC8134949 DOI: 10.1016/j.asmart.2021.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/05/2021] [Accepted: 03/21/2021] [Indexed: 01/11/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) is a commonly performed procedure in Orthopaedic sports medicine. With advances in surgical techniques providing better positioning and fixation of the graft, subsequent graft failure to certain extent should be accounted by poor graft healing. Although different biological modulations for enhancement of graft healing have been tried in different clinical and animal studies, complete graft incorporation into bone tunnels and the “ligamentization” of the intra-articular part have not been fully achieved yet. Based on the understanding of graft healing process and its failure mechanism, the purpose of this review is to combine both the known basic science & clinical evidence, to provide a much clearer picture of the obstacle encountered in graft healing, so as to facilitate researchers on subsequent work on the enhancement of ACL graft healing.
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Affiliation(s)
- Shiyi Yao
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Bruma Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
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22
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DeFroda SF, ODonnell RM, Fadale PD, Owens BD, Fleming BC. The role of magnetic resonance imaging in evaluating postoperative ACL reconstruction healing and graft mechanical properties: a new criterion for return to play? PHYSICIAN SPORTSMED 2021; 49:123-129. [PMID: 32897799 PMCID: PMC8007665 DOI: 10.1080/00913847.2020.1820846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/02/2020] [Indexed: 01/13/2023]
Abstract
Background: Disruption of the anterior cruciate ligament (ACL) is a common injury. In active patients, it is routinely treated with ACL reconstruction surgery. Following reconstruction, one of the critical decisions that must be made is the optimal timing of return to sport. While many biomechanical, biological, and functional criteria have been proposed to determine return to play, these methods are limited at best.Reasoning: As criteria for return to play are multifactorial, there is a growing need for noninvasive technologies, such as magnetic resonance imaging (MRI), to objectively track graft healing, to better assess the graft itself. Measuring the changes in the strength of the healing ligament has been shown to be a reliable means of objectively documenting graft healing in preclinical studies. While the initial studies of MR-based modeling of ACL graft healing are promising, this technology is still in its infancy and requires optimization.Purpose: The goals of this review are: 1) to outline the shortcomings of current return to play criteria, 2) to highlight the ability of MRI to determine the status of ACL graft healing, and 3) to discuss the future of imaging technology to determine return to play and its potential role in the clinical evaluation of patientsConclusion: There continues to be a wide variabiltiy regarding adequate return to play criteria, most of which are subjective in nature.
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Affiliation(s)
- Steven F DeFroda
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, US
| | - Ryan M ODonnell
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, US
| | - Paul D Fadale
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, US
| | - Brett D Owens
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, US
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, US
- School of Engineering, Brown University, Providence, RI, US
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23
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Ming-Jin Z, Kan O, Weimin Z. Letter to the Editor. J Orthop Res 2021; 39:1133-1134. [PMID: 32639609 DOI: 10.1002/jor.24796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/14/2020] [Accepted: 06/30/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Zhong Ming-Jin
- Department of Sports Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Ouyang Kan
- Department of Sports Medicine, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China
| | - Zhu Weimin
- Department of Sports Medicine, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China
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24
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Flannery SW, Kiapour AM, Edgar DJ, Murray MM, Fleming BC. Automated magnetic resonance image segmentation of the anterior cruciate ligament. J Orthop Res 2021; 39:831-840. [PMID: 33241856 PMCID: PMC8005419 DOI: 10.1002/jor.24926] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/27/2020] [Accepted: 11/19/2020] [Indexed: 02/04/2023]
Abstract
The objective of this study was to develop an automated segmentation method for the anterior cruciate ligament that is capable of facilitating quantitative assessments of the ligament in clinical and research settings. A modified U-Net fully convolutional network model was trained, validated, and tested on 246 Constructive Interference in Steady State magnetic resonance images of intact anterior cruciate ligaments. Overall model performance was assessed on the image set relative to an experienced (>5 years) "ground truth" segmenter in two domains: anatomical similarity and the accuracy of quantitative measurements (i.e., signal intensity and volume) obtained from the automated segmentation. To establish model reliability relative to manual segmentation, a subset of the imaging data was resegmented by the ground truth segmenter and two additional segmenters (A, 6 months and B, 2 years of experience), with their performance evaluated relative to the ground truth. The final model scored well on anatomical performance metrics (Dice coefficient = 0.84, precision = 0.82, and sensitivity = 0.85). The median signal intensities and volumes of the automated segmentations were not significantly different from ground truth (0.3% difference, p = .9; 2.3% difference, p = .08, respectively). When the model results were compared with the independent segmenters, the model predictions demonstrated greater median Dice coefficient (A = 0.73, p = .001; B = 0.77, p = NS) and sensitivity (A = 0.68, p = .001; B = 0.72, p = .003). The model performed equivalently well to retest segmentation by the ground truth segmenter on all measures. The quantitative measures extracted from the automated segmentation model did not differ from those of manual segmentation, enabling their use in quantitative magnetic resonance imaging pipelines to evaluate the anterior cruciate ligament.
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Affiliation(s)
- Sean W. Flannery
- Center for Biomedical Engineering, Brown University,
Providence, RI,Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA
| | - David J. Edgar
- Center for Biomedical Engineering, Brown University,
Providence, RI,Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA
| | - Braden C. Fleming
- Center for Biomedical Engineering, Brown University,
Providence, RI,Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI
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25
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Wang HM, Shultz SJ, Ross SE, Henson RA, Perrin DH, Schmitz RJ. Relationship of Anterior Cruciate Ligament Volume and T2* Relaxation Time to Anterior Knee Laxity. Orthop J Sports Med 2021; 9:2325967120979986. [PMID: 33718498 PMCID: PMC7925955 DOI: 10.1177/2325967120979986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022] Open
Abstract
Background: High anterior knee laxity (AKL) has been prospectively identified as a risk factor for anterior cruciate ligament (ACL) injuries. Given that ACL morphometry and structural composition have the potential to influence ligamentous strength, understanding how these factors are associated with greater AKL is warranted. Hypothesis: Smaller ACL volumes combined with longer T2* relaxation times would collectively predict greater AKL. Study Design: Cross-sectional study; Level of evidence, 3. Methods: College-aged active male (n = 20) and female (n = 30) participants underwent magnetic resonance imaging (MRI) and AKL testing. T2-weighted MRI scans were used to assess ACL volumes, and T2* relaxation times were used to assess ACL structural composition. AKL was measured via a commercial knee arthrometer. Forward stepwise linear regression with sex and weight (first step; suppressor variables) as well as ACL volume and T2* relaxation time (second step; independent variables) was used to predict AKL (dependent variable). Results: After initially adjusting for sex and weight (R2 = 0.19; P = .006), smaller ACL volumes combined with longer T2* relaxation times collectively predicted greater AKL (R2 = 0.52; P < .001; R2Δ = 0.32; PΔ < .001). A smaller ACL volume was the primary predictor of greater AKL (R2Δ = 0.28; P < .001), with a longer T2* relaxation time trending toward a significant contribution to greater AKL (R2Δ = 0.04; P = .062). After adjusting for ACL volume and T2* relaxation time, sex (partial r = 0.05; P = .735) and weight (partial r = 0.05; P = .725) were no longer significant predictors. Conclusion: AKL was largely predicted by ACL volume and to a lesser extent by T2* relaxation time (and not a person’s sex and weight). These findings enhance our understanding of how AKL may be associated with a structurally weaker ACL. The current study presents initial evidence that AKL is a cost-effective and clinically accessible measure that shows us something about the structural composition of the ACL. As AKL has been consistently shown to be a risk factor for ACL injuries, work should be done to continue to investigate what AKL may tell a clinician about the structure and composition of the ACL.
