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Cai Z, Liu D, Yang Y, Lu W, Pan L, Liu X, Liu G, Vithran DTA, Li Y, Xiao W. Outcomes from different aspects indicate the all-inside technique may serve as an ideal option for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38769796 DOI: 10.1002/ksa.12259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE To evaluate the postoperative outcomes of the all-inside technique in arthroscopic anterior cruciate ligament reconstruction (ACLR). METHODS Patients who underwent ACLR using the all-inside technique between 2018 and 2021 were retrospectively assessed. All patients were followed up for at least 2 years. Functional recovery and pain relief were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS). Instrumented laxity was assessed via side-to-side difference using the Kneelax3 arthrometer. Graft maturity was estimated using the signal-to-noise quotient value based on magnetic resonance imaging (MRI). Adverse events during and after the surgery were recorded. RESULTS A total of 78 patients were included in this study, with a mean age of 28.1 ± 7.6 years. The IKDC (p < 0.001), Lysholm (p < 0.001) and KOOS (p < 0.001 for all subgroups) scores at the final follow-up were significantly higher than those before the surgery. The VAS scores (p < 0.05) were significantly lower than those before surgery. The side-to-side difference results indicated that 50 patients had a difference of less than 3 mm, indicating a tight graft, whereas only 1 patient had a difference of >5 mm, indicating a loose graft. The median signal-to-noise quotient of the graft on MRI was 1.4 (P25, P75: 1.0, 2.0). No intraoperative adverse events were observed. Postoperative adverse events included three cases of infection, three cases of graft rerupture, two cases of cyclops lesion and one case of surgical intervention for a meniscal tear. CONCLUSION ACLR using the all-inside technique offers promising results in patients with ACL rupture. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Zijun Cai
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Di Liu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuntao Yang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wenhao Lu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Linyuan Pan
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xu Liu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Gaoming Liu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Djandan Tadum Arthur Vithran
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yusheng Li
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wenfeng Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Shimodaira H, Tensho K, Koyama S, Iwaasa T, Kumaki D, Yoshida K, Horiuchi H, Takahashi J. Effect of a new remnant-preserving technique with anatomical double-bundle anterior cruciate ligament reconstruction on MRI-based graft maturity: a comparison cohort study. Knee Surg Sports Traumatol Arthrosc 2022; 31:2394-2405. [PMID: 36181522 DOI: 10.1007/s00167-022-07180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To investigate the effects of a new remnant-preserving double-bundle anterior cruciate ligament reconstruction (ACLR) technique, focused on avoiding remnant damage and preserving continuity of remnants, on graft maturity using magnetic resonance imaging (MRI). METHODS A total of 169 patients were divided into three groups: 41 in the preservation group, 70 in the resection group, and 58 in the absent group. In the preservation group, rather than passing the graft through the remnant tissue, the graft was reconstructed such that the anteromedial and posterolateral bundles sandwiched the remnant to avoid damage to the remnant and maintain its continuity. Based on 1-year postoperative MRI, the grafts were divided into three regions: distal, middle, and proximal. The signal/noise quotient (SNQ) of each region of interest was calculated to evaluate the signal intensity of the graft and was compared among the three groups. Additionally, to identify factors influencing graft maturity, a multiple regression analysis was performed with SNQ as the dependent variable and patient demographics, bone morphology, and surgical factors as independent variables. RESULTS In a three-group comparison of mean SNQs, the distal region was 3.3 ± 3.4, 8.9 ± 8.3, and 9.0 ± 8.6 (p < 0.001), the middle region was 5.3 ± 3.7, 10.9 ± 11.1, and 11.3 ± 10.2 (p < 0.001), and the proximal region was 6.8 ± 4.5, 11.1 ± 8.8, and 11.7 ± 10.8 (p = 0.017), in order of the preservation, resection, and absent groups, respectively. That indicated that the remnant-preserving ACLR was more hypointense than ACLR with remnant resection or absent in all three regions. Multiple regression analysis showed that remnant preservation remained the relevant factor affecting SNQ of the graft at the distal and middle levels. CONCLUSION The new remnant-preserving anatomic double-bundle ACLR had significantly better graft maturity, measured by SNQ on MRI, than the remnant resection and absent groups. The remnant procedure was the relevant factor affecting graft maturity. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hiroki Shimodaira
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Daiki Kumaki
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kazushige Yoshida
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroshi Horiuchi
- Department of Rehabilitation, Shinshu University Hospital, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
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Kinoshita T, Hashimoto Y, Iida K, Nakamura H. ACL Graft Matching: Cadaveric Comparison of Microscopic Anatomy of Quadriceps and Patellar Tendon Grafts and the Femoral ACL Insertion Site. Am J Sports Med 2022; 50:2953-2960. [PMID: 35914183 DOI: 10.1177/03635465221110895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal graft choice between the bone-patellar tendon-bone (BPTB) and the quadriceps tendon remains controversial. Studies evaluating the microscopic anatomy of the quadriceps tendon-patellar bone (QTB) and BPTB grafts for anterior cruciate ligament (ACL) reconstruction are currently lacking. HYPOTHESIS The relationship between post-ACL reconstruction graft bending angle (GBA) and the angle corresponding to the GBA (cGBA) would indicate that the BPTB can bend more than the QTB at the femoral tunnel aperture. STUDY DESIGN Controlled laboratory study. METHODS Twenty paired human cadaveric knees fixed at <10° of knee joint flexion (mean age, 82.5 years) underwent histological sectioning and staining with Masson trichrome and toluidine blue. The femoral ACL insertion, QTB graft, and BPTB graft were microscopically analyzed. The width of the direct insertion, thickness of the uncalcified fibrocartilage and calcified fibrocartilage, ligament attachment angle, and cGBA for each group were measured. Eighteen patients who underwent ACL reconstruction with QTB or BPTB autograft were included for the evaluation of GBA using computed tomography images at 1 week postoperatively. RESULTS The mean insertion widths of the femoral ACL, QTB, and BPTB were 7.81, 9.07, and 6.54 mm, respectively. The QTB was 16% wider than the ACL, while the BPTB was 16% narrower than the ACL. The mean insertion thicknesses of the femoral ACL, QTB, and BPTB were 0.53, 0.94, and 0.38 mm, respectively. The QTB was 77% thicker than the ACL (P < .001), while the BPTB was 28% thinner than the ACL (P = .017). The mean ligament attachment angles of the femoral ACL, QTB, and BPTB were 20.3°, 30.2°, and 33.3°, respectively, and the QTB and the BPTB were 49% and 64% larger, respectively, than the ACL. The mean cGBAs of the femoral ACL, QTB, and BPTB were 33.9°, 35.1°, and 12.3°, respectively. The BPTB was 64% smaller than the ACL, while there was no significant difference between the QTB and the ACL. The mean GBA was 57.7°. CONCLUSION The insertion width and thickness were significantly greater and smaller in the QTB and BPTB grafts, respectively, than in the ACL. The relationship between GBA after ACL reconstruction and cGBA in knee extension indicates that at the femoral tunnel aperture, the BPTB can bend more than the QTB. CLINICAL RELEVANCE QTB graft may allow more anatomic ACL reconstruction to be performed.
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Affiliation(s)
- Takuya Kinoshita
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ken Iida
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Chiba D, Yamamoto Y, Kimura Y, Sasaki E, Sasaki S, Tsuda E, Ishibashi Y. Association Between Early Postoperative Graft Signal Intensity and Residual Knee Laxity After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2022; 10:23259671221109608. [PMID: 35898202 PMCID: PMC9310230 DOI: 10.1177/23259671221109608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 03/31/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) graft signal intensity is associated with graft damage after anterior cruciate ligament reconstruction (ACLR). However, little is known about the relationship between graft signal intensity and residual laxity of the reconstructed knee based on patient age. Purpose/Hypothesis: To evaluate the relationship between graft signal intensity and residual laxity in younger and older patients who underwent ACLR. We hypothesized that higher graft signal intensity would be associated with reduced postoperative knee stability. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 192 patients who underwent double-bundle ACLR were recruited. Proton density–weighted and T2-weighted MRI was performed at 3, 6, and 12 months after surgery, and the signal intensity ratio (SIR) of the anteromedial and posterolateral bundles was measured as the graft signal intensity reference values. At 12 months after surgery, if the KT-1000 arthrometer measurement exhibited a side-to-side difference of ≥2 mm, the patient was determined as having anterior knee laxity. Rotatory knee laxity was defined as a positive pivot shift with International Knee Documentation Committee grade ≥1. The Mann-Whitney U test was used to compare the SIR in patients with and without residual laxity. The Spearman correlation coefficient was used to evaluate the relationship between demographic parameters and the SIR. Based on receiver operating characteristic curves, the optimal SIR cutoff values to predict residual laxity were calculated, and logistic regression analysis was conducted. Results: Of 192 patients, 26 (13.5%) had anterior knee laxity, and 20 (10.4%) had rotatory knee laxity. The SIR was negatively correlated with age. In younger patients (<30 years; n = 135), those with residual laxity had a significantly higher SIR than those without laxity; this relationship was not significant in older patients (≥30 years; n = 57). Based on receiver operating characteristic curves and logistic regression analysis, the cutoff values that were determined for the SIR were significantly associated with a higher odds ratio of residual laxity. Conclusion: Graft signal intensity decreased with patient age. Patients with higher graft signal intensity in the early postoperative phase after ACLR exhibited a higher prevalence of residual laxity, particularly in younger patients.