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Affiliation(s)
- Hsin-Min Wang
- Department of Sports, National Changhua University of Education, Changhua City, Taiwan
| | - Sandra J Shultz
- Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Scott E Ross
- Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Robert A Henson
- Department of Educational Research Methodology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - David H Perrin
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Randy J Schmitz
- Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
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26
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Hamstring grafts for anterior cruciate ligament reconstruction show better magnetic resonance features when tibial insertion is preserved. Knee Surg Sports Traumatol Arthrosc 2021; 29:507-518. [PMID: 32266415 DOI: 10.1007/s00167-020-05948-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. METHODS Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the "Graft" was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The "Tibial Tunnel" was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0-10. Tunnel and graft positioning were evaluated. RESULTS At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months (p = 0.008) and 18-months (p = 0.028), the tunnel was significantly smaller (p < 0.05) and less enlarged at both follow-ups (p < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months (p < 0.05). The total score of the non-detached group saw a significant improvement at 4-months (p = 0.006) that remained stable at 18-months (n.s.). CONCLUSIONS Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. LEVEL OF EVIDENCE IV.
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Csapo R, Juras V, Heinzle B, Trattnig S, Fink C. Compositional MRI of the anterior cruciate ligament of professional alpine ski racers: preliminary report on seasonal changes and load sensitivity. Eur Radiol Exp 2020; 4:64. [PMID: 33230703 PMCID: PMC7683641 DOI: 10.1186/s41747-020-00191-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
The purpose of this study was to investigate potential changes in the anterior cruciate ligament (ACL) structure of alpine ski racers over the course of an entire season using quantitative magnetic resonance imaging (T2* mapping). The dominant legs of three alpine ski racers were examined on a 3-T MR scanner four times at 3-month intervals. Multi-echo sequences for T2* maps, which were coregistered with high-resolution morphological sequences for reproducible definition of ACL regions of interest, were acquired. Means and standard deviations of T2* values from the central and femoral portion of the ACL were extracted and presented in a descriptive manner. T2* values were subject to seasonal changes, which were most pronounced in the ligament central region. Substantial increases (+ 41%) occurred between the measurements taken in January and April. A partial recovery of T2* (-19%) was observed in the July follow-up. The increased T2* times may reflect decreased stress tolerance and increased susceptibility for fatigue tears at the end of the competitive season. Further research in larger samples is required. The likeliness of ACL tears may depend on the precedent history of mechanical loading and vary in professional athletes over the course of the competitive season.
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Affiliation(s)
- Robert Csapo
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, ISAG, University for Health Sciences, Medical Informatics and Technology, Hall, A-6060, Austria
| | - Vladimir Juras
- Highfield MR Center, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Lazarettgasse 14, A-1090, Vienna, Austria.
| | | | - Siegfried Trattnig
- Highfield MR Center, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Lazarettgasse 14, A-1090, Vienna, Austria.,CD Laboratory for Molecular Clinical MR Imaging, Vienna, Austria
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, ISAG, University for Health Sciences, Medical Informatics and Technology, Hall, A-6060, Austria.,Gelenkpunkt Sports and Joint Surgery, Innsbruck, A-6020, Austria
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Jang H, McMillan AB, Ma Y, Jerban S, Chang EY, Du J, Kijowski R. Rapid single scan ramped hybrid-encoding for bicomponent T2* mapping in a human knee joint: A feasibility study. NMR IN BIOMEDICINE 2020; 33:e4391. [PMID: 32761692 PMCID: PMC7584401 DOI: 10.1002/nbm.4391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 06/20/2020] [Accepted: 07/21/2020] [Indexed: 05/03/2023]
Abstract
The purpose of this study is to determine the feasibility of using a single scan ramped hybrid-encoding (RHE) method for rapid bicomponent T2* analysis of the human knee joint. The proposed method utilizes RHE to acquire ultrashort echo time (UTE) and subsequent gradient echo images at 16 different echo times ranging between 40 μs and 30 ms in a single scan. In the proposed RHE technique, UTE imaging was followed by acquisition of 14 gradient recalled echo images, where an additional UTE image was obtained within the first readout by oversampling single point imaging (SPI) encoding. The single scan RHE method with a 9-minute scan time was performed on human cadaveric knee joints from six donors and in vivo knee joints from four healthy volunteers at 3 T. A bicomponent signal model was used to characterize the short T2* and long T2* water components. Mean bicomponent T2* parameters for patellar tendon, anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) and meniscus were calculated. In the experimental results, the RHE technique provided bicomponent T2* parameter estimations of tendon, ACL, PCL and meniscus, which were similar to previously reported values in the literature. In conclusion, the proposed single scan RHE technique provides rapid bicomponent T2* analysis of the human knee joint with a total scan time of less than 9 minutes.
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Affiliation(s)
- Hyungseok Jang
- Department of Radiology, University of California San Diego, San Diego, CA 92103, USA
- Corresponding Author: Hyungseok Jang, Ph.D., University of California, San Diego, Department of Radiology, 200 West Arbor Drive, San Diego, CA 92103-8226, Phone (858) 246-2225,
| | - Alan B McMillan
- Department of Radiology, University of Wisconsin Madison, Madison, WI 53705, USA
| | - Yajun Ma
- Department of Radiology, University of California San Diego, San Diego, CA 92103, USA
| | - Saeed Jerban
- Department of Radiology, University of California San Diego, San Diego, CA 92103, USA
| | - Eric Y Chang
- Department of Radiology, University of California San Diego, San Diego, CA 92103, USA
- Radiology Service, VA San Diego Healthcare System, San Diego, CA 92037, USA
| | - Jiang Du
- Department of Radiology, University of California San Diego, San Diego, CA 92103, USA
| | - Richard Kijowski
- Department of Radiology, University of Wisconsin Madison, Madison, WI 53705, USA
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Warth RJ, Zandiyeh P, Rao M, Gabr RE, Tashman S, Kumaravel M, Narayana PA, Lowe WR, Harner CD. Quantitative Assessment of In Vivo Human Anterior Cruciate Ligament Autograft Remodeling: A 3-Dimensional UTE-T2* Imaging Study. Am J Sports Med 2020; 48:2939-2947. [PMID: 32915640 DOI: 10.1177/0363546520949855] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The timing of return to play after anterior cruciate ligament (ACL) reconstruction is still controversial due to uncertainty of true ACL graft state at the time of RTP. Recent work utilizing ultra-short echo T2* (UTE-T2*) magnetic resonance imaging (MRI) as a scanner-independent method to objectively and non-invasively assess the status of in vivo ACL graft remodeling has produced promising results. PURPOSE/HYPOTHESIS The purpose of this study was to prospectively and noninvasively investigate longitudinal changes in T2* within ACL autografts at incremental time points up to 12 months after primary ACL reconstruction in human patients. We hypothesized that (1) T2* would increase from baseline and initially exceed that of the intact contralateral ACL, followed by a gradual decline as the graft undergoes remodeling, and (2) remodeling would occur in a region-dependent manner. STUDY DESIGN Case series; Level of evidence, 4. METHODS Twelve patients (age range, 14-45 years) who underwent primary ACL reconstruction with semitendinosus tendon or bone-patellar tendon-bone autograft (with or without meniscal repair) were enrolled. Patients with a history of previous injury or surgery to either knee were excluded. Patients returned for UTE MRI at 1, 3, 6, 9, and 12 months after ACL reconstruction. Imaging at 1 month included the contralateral knee. MRI pulse sequences included high-resolution 3-dimensional gradient echo sequence and a 4-echo T2-UTE sequence (slice thickness, 1 mm; repetition time, 20 ms; echo time, 0.3, 3.3, 6.3, and 9.3 ms). All slices containing the intra-articular ACL were segmented from high-resolution sequences to generate volumetric regions of interest (ROIs). ROIs were divided into proximal/distal and core/peripheral sub-ROIs using standardized methods, followed by voxel-to-voxel registration to generate T2* maps at each time point. This process was repeated by a second reviewer for interobserver reliability. Statistical differences in mean T2* values and mean ratios of T2*inj/T2*intact (ie, injured knee to intact knee) among the ROIs and sub-ROIs were assessed using repeated measures and one-way analyses of variance. P < .05 represented statistical significance. RESULTS Twelve patients enrolled in this prospective study, 2 withdrew, and ultimately 10 patients were included in the analysis (n = 7, semitendinosus tendon; n = 3, bone-patellar tendon-bone). Interobserver reliability for T2* values was good to excellent (intraclass correlation coefficient, 0.84; 95% CI, 0.59-0.94; P < .001). T2* values increased from 5.5 ± 2.1 ms (mean ± SD) at 1 month to 10.0 ± 2.9 ms at 6 months (P = .001), followed by a decline to 8.1 ± 2.0 ms at 12 months (P = .129, vs 1 month; P = .094, vs 6 months). Similarly, mean T2*inj/T2*intact ratios increased from 62.8% ± 22.9% at 1 month to 111.1% ± 23.9% at 6 months (P = .001), followed by a decline to 92.8% ± 29.8% at 12 months (P = .110, vs 1 month; P = .086, vs 6 months). Sub-ROIs exhibited similar increases in T2* until reaching a peak at 6 months, followed by a gradual decline until the 12-month time point. There were no statistically significant differences among the sub-ROIs (P > .05). CONCLUSION In this preliminary study, T2* values for ACL autografts exhibited a statistically significant increase of 82% between 1 and 6 months, followed by an approximate 19% decline in T2* values between 6 and 12 months. In the future, UTE-T2* MRI may provide unique insights into the condition of remodeling ACL grafts and may improve our ability to noninvasively assess graft maturity before return to play.
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Affiliation(s)
- Ryan J Warth
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Payam Zandiyeh
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mayank Rao
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Refaat E Gabr
- Department of Diagnostic & Interventional Imaging, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Scott Tashman
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Manickam Kumaravel
- Department of Diagnostic & Interventional Imaging, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ponnada A Narayana
- Department of Diagnostic & Interventional Imaging, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Walter R Lowe
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher D Harner
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Xie Y, Liu S, Qu J, Wu P, Tao H, Chen S. Quantitative Magnetic Resonance Imaging UTE-T2* Mapping of Tendon Healing After Arthroscopic Rotator Cuff Repair: A Longitudinal Study. Am J Sports Med 2020; 48:2677-2685. [PMID: 32813550 DOI: 10.1177/0363546520946772] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quantitative ultrashort echo time-T2* (UTE-T2*) mapping shows promise for the detection of potential tendon biochemical conditions, while validation against established clinical studies in the shoulder is needed. PURPOSE To evaluate and characterize the healing process of the repaired rotator cuff based on longitudinal changes in UTE-T2* values, clinical outcomes, and repair status in patients after arthroscopic rotator cuff repair (ARCR). STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients with ARCR (n = 25) underwent quantitative MRI and clinical examinations at serial follow-up time points: 3, 6, 12, and 24 months postoperatively. Age-matched healthy controls (n = 15) were evaluated at 3 and 12 months after enrollment. Clinical scores included the Constant, American Shoulder and Elbow Surgeons, and Fudan University Shoulder score, and visual analog scale for pain. The MRI examination included UTE-T2*mapping. UTE-T2* maps were generated for T2* values at the healing site. Sugaya classification was adopted to evaluate the repair status. Longitudinal analyses of clinical outcomes, UTE-T2* changes, and Sugaya classification were conducted. RESULTS The overall retear rate was 8% (2/25, all Sugaya type IV). All patients (including the ones with retear) achieved satisfactory outcomes at 12 months that lasted to 24 months on the basis of clinical scores. The mean UTE-T2* values at the healing site showed an increase from 3 to 6 months (P = .03) and then decreased to a level similar to that observed in age-matched healthy tendons at 12 months (P = .1). No significant differences were found between UTE-T2* values at 12 and 24 months (P = .6). UTE-T2* values at the healing site significantly varied with the repair status according to Sugaya classification (P < .05). Moreover, significant correlations were noted between clinical scores and UTE-T2* values at 6 months (r = -0.6 to -0.3; all P < .05) and 12 months (r = -0.6 to -0.2; all P < .05). CONCLUSION This study indicated a healing-related relationship between clinical outcomes and quantitative UTE-T2* values, which highlights the potential of using UTE-T2* mapping to track the tendon-healing process noninvasively. Moreover, the repaired tendon was comparable to age-matched healthy controls at 12-month follow-up based on UTE-T2* values.
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Affiliation(s)
- Yuxue Xie
- Department of Radiology and Institute of Medical Functional and Molecular Imaging, Huashan Hospital, Fudan University, Shanghai, China
| | - Shaohua Liu
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | | | - Puye Wu
- GE Healthcare, MR Research, Beijing, China
| | - Hongyue Tao
- Department of Radiology and Institute of Medical Functional and Molecular Imaging, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuang Chen
- Department of Radiology and Institute of Medical Functional and Molecular Imaging, Huashan Hospital, Fudan University, Shanghai, China
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Ferretti A, Monaco E, Annibaldi A, Carrozzo A, Bruschi M, Argento G, DiFelice GS. The healing potential of an acutely repaired ACL: a sequential MRI study. J Orthop Traumatol 2020; 21:14. [PMID: 32869122 PMCID: PMC7459035 DOI: 10.1186/s10195-020-00553-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/27/2020] [Indexed: 01/14/2023] Open
Abstract
Background Recently, there has been renewed interest in primary anterior cruciate ligament (ACL) repair. The aim of this study is to report early clinical and radiological results of a consecutive series of acute ACL tears treated with arthroscopic primary ACL repair within 14 days from injury. Patients and methods A consecutive series of patients with acute ACL tears were prospectively included in the study. Based on MRI appearance, ACL tears were classified into five types, and tissue quality was graded as good, fair, and poor. Patients with type I, II, and III tears and at least 50% of ACL tibial remnant intact with good tissue quality were ultimately included. Clinical outcomes were measured using the Tegner Lysholm Knee Scoring Scale (TLKSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), subjective and objective International Knee Documentation Committee (IKDC) scores, and KT-1000. Patients were also followed up with MRI evaluations at 1, 3, and 6 months postoperatively. ACL appearance was graded based on morphology (normal or abnormal) and signal intensity (isointense, intermediate, and hyperintense). Results The mean TLKSS was 98.1, the mean subjective IKDC was 97.6, and the mean KOOS was 98.2. The objective IKDC score was A in eight of ten patients and B in two patients. KT-1000 measurements showed a maximum manual side-to-side difference of less than 2 mm in eight of ten patients, whereas two patients showed a difference of 3 mm. The morphology of the repaired ACL was normal (grade 1) at 1 month follow-up in ten of ten cases, and this appearance persisted at 3 and 6 months postoperatively. The signal intensity at 1 month postoperatively was graded as isointense (grade 1) in four of ten patients, intermediate (grade 2) in five of ten patients, and hyperintense (grade 3) in one of ten patients. At both 3 and 6 months postoperatively, the signal intensity was graded as isointense (grade 1) in nine of ten patients and intermediate (grade 2) in one of ten patients. Conclusions Arthroscopic primary ACL repair performed acutely in a carefully selected group of patients with proximal ACL tears and good tissue quality showed good early clinical and radiological results. Level of evidence Level 4.
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Affiliation(s)
- Andrea Ferretti
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Edoardo Monaco
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Alessandro Annibaldi
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome La Sapienza, Rome, Italy.
| | - Alessandro Carrozzo
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Mattia Bruschi
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Giuseppe Argento
- Department of Radiology, S. Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Gregory S DiFelice
- Hospital for Special Surgery/Weill Cornell Medical Center, New York, NY, USA
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Jang H, von Drygalski A, Wong J, Zhou JY, Aguero P, Lu X, Cheng X, Ball ST, Ma Y, Chang EY, Du J. Ultrashort echo time quantitative susceptibility mapping (UTE-QSM) for detection of hemosiderin deposition in hemophilic arthropathy: A feasibility study. Magn Reson Med 2020; 84:3246-3255. [PMID: 32662904 DOI: 10.1002/mrm.28388] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to investigate the feasibility of ultrashort echo time quantitative susceptibility mapping (UTE-QSM) for assessment of hemosiderin deposition in the joints of hemophilic patients. METHODS The UTE-QSM technique was based on three sets of dual-echo 3D UTE Cones data acquired with TEs of 0.032/2.8, 0.2/3.6, and 0.4/4.4 ms. The images were processed with iterative decomposition of water and fat with echo asymmetry and least-squares estimation to estimate the B0 field map in the presence of fat. Then, the projection onto dipole field (PDF) algorithm was applied to acquire a local field map generated by tissues, followed by application of the morphology-enabled dipole inversion (MEDI) algorithm to estimate a final susceptibility map. Three healthy volunteers and three hemophilic patients were recruited to evaluate the UTE-QSM technique's ability to assess hemosiderin in the knee or ankle joint at 3T. One patient subsequently underwent total knee arthroplasty after the MR scan. The synovial tissues harvested from the knee joint during surgery were processed for histological analysis to confirm iron deposition. RESULTS UTE-QSM successfully yielded tissue susceptibility maps of joints in both volunteers and patients. Multiple regions with high susceptibility over 1 ppm were detected in the affected joints of hemophilic patients, while no localized regions with high susceptibility were detected in asymptomatic healthy volunteers. Histology confirmed the presence of iron in regions where high susceptibility was detected by UTE-QSM. CONCLUSION The UTE-QSM technique can detect hemosiderin deposition in the joint, and provides a potential sensitive biomarker for the diagnosis and prognosis of hemophilic arthropathy.