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Affiliation(s)
- Daisuke Chiba
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Lin R, Zhong Q, Wu X, Cui L, Huang R, Deng Q, Zuo J, Jiang C, Li W. Randomized controlled trial of all-inside and standard single-bundle anterior cruciate ligament reconstruction with functional, MRI-based graft maturity and patient-reported outcome measures. BMC Musculoskelet Disord 2022; 23:289. [PMID: 35337306 PMCID: PMC8957124 DOI: 10.1186/s12891-022-05231-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/16/2022] [Indexed: 12/20/2022] Open
Abstract
Background All-inside anterior cruciate ligament reconstruction (ACLR) is a novel technique that has gained attention due to its minimally invasive and graft-saving properties. However, studies comparing MRI-based graft maturity between all-inside and standard ACLR are lacking. Purpose This study focused on the functional, knee laxity, and MRI-based graft maturity characteristics of all-inside and standard single-bundle ACLR. Study Design Randomized controlled trial (RCT). Methods Fifty-four patients were randomly assigned to an all-inside reconstruction group (n = 27) or standard reconstruction group (n = 27). Using the same rehabilitation strategy. The Tegner, International Knee Documentation Committee, and Lysholm scores were recorded at postoperative months 3, 6, and 12 to assess functional recovery. MRI was conducted to measure the signal/noise quotient (SNQ) of the intra-articular graft to assess the maturity. A higher SNQ indicates lower graft maturity. Knee laxity was assessed using GNRB arthrometer at the postoperative month 12. Results The graft SNQ of the all-inside group was significantly higher than that of the standard group at postoperative month 6 (p < 0.05). There was no statistical difference in graft SNQ between the two groups at postoperative months 3 and 12 (p > 0.05). Both groups exhibited the highest SNQ in the middle region of the graft, followed by the proximal region, and the distal region. Functional scores improved significantly for both groups and had no statistical difference (p > 0.05). The knee laxity was higher in the all-inside group (p < 0.05) at postoperative month 12. There was no correlation between the functional scores and graft maturity in both groups (p > 0.05). Conclusions All-inside and standard single-bundle ACLR show good functional outcomes; however, knee laxity was relatively higher in the all-inside ACLR group than in the standard ACLR group. Moreover, both techniques exhibited poor maturity in the middle graft region and the best in the distal region. Graft maturity with all-inside ACLR is inferior to that with standard ACLR in the early postoperative stages. There is no correlation between knee function and graft maturity. Trial registration Clinical trial registration numbers: ChiCTR1800018543. Date of registration: 09/23/2018.
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Affiliation(s)
- Rubing Lin
- Peking University Shenzhen Hospital, Clinical College of Anhui Medical University, Lianhua Road 1120, Futian District, Shenzhen City, Guangdong Province, 518036, People's Republic of China.,Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China
| | - Qiuwen Zhong
- Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China
| | - Xiao Wu
- Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China
| | - Lei Cui
- Peking University Shenzhen Hospital, Clinical College of Anhui Medical University, Lianhua Road 1120, Futian District, Shenzhen City, Guangdong Province, 518036, People's Republic of China.,Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China
| | - Rong Huang
- Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China
| | - Qianhua Deng
- Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China
| | - Jianwei Zuo
- Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China
| | - Changqing Jiang
- Huazhong University of Science and Technology Union Shenzhen Hospital, Taoyuan Road 89, Nanshan District, Shenzhen City, GuangDong Province, 518036, People's Republic of China
| | - Wei Li
- Peking University Shenzhen Hospital, Lianhua Road 1120, FuTian District, ShenZhen City, GuangDong Province, 518036, People's Republic of China.
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Asai K, Nakase J, Yoshimizu R, Kimura M, Tsuchiya H. Does remnant tissue preservation in anterior cruciate ligament reconstruction influence the creation of the rectangular femoral tunnel? J Orthop Surg (Hong Kong) 2022; 29:23094990211061249. [PMID: 34893002 DOI: 10.1177/23094990211061249] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE We have previously described anterior cruciate ligament reconstruction with a rounded rectangular femoral tunnel created using a rounded rectangular dilator designed to enable a more anatomical and wider tendon-bone junction. However, the influence of remnant tissue preservation on the creation of the rounded rectangular femoral tunnel is not clear. This study aimed to evaluate the influence of remnant tissue preservation on the creation of the rounded rectangular femoral tunnel. METHODS A total of 198 patients who underwent primary anterior cruciate ligament reconstruction with a rounded rectangular femoral tunnel were evaluated retrospectively. Patients were categorized into a remnant preservation group (group P) and a non-preservation group (group N). Computed tomography images taken 1 week postoperatively were analyzed. The location of the rounded rectangular femoral tunnel evaluated using the quadrant method, its rotation angle, and the graft bending angle were compared between the two groups. The differences and the variance in femoral tunnel assessment were compared using the two-sample t-test and Levene's test. RESULTS Although there was no significant difference in the location of femoral tunnel for the deep/shallow direction along the Blumensaat's line (difference, p = .326; variances, p = .970), the tunnel was significantly lower in group P than in group N, with no variances (difference, p = .001; variances, p = .326). There were no significant differences and no variances in the tunnel rotation angle and the graft bending angle (difference, p = .727 and 0.514, respectively; variances, p = .827 and .445, respectively). Blow out of the posterior wall of the medial aspect of the femoral lateral condyle was an intraoperative complication that occurred in one case in group N. CONCLUSION The remnant preservation approach creates a lower femoral tunnel compared to the non-preservation technique. However, a rounded rectangular femoral tunnel can be created safely and is reproducible with remnant tissue preservation.