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Affiliation(s)
- Hyungseok Jang
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Jonathan Wong
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Jenny Y Zhou
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Peter Aguero
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Xing Lu
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Xin Cheng
- Department of Histology and Embryology, Jinan University, Guangzhou, China
| | - Scott T Ball
- Orthopedic Surgery, University of California San Diego, San Diego, California, USA
| | - Yajun Ma
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Eric Y Chang
- Department of Radiology, University of California San Diego, San Diego, California, USA.,Radiology Service, Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Jiang Du
- Department of Radiology, University of California San Diego, San Diego, California, USA
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Freiberger C, Kiapour AM, Liu S, Henderson RN, Barnett S, Sant NJ, Proffen BL, Fleming BC, Ecklund K, Kramer DE, Micheli LJ, Murray MM, Yen YM. Higher Physiologic Platelet Counts in Whole Blood Are Not Associated With Improved ACL Cross-sectional Area or Signal Intensity 6 Months After Bridge-Enhanced ACL Repair. Orthop J Sports Med 2020; 8:2325967120927655. [PMID: 32656289 PMCID: PMC7331772 DOI: 10.1177/2325967120927655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 01/08/2023] Open
Abstract
Background: A bridge-enhanced anterior cruciate ligament (ACL) repair (BEAR) procedure places an extracellular matrix implant, combined with autologous whole blood, in the gap between the torn ends of the ligament at the time of suture repair to stimulate healing. Prior studies have suggested that white blood cell (WBC) and platelet concentrations significantly affect the healing of other musculoskeletal tissues. Purpose/Hypothesis: The purpose of this study was to determine whether concentrations of various blood cell types placed into a bridging extracellular matrix implant at the time of ACL repair would have a significant effect on the healing ligament cross-sectional area or tissue organization (as measured by signal intensity). We hypothesized that patients with higher physiologic platelet and lower WBC counts would have improved healing of the ACL on magnetic resonance imaging (MRI) (higher cross-sectional area and/or lower signal intensity) 6 months after surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 61 patients underwent MRI at 6 months after bridge-enhanced ACL repair as part of the BEAR II trial. The normalized signal intensity and average cross-sectional area of the healing ligament were measured from a magnetic resonance stack obtained using a gradient echo sequence. The results were stratified by sex, and univariate and multivariate regression analyses determined significant correlations between blood cell concentrations on these 2 magnetic resonance parameters. Results: In unadjusted analyses, older age and male sex were associated with greater healing ligament cross-sectional area (P < .04) but not signal intensity (P > .15). Adjusted multivariable analyses indicated that in female patients, a higher monocyte concentration correlated with a higher ACL cross-sectional area (β = 1.01; P = .049). All other factors measured, including the physiologic concentration of platelets, neutrophils, lymphocytes, basophils, and immunoglobulin against bovine gelatin, were not significantly associated with either magnetic resonance parameter in either sex (P > .05 for all). Conclusion: Although older age, male sex, and monocyte concentration in female patients were associated with greater healing ligament cross-sectional area, signal intensity of the healing ligament was independent of these factors. Physiologic platelet concentration did not have any significant effect on cross-sectional area or signal intensity of the healing ACL at 6 months after bridge-enhanced ACL repair in this cohort. Given these findings, factors other than the physiologic platelet concentration and total WBC concentration may be more important in the rate and amount of ACL healing after bridge-enhanced ACL repair.
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Affiliation(s)
- Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ata M Kiapour
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shanshan Liu
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Rachael N Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel Barnett
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicholas J Sant
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt L Proffen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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Lansdown DA, Xiao W, Zhang AL, Allen CR, Feeley BT, Li X, Majumdar S, Ma CB. Quantitative imaging of anterior cruciate ligament (ACL) graft demonstrates longitudinal compositional changes and relationships with clinical outcomes at 2 years after ACL reconstruction. J Orthop Res 2020; 38:1289-1295. [PMID: 31868948 PMCID: PMC7433779 DOI: 10.1002/jor.24572] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/11/2019] [Indexed: 02/04/2023]
Abstract
T1 ρ and T2 magnetic resonance imaging (MRI) may allow for a noninvasive assessment of ligamentization after anterior cruciate ligament (ACL) reconstruction. We hypothesized that ACL graft T1 ρ and T2 relaxation times would decrease over time, that T1 ρ and T2 relaxation times would be inversely correlated with Knee Osteoarthritis Outcome Scores (KOOS), and that T1 ρ and T2 values would be lower for autograft relative to allograft reconstruction. Thirty-nine patients (age: 30.5 ± 8.2 years) were followed prospectively after ACL reconstruction with hamstring autograft (N = 27) or soft-tissue allograft (N = 12). Magnetic resonance (MR) imaging and KOOS surveys were completed at 6, 12, 24, and 36 months after surgery. ACL graft was segmented to define T1 ρ and T2 relaxation times. Relaxation times were compared between time points with ANOVA tests. Log-transformed autograft and allograft relaxation times were compared with the Student t tests. The relationship between KOOS and relaxation times at 24 months was investigated with Spearman's rank correlation. ACL graft T1 ρ relaxation times were significantly higher at 6 months relative to 12 months (P = .042), 24 months (P < .001), and 36 months (P < .001). ACL graft T2 relaxation times were significantly higher at 6 months relative to 12 months (P = .036), 24 months (P < .001), and 36 months (P < .001). T1 ρ and T2 relaxation times were significantly lower for autograft reconstruction vs allograft reconstruction at 24 months postreconstruction. Two-year KOOS Sports, Pain, and Symptoms were significantly inversely correlated with T1 ρ and T2 relaxation times. T1 ρ and T2 sequences may offer a noninvasive method for monitoring ACL graft maturation that correlates with patient-reported knee function after ACL reconstruction.
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Affiliation(s)
- Drew A. Lansdown
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Weiyuan Xiao
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Alan L. Zhang
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Christina R. Allen
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Brian T. Feeley
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Xiaojuan Li
- Department of Biomedical Engineering, Cleveland Clinic, Lerner Research Institute, Cleveland, Ohio
| | - Sharmila Majumdar
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - C. Benjamin Ma
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
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Barber-Westin S, Noyes FR. One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years. Sports Health 2020; 12:587-597. [PMID: 32374646 DOI: 10.1177/1941738120912846] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
CONTEXT Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures. OBJECTIVE To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates. DATA SOURCES A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases. STUDY SELECTION Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. RESULTS A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS. CONCLUSION A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.
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Affiliation(s)
- Sue Barber-Westin
- Cincinnati Sportsmedicine and Orthopaedic Center-Mercy Health, and the Noyes Knee Institute, Cincinnati, Ohio
| | - Frank R Noyes
- Cincinnati Sportsmedicine and Orthopaedic Center-Mercy Health, and the Noyes Knee Institute, Cincinnati, Ohio
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36
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Lansdown DA, Ma CB. Clinical Utility of Advanced Imaging of the Knee. J Orthop Res 2020; 38:473-482. [PMID: 31498473 DOI: 10.1002/jor.24462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/17/2019] [Indexed: 02/04/2023]
Abstract
Advanced imaging modalities, including computed tomography, magnetic resonance imaging (MRI), and dynamic fluoroscopic imaging, allow for a comprehensive evaluation of the knee joint. Compositional sequences for MRI can allow for an evaluation of the biochemical properties of cartilage, meniscus, and ligament that offer further insight into pathology that may not be apparent on conventional clinical imaging. Advances in image processing, shape modeling, and dynamic studies also offer a novel way to evaluate common conditions and to monitor patients after treatment. The purpose of this article is to review advanced imaging modalities of the knee and their current and anticipated future applications to clinical practice. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:473-482, 2020.
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Affiliation(s)
- Drew A Lansdown
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - C Benjamin Ma
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
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Anz AW, Edison J, Denney TS, Branch EA, Walz CR, Brock KV, Goodlett MD. 3-T MRI mapping is a valid in vivo method of quantitatively evaluating the anterior cruciate ligament: rater reliability and comparison across age. Skeletal Radiol 2020; 49:443-452. [PMID: 31482257 DOI: 10.1007/s00256-019-03301-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 08/13/2019] [Accepted: 08/15/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE As biologic augmentation methods emerge, objective measures of soft tissues are necessary for developmental study. The purpose of this study was to develop a quantitative MRI mapping protocol for the ACL. The objectives were (1) to provide age-based T2 relaxation, T2* relaxation, and volume values in healthy individuals, (2) to establish the intra-rater and inter-rater reliability of ACL mapping, and (3) to determine whether 3-T or 7-T MRI is more appropriate for future clinical trials. MATERIALS AND METHODS Thirty healthy participants, aged 18-62, asymptomatic for knee pathology and without history of knee injury underwent both a 3-T and 7-T MRI. Manual image mapping of the anterior cruciate ligament was performed by two observers and processed to obtain T2, T2*, and volume values. Analysis of variance and two-way random effects model were used to calculate statistical significance and intraclass correlation coefficients. RESULTS Across all participants, 3-T and 7-T mean T2, T2* and volume values were 37.1 ± 7.9 and 39.7 ± 6.2 ms (p = 0.124), 10.9 ± 1.3 and 10.9 ± 0.9 ms (p = 0.981), and 2380 ± 602 and 2484 ± 736 mm3 (p = 0.551), respectively. The T2, T2*, and volume did not vary between age cohorts (p > 0.05). Excellent inter-rater and intra-rater reliability regarding T2 and T2* values was found. While ACL volume exhibited good inter-rater reliability and excellent intra-rater reliability. CONCLUSIONS T2 relaxation values and ACL volume do not vary with age and therefore can be used as a quantifiable, non-invasive method to assess ACL graft maturation. 7-T MRI analysis was not superior to 3-T MRI analysis, suggesting that 3-T MRI is practical and capable for future comparative studies.
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Affiliation(s)
- Adam W Anz
- Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Parkway, Gulf Breeze, FL, 32561, USA.
| | - Jos Edison
- Edward Via College of Osteopathic Medicine, 910 South Donahue Drive, Auburn, AL, 36832, USA
| | - Thomas S Denney
- Department of Electrical and Computer Engineering, Auburn University, 200 Broun Hall, Auburn, AL, 36849, USA
| | - Eric A Branch
- Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Parkway, Gulf Breeze, FL, 32561, USA
| | - Christopher R Walz
- Department of Electrical and Computer Engineering, Auburn University, 200 Broun Hall, Auburn, AL, 36849, USA
| | - Kenny V Brock
- Edward Via College of Osteopathic Medicine, 910 South Donahue Drive, Auburn, AL, 36832, USA
| | - Michael D Goodlett
- Auburn University Athletics, Auburn Athletics Complex, 392 S Donahue Drive, Auburn, AL, 36849, USA
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38
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Lockard CA, Chang A, Clanton TO, Ho CP. T2* mapping and subregion analysis of the tibialis posterior tendon using 3 Tesla magnetic resonance imaging. Br J Radiol 2019; 92:20190221. [PMID: 31596118 DOI: 10.1259/bjr.20190221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Early detection of tibialis posterior tendon changes and appropriate intervention is necessary to prevent disease progression to flat-foot deformity and foot/ankle dysfunction, and the need for operative treatment. Currently, differentiating between early-stage tibialis posterior tendon deficiency patients who will benefit from conservative vs more aggressive treatment is challenging. The objective of this work was to establish a quantitative MRI T2* mapping method and subregion baseline values in the tibialis posterior tendon in asymptomatic ankles for future clinical application in detecting tendon degeneration. METHODS 26 asymptomatic volunteers underwent T2* mapping. The tendon was divided axially into seven subregions. Summary statistics for T2* within each subregion were calculated and compared using Tukey post-hoc pairwise comparisons. RESULTS Results are reported for 24 subjects. The mean tibialis posterior tendon T2* was 7 ± 1 ms. Subregion values ranged from 6 ± 1 to 9 ± 2 ms with significant between-region differences in T2*. Inter- and intrarater absolute agreement intraclass correlation coefficient (ICC) values were all "excellent" (0.75 < ICC=1.00) except for regions 5 through 7, which had "fair to good" interrater and/or and intrarater ICC values (0.4 < ICC=0.75). CONCLUSION A tibialis posterior tendon T2* mapping protocol, subregion division method, and baseline T2* values for clinically relevant regions were established. Significant differences in T2* were observed along the tendon length. ADVANCES IN KNOWLEDGE This work demonstrates that regional variation exists and should be considered for future T2*-based research on posterior tibias tendon degeneration and when using T2* mapping to evaluate for potential tibialis posterior tendon degeneration.
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Affiliation(s)
- Carly Anne Lockard
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000 Vail, Colorado 81657, United States
| | - Angela Chang
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000 Vail, Colorado 81657, United States
| | - Thomas O Clanton
- The Steadman Clinic, 181 West Meadow Drive, Suite 400 Vail, Colorado 81657, United States
| | - Charles P Ho
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000 Vail, Colorado 81657, United States
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Beveridge JE, Proffen BL, Karamchedu NP, Chin KE, Sieker JT, Badger GJ, Kiapour AM, Murray MM, Fleming BC. Cartilage Damage Is Related to ACL Stiffness in a Porcine Model of ACL Repair. J Orthop Res 2019; 37:2249-2257. [PMID: 31125133 PMCID: PMC6739195 DOI: 10.1002/jor.24381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 05/02/2019] [Indexed: 02/04/2023]
Abstract
Inferior anterior cruciate ligament (ACL) structural properties may inadequately restrain tibiofemoral joint motion following surgery, contributing to the increased risk of post-traumatic osteoarthritis. Using both a direct measure of ACL linear stiffness and an in vivo magnetic resonance imaging (MRI) T2 *-based prediction model, we hypothesized that cartilage damage and ACL stiffness would increase over time, and that an inverse relationship between cartilage damage and ACL stiffness would emerge at a later stage of healing. After either 6, 12, or 24 weeks (w) of healing after ACL repair, ACL linear stiffness was determined from the force-displacement relationship during tensile testing ex vivo and predicted in vivo from the MRI T2 *-based multiple linear regression model in 24 Yucatan minipigs. Tibiofemoral cartilage was graded postmortem. There was no relationship between cartilage damage and ACL stiffness at 6 w (R2 = 0.04; p = 0.65), 12 w (R2 = 0.02; p = 0.77), or when the data from all animals were pooled (R2 = 0.02; p = 0.47). A significant inverse relationship between cartilage damage and ACL stiffness based on both ex vivo measurement (R2 = 0.90; p < 0.001) and in vivo MRI prediction (R2 = 0.78; p = 0.004) of ACL stiffness emerged at 24 w. This result suggests that 90% of the variability in gross cartilage changes is associated with the repaired ACL linear stiffness at 6 months of healing. Clinical Significance: Techniques that provide a higher stiffness to the repaired ACL may be required to mitigate the post-traumatic osteoarthritis commonly seen after ACL injury, and MRI T2 * can be used as a noninvasive estimation of ligament stiffness. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2249-2257, 2019.