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Affiliation(s)
- Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa UniversityKanazawa, Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa UniversityKanazawa, Japan
| | - Rikuto Yoshimizu
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa UniversityKanazawa, Japan
| | - Mitsuhiro Kimura
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa UniversityKanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa UniversityKanazawa, Japan
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Different timing in allograft and autograft maturation after primary anterior cruciate ligament reconstruction does not influence the clinical outcome at mid-long-term follow-up. Knee Surg Sports Traumatol Arthrosc 2022; 30:2281-2290. [PMID: 34782927 PMCID: PMC8592808 DOI: 10.1007/s00167-021-06785-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE The use of allografts in primary anterior cruciate ligament reconstruction (ACLR) is increasing although they are still supposed to be associated to greater risk of re-rupture due to a slower and less efficient graft maturation. The aim of this prospective randomized controlled study was to compare the graft maturation after ACLR with allograft and autograft by MRI at 6- and 12-month follow-up and integrate these data with the functional and clinical results observed at 6-, 12- and 60-month follow-up. METHODS Fifty patients with indication to primary ACLR were randomly and equally divided into hamstring autograft or allograft tendon groups. The graft maturation was measured at 6- and 12-month follow-up by the SNQ score and other radiological parameters on MRI scans. Clinical and functional recovery was evaluated by Lysholm score, Visual Analogues Scale, Tegner activity scale and modified Cincinnati knee rating system at 6, 12 and 60 months after surgery to estimate the predictive value of the radiological parameters for clinical outcomes. Return-to-sport (ACL-RSI) was measured 60 months after surgery. RESULTS Three patients had retear of the neo-ligament (two from Auto group and one from Allo group). All the clinical/functional parameters significantly improved over time, with no statistically significant difference between the groups. At 6 months, the SNQ value was significantly higher in the Auto than in the Allo group (12.9 vs 7.9, p = 0.038), but at 12 months they were comparable (9.8 vs 10.4). The 6-month SNQ values did not correlate with the clinical scores, whereas the 12-month SNQ values significantly correlated with the Cincinnati score, Lysholm score and Tegner activity scale collected at 60-month follow-up. CONCLUSION No clinical or functional differences have been found between the two treatment groups, supporting the suitability of using allograft in primary ACLR, when available. The results at MRI scans showed a different graft maturation trend in the two groups, with allografts being more reactive in the first 6 months. MRI together with the subjective evaluation allows to evaluate objectively the status of the neo-ligamentization process and therefore helps the surgeon to dictate the individual time for return-to-sport. LEVEL OF EVIDENCE Level I.
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Lutz PM, Achtnich A, Schütte V, Woertler K, Imhoff AB, Willinger L. Anterior cruciate ligament autograft maturation on sequential postoperative MRI is not correlated with clinical outcome and anterior knee stability. Knee Surg Sports Traumatol Arthrosc 2022; 30:3258-3267. [PMID: 34739559 PMCID: PMC9464175 DOI: 10.1007/s00167-021-06777-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 10/18/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE Magnetic resonance imaging (MRI) signal intensity is correlated to structural postoperative changes of the anterior cruciate ligament (ACL) autograft. The purpose of this study was to investigate the ACL autograft maturation process via MRI over 2 years postoperatively, compare it to a native ACL signal and correlate the results with clinical outcome, return to preinjury sports levels, and knee laxity measurements. METHODS ACL autograft signal intensity was measured in 17 male patients (age, 28.3 ± 7.0 years) who underwent ACL reconstruction with hamstring autograft at 6 weeks, 3-, 6-, 12-, and 24 months postoperatively by 3 Tesla MRI. Controls with an intact ACL served as control group (22 males, 8 females; age, 26.7 ± 6.8 years). An ACL/PCL ratio (APR) and ACL/muscle ratio (AMR) was calculated to normalize signals to soft tissue signal. APR and AMR were compared across time and to native ACL signal. Clinical outcome scores (IKDC, Lysholm), return to preinjury sports levels (Tegner activity scale), and knee laxity measurement (KT-1000) were obtained and correlated to APR and AMR at the respective time points. RESULTS The APR and AMR of the ACL graft changed significantly from the lowest values at 6 weeks to reach the highest intensity after 6 months (p < 0.001). Then, the APR and AMR were significantly different from a native ACL 6 months after surgery (p < 0.01) but approached the APR and AMR of the native ACL at 1- and 2 years after surgery (p < 0.05). The APR changed significantly during the first 2 years postoperatively in the proximal (p < 0.001), mid-substance (p < 0.001), and distal (p < 0.01) intraarticular portion of the ACL autograft. A hypo-intense ACL MRI signal was associated with return to the preinjury sports level (p < 0.05). No correlation was found between ACL MRI graft signal and clinical outcome scores or KT-1000 measurements. CONCLUSION ACL grafts undergo a continuous maturation process in the first 2 years after surgery. The ACL graft signals became hyper-intense 6 months postoperatively and approximated the signal of a native intact ACL at 12- and 24 months. Patients with a hypo-intense ACL graft signal at 2 years follow-up were more likely to return to preinjury sports levels. The results of the present study provide a template for monitoring the normal ACL maturation process via MRI in case of prolonged clinical symptoms. However, subjective outcome and clinical examination of knee laxity remain important to assess the treatment success and to allow to return to sports. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Patricia M. Lutz
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Vincent Schütte
- Department for Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120 Halle (Saale), Germany
| | - Klaus Woertler
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Andreas B. Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Lukas Willinger
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675 Munich, Germany
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Chen RJ, Zhu HZ, Gu XY, Xiang XX. Effects of Platelet-Rich Plasma on Tendon-Bone Healing After Anterior Cruciate Ligament Reconstruction. Orthop Surg 2021; 14:88-95. [PMID: 34870370 PMCID: PMC8755887 DOI: 10.1111/os.13175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/05/2021] [Accepted: 10/20/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To investigate the effect of platelet-rich plasma on tendon-bone healing after anterior cruciate ligament reconstruction. METHODS This retrospective study included 85 patients (range, 18-50 years; mean age, 33.95 ± 10.53 years; male/female, 49/36) who underwent anterior cruciate ligament reconstruction using autologous hamstring tendons between August 2017 and June 2019 at our institute. The participants in the study group (n = 42) were injected with platelet-rich plasma at both ends of the tendon graft, while those in the control group (n = 43) received an injection of normal saline. Magnetic resonance imaging signal/noise quotient values of the femoral and tibial ends, knee Lysholm scores, and International Knee Documentation Committee scores were compared at 3, 6, and 12 months postoperatively. RESULTS The signal/noise quotient values of the femoral and tibial ends in both groups were higher at 6 months than at 3 and 12 months postoperatively. The signal/noise quotient values of the tibial end were significantly lower in the platelet-rich plasma group than in the normal saline group at all follow-up time points (P < 0.05). The signal/noise quotient values of the tibial and femoral ends in both groups were significantly different at 3, 6, and 12 months postoperatively (P < 0.05). Additionally, the signal/noise quotient values of the tibia were significantly lower than those of the femur in both groups (P < 0.05). The Lysholm and International Knee Documentation Committee scores were significantly better in the platelet-rich plasma group than in the normal saline group only at 3 months postoperatively. No complications, such as knee joint infection or vascular and nerve injuries, occurred in any of the 85 patients. The knee flexion of all patients were more than 90°, and the straight degree was 0°. No joint stiffness was observed in all patients. CONCLUSION Platelet-rich plasma can promote tendon-bone healing in grafts and can improve early postoperative knee joint function.
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Affiliation(s)
- Rong-Jin Chen
- Department of Orthopedic Surgery, Affiliated Sichuan Provincial Rehabilitation Hospital of Chengdu University of TCM, Chengdu, China.,Department of Orthopedic Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Hao-Zhong Zhu
- Department of Orthopedic Surgery, Chengdu Fifth People's Hospital, Chengdu, China
| | - Xin-Yi Gu
- Department of Oncology, Chengdu Fifth People's Hospital, Chengdu, China
| | - Xian-Xiang Xiang
- Department of Orthopedic Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
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10
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Iriuchishima T, Goto B. Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction. J Knee Surg 2021; 34:1531-1538. [PMID: 32480416 DOI: 10.1055/s-0040-1710521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms "anterior cruciate ligament reconstruction," "anatomic or anatomical," and "single bundle." Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow-deep direction (32.3%) and in a high-low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.
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Affiliation(s)
| | - Bunsei Goto
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
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11
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Anatomic all-epiphyseal ACL reconstruction with "inside-out" femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:4251-4260. [PMID: 33811490 DOI: 10.1007/s00167-021-06542-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/18/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To understand if anatomic physeal-sparing ACL reconstruction in the immature host preserves range of motion, permits a return to sports, and avoids limb length discrepancy and accelerated intra-articular degeneration with a cross-sectional radiographic, physical examination and patient-reported outcomes analysis. METHODS A cross-sectional recall study included 38 patients aged 7-15 who underwent all-epiphyseal ACL reconstruction with hamstring allograft performed by a single surgeon at a large academic medical center. All-epiphyseal reconstructions were performed using a modified Anderson physeal-sparing technique, with the femoral tunnel placed using an "inside-out" technique. Assessments consisted of a physical exam, long leg cassette radiographs, KT-1000 measurements, subjective patient metrics, and magnetic resonance imaging. RESULTS Thirty-eight (56.7%) of 66 eligible patients returned for in-person clinical and radiographic exams. Patients were 11.4 ± 1.8 years at the time of surgery. Five patients were females (13.2%). Mean follow-up was 5.5 ± 2.4 years. ACL re-injuries occurred in four patients (10.5%), all of whom underwent revision reconstructions. Thirty-three of the remaining 34 (97.1%) patients returned to sports following their reconstruction, and 24 (70.6%) returned to their baseline level of competition. Mean limb length discrepancy (LLD) was 0.2 ± 1.4 cm. Nine patients had an LLD of > 1 cm (26.5%), which occurred at an equivalent age as those with < 1 cm LLD (10.8 ± 2.0 vs. 11.7 ± 1.7, n.s.). Pre-operative Marx scores (13.1 ± 3.5) were not significantly different from post-operative values (12.3 ± 5.1, n.s.). Patients who required ACL revisions had significantly lower Marx scores than those with intact primary grafts (8.3 ± 7.1 vs. 13.4 ± 4.5, p = 0.047). Cohort mean International Knee Documentation Committee (IKDC) score was 89.7 ± 12.7. CONCLUSION Anatomic all-epiphyseal anatomic ACL reconstruction appears to be useful in patients with significant projected remaining growth, with good return-to-sport outcomes and minimal risk of clinically significant physeal complications. However, given the limited patient recall possible in the present study, further large sample size, high-quality works are necessary to validate our findings. LEVEL OF EVIDENCE Level IV.