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Affiliation(s)
- Jillian E. Beveridge
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
| | - Benedikt L. Proffen
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - N. Padmini Karamchedu
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
| | - Kaitlyn E. Chin
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
| | - Jakob T. Sieker
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
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40
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Shultz SJ, Schmitz RJ, Cameron KL, Ford KR, Grooms DR, Lepley LK, Myer GD, Pietrosimone B. Anterior Cruciate Ligament Research Retreat VIII Summary Statement: An Update on Injury Risk Identification and Prevention Across the Anterior Cruciate Ligament Injury Continuum, March 14-16, 2019, Greensboro, NC. J Athl Train 2019; 54:970-984. [PMID: 31461312 PMCID: PMC6795093 DOI: 10.4085/1062-6050-54.084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sandra J. Shultz
- Applied Neuromechanics Research Laboratory, University of North Carolina at Greensboro
| | - Randy J. Schmitz
- Applied Neuromechanics Research Laboratory, University of North Carolina at Greensboro
| | - Kenneth L. Cameron
- John A. Feagin Jr Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, West Point, NY
| | - Kevin R. Ford
- Human Biomechanics and Physiology Laboratory, Department of Physical Therapy, High Point University, NC
| | - Dustin R. Grooms
- Ohio Musculoskeletal & Neurological Institute and Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens
| | | | - Gregory D. Myer
- The SPORT Center, Division of Sports Medicine, and Departments of Pediatrics and Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, OH
| | - Brian Pietrosimone
- MOTION Science Institute, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
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Chu CR, Williams AA. Quantitative MRI UTE-T2* and T2* Show Progressive and Continued Graft Maturation Over 2 Years in Human Patients After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2019; 7:2325967119863056. [PMID: 31448301 PMCID: PMC6693027 DOI: 10.1177/2325967119863056] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Noninvasive quantitative magnetic resonance imaging (MRI) measures to assess
anterior cruciate ligament (ACL) graft maturity are needed to help inform
return to high-demand activities and to evaluate the effectiveness of new
treatments to accelerate ACL graft maturation. Quantitative MRI ultrashort
echo time T2* (UTE-T2*) and T2* mapping captures short T2 signals arising
from collagen-associated water in dense regular connective tissues, such as
tendon, ligament, and maturing grafts, which are invisible to conventional
MRI. Hypothesis: Quantitative MRI UTE-T2* and T2* mapping is sensitive to ACL graft changes
over the first 2 years after ACL reconstruction (ACLR). Study Design: Case series; Level of evidence, 4. Methods: A total of 32 patients (18 men; mean ± SD age, 30 ± 9 years) undergoing
unilateral ACLR and 30 uninjured age-matched controls (18 men; age, 30 ± 9
years) underwent 3-T MRI examination. Patients who underwent ACLR were
imaged at 6 weeks, 6 months, and 1 and 2 years postoperatively. Two separate
ACLR cohorts were scanned with 2 MRI platforms at 2 institutions. Twelve
ACLR knees were scanned with a 3-dimensional acquisition-weighted stack of
spirals UTE sequence on a Siemens scanner, and 20 ACLR knees were scanned
with a 3-dimensional Cones UTE sequence on a GE scanner. UTE-T2* or T2* maps
were calculated for the intra-articular portion of the ACL graft. Results: Mean ACL graft UTE-T2* and T2* decreased from 1 to 2 years after ACLR. ACL
graft T2* increased 25% to 30% during the first 6 months (P
< .013) to a level not different from that of uninjured native ACL
(P > .4), stabilized between 6 months and 1 year
(P ≥ .999), and then decreased 19% between 1 and 2
years after ACLR (P = .027). At 6-month follow-up, ACL
graft UTE-T2* differed from that of tendon (P < .02) but
not uninjured native ACL (P > .7) and showed the
greatest variability among patients. Conclusion: UTE-T2* mapping suggested substantial changes within the graft during the
first 6 months postsurgery. T2* and UTE-T2* mapping showed relatively stable
graft composition from 6 months to 1 year, consistent with remodeling,
followed by decreases from 1 to 2 years, suggestive of continuing
maturation. MRI UTE-T2* and T2* mapping demonstrated potential clinical
utility as noninvasive quantitative imaging metrics for evaluation of human
ACL grafts.
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Affiliation(s)
- Constance R Chu
- Department of Orthopedic Surgery, School of Medicine, Stanford University, Redwood City, California, USA
| | - Ashley A Williams
- Department of Orthopedic Surgery, School of Medicine, Stanford University, Redwood City, California, USA
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Kiapour AM, Ecklund K, Murray MM, Fleming BC, Freiberger C, Henderson R, Kramer D, Micheli L, Thurber L, Yen YM, Fleming BC. Changes in Cross-sectional Area and Signal Intensity of Healing Anterior Cruciate Ligaments and Grafts in the First 2 Years After Surgery. Am J Sports Med 2019; 47:1831-1843. [PMID: 31166701 PMCID: PMC6599545 DOI: 10.1177/0363546519850572] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The quality of a repaired anterior cruciate ligament (ACL) or reconstructed graft is typically quantified in clinical studies by evaluating knee, lower extremity, or patient performance. However, magnetic resonance imaging of the healing ACL or graft may provide a more direct measure of tissue quality (ie, signal intensity) and quantity (ie, cross-sectional area). HYPOTHESES (1) Average cross-sectional area or signal intensity of a healing ACL after bridge-enhanced ACL repair (BEAR) or a hamstring autograft (ACL reconstruction) will change postoperatively from 3 to 24 months. (2) The average cross-sectional area and signal intensity of the healing ligament or graft will correlate with anatomic features of the knee associated with ACL injury. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients with a complete midsubstance ACL tear who were treated with either BEAR (n = 10) or ACL reconstruction (n = 10) underwent magnetic resonance imaging at 3, 6, 12, and 24 months after surgery. Images were analyzed to determine the average cross-sectional area and signal intensity of the ACL or graft at each time point. ACL orientation, stump length, and bony anatomy were also assessed. RESULTS Mean cross-sectional area of the grafts was 48% to 98% larger than the contralateral intact ACLs at all time points (P < .01). The BEAR ACLs were 23% to 28% greater in cross-sectional area than the contralateral intact ACLs at 3 and 6 months (P < .02) but similar at 12 and 24 months. The BEAR ACLs were similar in sagittal orientation to the contralateral ACLs, while the grafts were 6.5° more vertical (P = .005). For the BEAR ACLs, a bigger notch correlated with a bigger cross-sectional area, while a shorter ACL femoral stump, steeper lateral tibial slope, and shallower medial tibial depth were associated with higher signal intensity (R2 > .40, P < .05). Performance of notchplasty resulted in an increased ACL cross-sectional area after the BEAR procedure (P = .007). No anatomic features were correlated with ACL graft size or signal intensity. CONCLUSION Hamstring autografts were larger in cross-sectional area and more vertically oriented than the native ACLs at 24 months after surgery. BEAR ACLs had a cross-sectional area, signal intensity, and sagittal orientation similar to the contralateral ACLs at 24 months. The early signal intensity and cross-sectional area of the repaired ACL may be affected by specific anatomic features, including lateral tibial slope and notch width-observations that deserve further study in a larger cohort of patients. REGISTRATION NCT02292004 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston MA 02115
| | - Kirsten Ecklund
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston MA 02115
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston MA 02115
| | | | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI 02818,School of Engineering, Brown University, Providence, RI 02818
| | - Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Laura Thurber
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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43
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Cone SG, Howe D, Fisher MB. Size and Shape of the Human Anterior Cruciate Ligament and the Impact of Sex and Skeletal Growth: A Systematic Review. JBJS Rev 2019; 7:e8. [PMID: 31246862 DOI: 10.2106/jbjs.rvw.18.00145] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND High rates of anterior cruciate ligament (ACL) injury and surgical reconstruction in both skeletally immature and mature populations have led to many studies investigating the size and shape of the healthy ligament. The purposes of the present study were to compile existing quantitative measurements of the geometry of the ACL, its bundles, and its insertion sites and to describe effects of common covariates such as sex and age. METHODS A search of the Web of Science was conducted for studies published from January 1, 1900, to April 11, 2018, describing length, cross-sectional area, volume, orientation, and insertion sites of the ACL. Two reviewers independently screened and reviewed the articles to collect quantitative data for each parameter. RESULTS Quantitative data were collected from 92 articles in this systematic review. In studies of adults, reports of average ACL length, cross-sectional area, and volume ranged from 26 to 38 mm, 30 to 53 mm, and 854 to 1,858 mm, respectively. Reported values were commonly found to vary according to sex and skeletal maturity as well as measurement technique. CONCLUSIONS Although the geometry of the ACL has been described widely in the literature, quantitative measurements can depend on sex, age, and measurement modality, contributing to variability between studies. As such, care must be taken to account for these factors. The present study condenses measurements describing the geometry of the ACL, its individual bundles, and its insertion sites, accounting for common covariates when possible, to provide a resource to the clinical and scientific communities. CLINICAL RELEVANCE Quantitative measures of ACL geometry are informative for developing clinical treatments such as ACL reconstruction. Age and sex can impact these parameters.