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12
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Lee DK, Kim JH, Lee BH, Kim H, Jang MJ, Lee SS, Wang JH. Influence of Graft Bending Angle on Femoral Tunnel Widening After Double-Bundle ACL Reconstruction: Comparison of Transportal and Outside-In Techniques. Orthop J Sports Med 2021; 9:23259671211035780. [PMID: 34708137 PMCID: PMC8543726 DOI: 10.1177/23259671211035780] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Previous studies have suggested that increased mechanical stress due to acute
graft bending angle (GBA) is associated with tunnel widening and graft
failure after anterior cruciate ligament (ACL) reconstruction. Few studies
have compared the GBA between the outside-in (OI) and the transportal (TP)
techniques. Purpose: To evaluate the influence of GBA on clinical outcomes and tunnel widening
after ACL reconstruction with OI versus TP technique. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the study were 56 patients who underwent double-bundle ACL
reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical
outcomes (Lysholm, International Knee Documentation Committee, Tegner score,
and knee laxity) 1 year postoperatively were evaluated. Computed tomography
scans at 5 days and 1 year postoperatively were used for imaging
measurements, and the femoral tunnel was divided into the proximal third,
middle, and aperture sections. The GBA and cross-sectional area (CSA) were
measured using image analysis software and were compared between groups. A
correlation analysis was performed to determine if the GBA affected clinical
outcomes or tunnel widening. Results: No significant difference was observed in clinical outcomes between the
groups. The GBA of both the anteromedial (AM) and posterolateral bundles
were more acute in the OI group compared with the TP group
(P < .05). The CSA at the AM tunnel aperture
increased significantly in the OI group (84.2% ± 64.3%) compared with the TP
group (51.4% ± 36.7%) (P = .04). However, there were no
differences in the other sections. In the Pearson correlation test, GBA was
not correlated with tunnel widening or clinical outcomes. Conclusion: Regardless of technique, the GBA did not have a significant influence on
tunnel widening or clinical outcomes. Considering a wider AM tunnel
aperture, a more proximal and posterior AM tunnel position might be
appropriate with the OI technique.
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Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, South Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Hyeonsoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Min Jae Jang
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Health Science and Technology and Department of Medical Device Management and Research, SAIHST (Samsung Advanced Institute for Health Sciences & Technology), Sungkyunkwan University, Seoul, South Korea
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13
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Skeletally immature patient showed lower graft maturity than skeletally mature patient after ACL reconstruction with a rounded rectangular femoral tunnel. Sci Rep 2021; 11:19968. [PMID: 34620936 PMCID: PMC8497465 DOI: 10.1038/s41598-021-99532-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/21/2021] [Indexed: 11/24/2022] Open
Abstract
To compare the clinical results and ligamentization of anterior cruciate ligament reconstruction (ACLR) between skeletally immature and mature patients. Two-hundred-and-two patients who underwent primary ACLR were evaluated retrospectively. The clinical outcomes were compared between skeletally immature (immature group 1, n = 27) and mature (control group 1, n = 175) groups. Graft ligamentization of the reconstructed anterior cruciate ligament (ACL) using magnetic resonance imaging (MRI) signal intensity at 6 months postoperatively was compared between immature group 2 (n = 16), which included participants from immature group 1, and control group 2 (n = 32), created by recruiting data-matched controls from control group 1. Immature group 1 had significantly higher revision (14.8%) and pivot shift test positive (22.2%) rates than control group 1 (2.9% and 4.0%, respectively) (P = 0.020 and 0.003, respectively). The signal intensity in immature group 2 were significantly higher at the mid-substance and distal site of the reconstructed ACL than those in control group 2 (P = 0.003 and 0.034, respectively). Skeletally immature patients had higher graft revision and residual rotational laxity rates. Reconstructed ACL in skeletally immature patients showed higher signal intensity on MRI at 6 months postoperatively.
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14
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Panos JA, Devitt BM, Feller JA, Klemm HJ, Hewett TE, Webster KE. Effect of Time on MRI Appearance of Graft After ACL Reconstruction: A Comparison of Autologous Hamstring and Quadriceps Tendon Grafts. Orthop J Sports Med 2021; 9:23259671211023512. [PMID: 34541010 PMCID: PMC8442487 DOI: 10.1177/23259671211023512] [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: 02/07/2021] [Accepted: 02/28/2021] [Indexed: 01/23/2023] Open
Abstract
Background: After anterior cruciate ligament (ACL) reconstruction (ACLR), changes in the
appearance of the ACL graft can be monitored using magnetic resonance
imaging (MRI). Purpose: The purpose of this study was to evaluate and compare the MRI signal
intensity (SI) of hamstring and quadriceps tendon grafts during the first
postoperative year after ACLR. As a secondary aim, the relationship of SI to
clinical and anatomic measurements was analyzed. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 78 patients who underwent ACLR with an autologous graft were
reviewed; 55 received hamstring grafts and 23 received quadriceps tendon
grafts. At 3 and 9 months postoperatively, 3-T MRI was performed using a
dedicated knee coil, and the median SI of the intra-articular ACL graft was
measured on sagittal-plane images. Postoperative lateral radiographs were
analyzed to determine medial and lateral posterior tibial slope (PTS).
Side-to-side difference in anterior knee laxity between injured and
uninjured limbs was measured at 6 and 12 months postoperatively. Results: The median SI of quadriceps grafts was significantly greater than hamstring
grafts at 3 months after ACLR (P = .02). Between 3 and 9
months, the median SI of quadriceps grafts decreased (P
< .001), while that of hamstring grafts did not significantly change
(P = .55). The lateral PTS was significantly correlated
with median SI measurements at 3 and 9 months such that greater lateral PTS
values were associated with greater median SI. The side-to-side difference
in anterior knee laxity decreased for the quadriceps group
(P = .04) between 6 and 12 months but did not change
for the hamstring group (P = .88). Conclusion: The median SI of quadriceps grafts significantly decreased on MRI between 3
and 9 months after ACLR, while the median SI of hamstring grafts did not
significantly change. The change in MRI appearance of the quadriceps grafts
was paralleled by a reduction in anterior knee laxity between 6 and 12
months after surgery. In the absence of standardized imaging techniques and
imaging analysis methods, the role of MRI in determining graft
maturation, and the implications for progression through rehabilitation to
return to sport, remain uncertain.
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Affiliation(s)
| | - Brian M Devitt
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Julian A Feller
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Victoria, Australia.,School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Haydn J Klemm
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Timothy E Hewett
- The Rocky Mountain Consortium for Sports Research, Edwards, Colorado, USA
| | - Kate E Webster
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
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Biomechanical Effects of Aspect Ratio of the Knee during Outside-In Anterior Cruciate Ligament Reconstruction Surgery. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3454475. [PMID: 34527735 PMCID: PMC8437649 DOI: 10.1155/2021/3454475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/20/2021] [Indexed: 11/18/2022]
Abstract
We analyzed tunnel length, graft bending angle, and stress of the graft according to tunnel entry position and aspect ratio (ASR: ratio of anteroposterior depth to mediolateral width) of the articular surface for the distal femur during single-bundle outside-in anterior cruciate ligament reconstruction (ACLR) surgery. We performed multiflexible body dynamic analyses with four ASR (98, 105, 111, and 117%) knee models. The various ASRs were associated with approximately 1 mm changes in tunnel length. The graft bending angle increased when the entry point was far from the lateral epicondyle and was larger when the ASR was smaller. The graft was at maximum stress, 117% ASR, when the tunnel entry point was near the lateral epicondyle. The maximum stress value at a 5 mm distance from the lateral epicondyle was 3.5 times higher than the 15 mm entry position, and the cases set to 111% and 105% ASR showed 1.9 times higher stress values when at a 5 mm distance compared with a 15 mm distance. In the case set at 98% ASR, the low-stress value showed a without-distance difference from the lateral epicondyle. Our results suggest that there is no relationship between the ASR and femoral tunnel length. A smaller ASR causes a higher graft bending angle, and a larger ASR causes greater stress in the graft.
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16
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The Graft Insertion Length in the Femoral Tunnel During Anterior Cruciate Ligament Reconstruction With Suspensory Fixation and Tibialis Anterior Allograft Does Not Affect Surgical Outcomes but Is Negatively Correlated With Tunnel Widening. Arthroscopy 2021; 37:2903-2914.e1. [PMID: 33887417 DOI: 10.1016/j.arthro.2021.03.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using a low-dose irradiated tibialis anterior allograft with a fixed-loop cortical suspension device for the femur based on the graft insertion length (GIL) in the femoral tunnel. METHODS Between January 2010 and January 2018, the medical records of consecutive patients who underwent arthroscopic ACL reconstruction with a tibialis anterior allograft fixed with the EndoButton CL for the femur and who had at least 2 years of follow-up were retrospectively evaluated. Patients were classified into 3 groups based on the GIL in the femoral tunnel (group 1, GIL < 15 mm; group 2, GIL of 15-20 mm; and group 3, GIL > 20 mm), and their functional scores, knee laxity, and radiographic parameters were evaluated. RESULTS A total of 91 patients were analyzed. There were no statistically significant differences in the functional scores and knee laxity between the 3 groups at 2 years postoperatively. However, significant differences were observed in tunnel widening at 1 year postoperatively in the femur (P = .045 for absolute value and P = .004 for relative value) and the tibia (P = .014 for absolute value and P = .012 for relative value), revealing that both the femoral and tibial tunnels widened as the GIL decreased. Additional linear regression analyses were performed to identify whether the GIL independently affects tunnel widening. Consequently, the femoral tunnel depth, tunnel diameter, and GIL were found to independently influence femoral tunnel widening (P = .008, P = .019, and P < .001, respectively), whereas the tunnel diameter and GIL affected tibial tunnel widening (P < .001 and P = .004, respectively). CONCLUSIONS The GIL in the femoral tunnel during ACL reconstruction using a tibialis anterior allograft with a fixed-loop cortical suspension device for the femur has no significant association with the postoperative functional outcomes and knee laxity, but it has a negative correlation with tunnel widening in the femur and the tibia. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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17
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Rojas G, Perelli S, Ibanez M, Formagnana M, Ormazabal I, Monllau JC. Effect of Modified Lemaire Anterolateral Extra-articular Tenodesis on the Magnetic Resonance Imaging Maturity Signal of Anterior Cruciate Ligament Hamstring Graft. Am J Sports Med 2021; 49:2379-2386. [PMID: 34133234 DOI: 10.1177/03635465211018858] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Lateral extra-articular tenodesis (LET) is one of the most widely used procedures to restore anterolateral stability. Clinical outcomes after the addition of LET to anterior cruciate ligament (ACL) reconstruction (ACLR) have been widely investigated; however, the potential influence of LET on the ACL ligamentization process has not been examined. PURPOSE/HYPOTHESIS The purpose was to use 10-month postoperative magnetic resonance imaging (MRI) scans to determine whether the maturity of grafts after hamstring autograft ACLR was affected by concomitant LET. The hypothesis was that when modified Lemaire lateral extra-articular tenodesis (MLLET) was performed, the MRI parameters of ACL graft maturity would be modified. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study included patients treated between December 2017 and December 2018 who had undergone anatomic 3-strand hamstring tendon autograft ACLR, with or without concomitant MLLET, and had undergone MRI 10 months postoperatively. Thus, the study included 30 patients who had isolated ACLR and 22 patients who had ACLR plus MLLET. The 2 groups were comparable based on all criteria analyzed. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in 3 regions of interest of the proximal, midsubstance, and distal ACL graft. Lower SNQ ratios indicate less water content and, theoretically, better maturity and healing of the graft. RESULTS The mean ± SD for SNQ was 4.62 ± 4.29 (range, 3.12-6.19) in the isolated ACLR group and 7.59 ± 4.68 (range, 4.38-8.04) in the ACLR plus MLLET group (P = .012). Upon comparing the mean values of the 3 portions between the 2 groups, we found a significant difference between the 2 groups for the proximal and middle portions (P = .007 and P = .049, respectively) but no difference in the distal portion (P = .369). CONCLUSION At the 10-month follow-up, hamstring tendon autografts for anatomic ACLR with MLLET did not show the same MRI signal intensity compared with isolated hamstring anatomic ACLR.