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Affiliation(s)
- Stephanie G Cone
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Danielle Howe
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina.,Department of Orthopaedics, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
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44
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Van Dyck P, Zazulia K, Smekens C, Heusdens CHW, Janssens T, Sijbers J. Assessment of Anterior Cruciate Ligament Graft Maturity With Conventional Magnetic Resonance Imaging: A Systematic Literature Review. Orthop J Sports Med 2019; 7:2325967119849012. [PMID: 31211151 PMCID: PMC6547178 DOI: 10.1177/2325967119849012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) signal intensity (SI) measurements are being
used increasingly in both clinical and research studies to assess the
maturity of anterior cruciate ligament (ACL) grafts in humans. However, SI
in conventional MRI with weighted images is a nonquantitative measure
dependent on hardware and software. Purpose: To conduct a systematic review of studies that have used MRI SI as a proxy
for ACL graft maturity and to identify potential confounding factors in
assessing the ACL graft in conventional MRI studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted by searching the MEDLINE/PubMed, Scopus,
and Cochrane Library electronic databases according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to
identify studies that examined the healing of the intra-articular portion of
the ACL graft by assessing SI on MRIs. Results: A total of 34 studies were selected for inclusion in this systematic review.
The MRI acquisition techniques and methods to evaluate the ACL graft SI
differed greatly across the studies. No agreement was found regarding the
time frames of SI changes in MRI reflecting normal healing of the ACL tendon
graft, and the graft SI and clinical outcomes after ACL reconstruction were
found to be poorly correlated. Conclusion: The MRI acquisition and evaluation methods used to assess ACL grafts are very
heterogeneous, impeding comparisons of SI between successive scans and
between independent studies. Therefore, quantitative MRI-based biomarkers of
ACL graft healing are greatly needed to guide the appropriate time of
returning to sports after ACL reconstruction.
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Affiliation(s)
- Pieter Van Dyck
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Katja Zazulia
- Department of Orthopedics, Antwerp University Hospital, Edegem, Belgium
| | | | | | | | - Jan Sijbers
- Imec/Vision Lab, Department of Physics, University of Antwerp, Wilrijk, Belgium
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45
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Wilson KJ, Fripp J, Lockard CA, Shin RC, Engstrom C, Ho CP, LaPrade RF. Quantitative mapping of acute and chronic PCL pathology with 3 T MRI: a prospectively enrolled patient cohort. J Exp Orthop 2019; 6:22. [PMID: 31139976 PMCID: PMC6538732 DOI: 10.1186/s40634-019-0188-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 05/13/2019] [Indexed: 11/26/2022] Open
Abstract
Background The diagnosis of incomplete acute and chronic posterior cruciate ligament (PCL) tears can be challenging with conventional magnetic resonance (MR) imaging, particularly for injuries in which the ligament appears continuous as occurs with chronic PCL tears that have scarred in continuity. Quantitative mapping from MR imaging may provide additional useful diagnostic information in these cases. The purpose of this study was to assess the feasibility of quantifying transverse relaxation time (T2) mapping values at 3 Tesla (T) in a prospectively enrolled patient cohort with chronic PCL tears. Methods Twelve subjects with acute or chronic functionally torn PCL, confirmed on clinical exam and posterior knee stress radiographs (with 8 mm or more of increased posterior tibial translation), were enrolled prospectively over a span of 4 years (age: 28–52 years, injury occurred 2 weeks to 15 years prior). Unilateral knee MR images were acquired at 3 T, including a multi-echo spin-echo T2 mapping scan in the sagittal plane. For the six subjects with a continuous PCL on MR imaging the PCL was manually segmented and divided into proximal, mid and distal thirds. Summary statistics for T2 values in each third of the ligament were compiled. Results Across the six patient subjects with a continuous ligament, the mean T2 for the entire PCL was 36 ± 9 ms, with the highest T2 values found in the proximal third (proximal: 41 ms, mid 30 ms, distal 37 ms). The T2 values for the entire PCL and for the proximal third subregion were higher than those recently published for asymptomatic volunteers (entire posterior cruciate ligament: 31 ± 5 ms, proximal: 30 ms, mid: 29 ms, distal: 37 ms) with similar methodology. Conclusion Mean T2 values were quantified for acute and chronic PCL tears in this prospectively enrolled patient cohort and were higher than those reported for asymptomatic volunteers. This novel approach of using quantitative mapping to highlight injured areas of the posterior cruciate ligament has potential to provide additional diagnostic information in the challenging case of a suspected posterior cruciate ligament tear which appears continuous, including chronic tears that have scarred in continuity and may appear intact on conventional magnetic resonance imaging.
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Affiliation(s)
| | - Jurgen Fripp
- The Australian e-Health Research Centre, CSIRO Health and Biosecurity, Level 5 - UQ Health Sciences Building 901/16, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia
| | | | | | - Craig Engstrom
- School of Human Movement and Nutrition Sciences, Human Movement Studies Building, University of Queensland, St Lucia, QLD 4067, Australia
| | - Charles P Ho
- Steadman Philippon Research Institute, Vail, CO, USA
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46
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Murray MM, Kiapour AM, Kalish LA, Ecklund K, Fleming BC, Henderson R, Kramer D, Micheli L, Yen YM, Fleming BC. Predictors of Healing Ligament Size and Magnetic Resonance Signal Intensity at 6 Months After Bridge-Enhanced Anterior Cruciate Ligament Repair. Am J Sports Med 2019; 47:1361-1369. [PMID: 30986359 PMCID: PMC6497549 DOI: 10.1177/0363546519836087] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Primary repair of the anterior cruciate ligament (ACL) augmented with a tissue engineered scaffold to facilitate ligament healing is a technique under development for patients with ACL injuries. The size (the amount of tissue) and signal intensity (the quality of tissue) of the healing ligament as visualized on magnetic resonance imaging (MRI) have been shown to be related to its strength in large animal models. HYPOTHESIS Both modifiable and nonmodifiable risk factors could influence the size and signal intensity of the repaired ligament in patients at 6 months after surgery. STUDY DESIGN Case series; Level of evidence, 4. METHODS 62 patients (mean age, 19.4 years; range, 14-35 years) underwent MRI of the knee 6 months after ACL repair augmented with an extracellular matrix scaffold. The signal intensity (normalized to cortical bone) and average cross-sectional area of the healing ligament were measured from the MRI stack obtained by use of a gradient echo sequence. Associations between these 2 measures and patient characteristics, which included demographic, clinical, and anatomic features, were determined by use of multivariable regression analysis. RESULTS A larger cross-sectional area of the repaired ligament at 6 months was associated with male sex, older age, and the performance of a larger notchplasty ( P < .05 for all associations). A lower signal intensity at 6 months, indicating greater similarity to normal ligament, was associated with a smaller tibial slope and greater side-to-side difference in quadriceps strength 3 months after surgery. Other factors, including preoperative body mass index, mechanism of injury, tibial stump length, and Marx activity score, were not significantly associated with either MRI parameter at 6 months. CONCLUSION Modifiable factors, including surgical notchplasty and slower recovery of quadriceps strength at 3 months, were associated with a larger cross-sectional area and improved signal intensity of the healing ACL after bridge-enhanced ACL repair in this preliminary study. Further studies to determine the optimal size of the notchplasty and the most effective postoperative rehabilitation strategy after ACL repair augmented by a scaffold are justified. REGISTRATION NCT02664545 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Martha M. Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital Boston, MA 02115
| | - Ata M. Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital Boston, MA 02115
| | - Leslie A. Kalish
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital Boston, MA 02115
| | - Kirsten Ecklund
- Department of Radiology, Boston Children’s Hospital, Boston, MA 02115
| | | | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence RI 02818
| | - Rachael Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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47
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Naghibi H, Mazzoli V, Gijsbertse K, Hannink G, Sprengers A, Janssen D, Van den Boogaard T, Verdonschot N. A noninvasive MRI based approach to estimate the mechanical properties of human knee ligaments. J Mech Behav Biomed Mater 2019; 93:43-51. [PMID: 30769233 DOI: 10.1016/j.jmbbm.2019.01.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 01/03/2019] [Accepted: 01/30/2019] [Indexed: 01/31/2023]
Abstract
Characterization of the main tibiofemoral ligaments is an essential step in developing patient-specific computational models of the knee joint for personalized surgery pre-planning. Tensile tests are commonly performed in-vitro to characterize the mechanical stiffness and rupture force of the knee ligaments which makes the technique unsuitable for in-vivo application. The time required for the limited noninvasive approaches for properties estimation based on knee laxity remained the main obstacle in clinical implementation. Magnetic resonance imaging (MRI) technique can be a platform to noninvasively assess the knee ligaments. In this study the aim was to explore the potential role of quantitative MRI and dimensional properties, in characterizing the mechanical properties of the main tibiofemoral ligaments. After MR scanning of six cadaveric legs, all 24 main tibiofemoral bone-ligaments-bone specimens were tested in vitro. During the tensile test cross sectional area of the specimens was captured using ultrasound and force-displacement curve was extracted. Digital image correlation technique was implemented to check the strain behavior of the specimen and rupture region and to assure the fixation of ligament bony block during the test. The volume of the specimen was measured using manual segmentation data, and quantitative MR parameters as T2*, T1ρ, and T2 were calculated. Linear mixed statistical models for repeated measures were used to examine the association of MRI parameters and dimensional measurements with the mechanical properties (stiffness and rupture force). The results shows that while the mechanical properties were mostly correlated to the volume, inclusion of the MR parameters increased the correlation strength for stiffness (R2 ≈ 0.48) and partial rupture force (R2 = 0.53). Inclusion of ligament type in the statistical analysis enhanced the correlation of mechanical properties with MR parameters and volume as for stiffness (R2 = 0.60) and partial rupture (R2 = 0.57). In conclusion, this study revealed the potentials in using quantitative MR parameters, T1ρ, T2 and T2*, combined with specimen volume to estimate the essential mechanical properties of all main tibiofemoral ligaments required for subject-specific computational modeling of human knee joint.
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Affiliation(s)
- Hamid Naghibi
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Robotics and Mechatronics Group, The Faculty of Electrical Engineering Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, the Netherlands.
| | - Valentina Mazzoli
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Radiology, Stanford University, Stanford, CA, USA
| | - Kaj Gijsbertse
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerjon Hannink
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andre Sprengers
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dennis Janssen
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ton Van den Boogaard
- Nonlinear Solid Mechanics, Faculty of Engineering Technology, University of Twente, Enschede, the Netherlands
| | - Nico Verdonschot
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Laboratory of Biomechanical Engineering, University of Twente, Enschede, the Netherlands
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49
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Beveridge JE, Machan JT, Walsh EG, Kiapour AM, Karamchedu NP, Chin KE, Proffen BL, Sieker JT, Murray MM, Fleming BC. Magnetic resonance measurements of tissue quantity and quality using T 2 * relaxometry predict temporal changes in the biomechanical properties of the healing ACL. J Orthop Res 2018; 36:1701-1709. [PMID: 29227559 PMCID: PMC5995620 DOI: 10.1002/jor.23830] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 12/04/2017] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to develop a magnetic resonance T2 * relaxometry-based multiple linear regression model to predict the structural properties of the healing anterior cruciate ligament (ACL) over a 24-week healing period following ACL repair in Yucatan minipigs. Two hypotheses were tested: (i) that a regression model based on ACL sub-volumes containing short and long T2 * relaxation times would outperform a competing model based on sub-volumes of short T2 * relaxation times only; and (ii) that an optimized regression model would be capable of predicting ACL structural properties between 6 and 24 weeks post-repair. ACLs were imaged in 24 minipigs (8/group) at either 6, 12, or 24 weeks after ACL repair. The structural properties of the ACLs were determined from tensile failure tests. Four multiple linear regression models of increasing complexity were fitted to the data. Akaike Information Criterion values and Bland-Altman tests were used to compare model performance and to test the hypotheses. The structural properties predicted from the multiple linear regression model that was based on the change in ACL sub-volumes of both the short and long T2 * relaxation times over the healing period were in closest agreement to the measured values, suggesting that the amounts of both organized and disorganized collagen, and the change in these quantities over time, are required to predict the structural properties of healing ACLs accurately. CLINICAL SIGNIFICANCE our time-specific, T2 *-based regression model may allow us to estimate the structural properties of ACL repairs in vivo longitudinally. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1701-1709, 2018.
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Affiliation(s)
- Jillian E Beveridge
- Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jason T Machan
- Rhode Island Hospital Biostatistics Core, Providence, Rhode Island
| | - Edward G Walsh
- Division of Biology and Medicine, Department of Neuroscience, Brown University, Providence, Rhode Island
| | | | - Naga Padmini Karamchedu
- Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kaitlyn E Chin
- Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | | | | | - Braden C Fleming
- Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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50
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Cone SG, Simpson SG, Piedrahita JA, Fordham LA, Spang JT, Fisher MB. Orientation changes in the cruciate ligaments of the knee during skeletal growth: A porcine model. J Orthop Res 2017; 35:2725-2732. [PMID: 28471537 PMCID: PMC5671372 DOI: 10.1002/jor.23594] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 04/24/2017] [Indexed: 02/04/2023]
Abstract
Musculoskeletal injuries in pediatric patients are on the rise, including significant increases in anterior cruciate ligament (ACL) injuries. Previous studies have found major anatomical changes during skeletal growth in the soft tissues of the knee. Specifically, the ACL and the posterior cruciate ligament (PCL) change in their relative orientation to the tibial plateau throughout growth. In order to develop age-specific treatments for ACL injuries, the purpose of this study was to characterize orientation changes in the cruciate ligaments of the Yorkshire pig, a common pre-clinical model, during skeletal growth in order to verify the applicability of this model for pediatric musculoskeletal studies. Hind limbs were isolated from female Yorkshire pigs ranging in age from newborn to late adolescence and were then imaged using high field strength magnetic resonance imaging. Orientation changes were quantified from the magnetic resonance images using image segmentation software. Statistically significant increases were found in the coronal and sagittal angles of the ACL relative to the tibial plateau during pre-adolescent growth. Additional changes were observed in the PCL angle, Blumensaat angle, intercondylar roof angle, and the aspect ratio of the intercondylar notch. Only the sagittal angle of the ACL relative to the tibial plateau experienced statistically significant changes through late adolescence. The age-dependent properties of the ACL and PCL in the female pig mirrored results found in female human patients, suggesting that the porcine model may provide a pre-clinical platform to study the cruciate ligaments during skeletal growth. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2725-2732, 2017.
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Affiliation(s)
- Stephanie G. Cone
- Department of Biomedical Engineering, North Carolina State University, Raleigh, NC 27695, USA and the University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA,Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, USA
| | - Sean G. Simpson
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC 27695, USA
| | - Jorge A. Piedrahita
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, USA,Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC 27695, USA
| | - Lynn A. Fordham
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Jeffrey T. Spang
- Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Matthew B. Fisher
- Department of Biomedical Engineering, North Carolina State University, Raleigh, NC 27695, USA and the University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA,Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, USA,Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA,Corresponding author: Matthew B. Fisher, Ph.D., Assistant Professor, Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, 4208C Engineering Building III, Raleigh, NC 27695, Phone: 919-515-5242,
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