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Affiliation(s)
- Gonzalo Rojas
- Department of Orthopaedic Surgery, Hospital Regional de Talca, Talca, Chile.,Universidad Católica del Maule, Talca, Chile
| | - Simone Perelli
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Maximiliano Ibanez
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mario Formagnana
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Orthopaedic Surgery, E. Agnelli Hospital, Pinerolo, Italy
| | - Inmaculada Ormazabal
- Radiology Department, Hospital Universitari Quiron Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos Monllau
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
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18
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Hodel S, Mania S, Vlachopoulos L, Fürnstahl P, Fucentese SF. Influence of femoral tunnel exit on the 3D graft bending angle in anterior cruciate ligament reconstruction. J Exp Orthop 2021; 8:44. [PMID: 34173071 PMCID: PMC8233443 DOI: 10.1186/s40634-021-00364-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To quantify the influence of the femoral tunnel exit (FTE) on the graft bending angle (GBA) and GBA-excursion throughout a full range of motion (ROM) in single-bundle anterior cruciate ligament (ACL) reconstruction. Methods Three-dimensional (3D) surface models of five healthy knees were generated from a weight-bearing CT obtained throughout a full ROM (0, 30, 60, 90, 120°) and femoral and tibial ACL insertions were computed. The FTE was simulated for 16 predefined positions, referenced to the Blumensaat's line, for each patient throughout a full ROM (0, 30, 60, 90, 120°) resulting in a total of 400 simulations. 3D GBA was calculated between the 3D directional vector of the ACL and the femoral tunnel, while the intra-articular ACL insertions remained unchanged. For each simulation the 3D GBA, GBA-excursion, tunnel length and posterior tunnel blow-out were analysed. Results Overall, mean GBA decreased with increasing knee flexion for each FTE (p < 0.001). A more distal location of the FTE along the Blumensaat's line resulted in an increase of GBA and GBA-excursion of 8.5 ± 0.6° and 17.6 ± 1.1° /cm respectively (p < 0.001), while a more anterior location resulted in a change of GBA and GBA-excursion of -2.3 ± 0.6° /cm (+ 0.6 ± 0.4°/ cm from 0–60° flexion) and 9.8 ± 1.1 /cm respectively (p < 0.001). Mean tunnel length was 38.5 ± 5.2 mm (range 29.6–50.5). Posterior tunnel blow-out did not occur for any FTE. Conclusion Aiming for a more proximal and posterior FTE, with respect to Blumensaat’s line, reliably reduces GBA and GBA-excursion, while preserving adequate tunnel length. This might aid to reduce excessive graft stress at the femoral tunnel aperture, decrease femoral tunnel widening and promote graft-healing. Level of Evidence IV
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Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Sylvano Mania
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
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19
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Combination of anterior tibial and femoral tunnels makes the signal intensity of antero-medial graft higher in double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:783-792. [PMID: 32350577 DOI: 10.1007/s00167-020-06014-4] [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: 05/02/2019] [Accepted: 04/17/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE To elucidate whether sagittal graft tunnel affects the signal intensity in anatomical ACL reconstruction (ACLR) and to clarify the prevalence of intercondylar roof impingement. It was hypothesized that if the tunnel apertures are located within the anatomical footprint of ACL, tunnel position would not affect the signal intensity. METHODS A total of 132 patients who underwent anatomical double-bundle ACLR (DB-ACLR) using hamstring autograft were recruited. Tunnel position was determined by the quadrant method on three-dimensional computed tomography; the femoral tunnel position was defined as "high and low" or "deep and shallow", while that of the tibial side was defined as "anterior and posterior" or "medial and lateral". Subjects were divided into three groups according to the tertile of % deep-shallow. The signal intensity was evaluated by the region of interest value of the antero-medial bundle (AMB) and postero-lateral bundle on magnetic resonance imaging at 12 months after reconstruction. Linear regression analysis was conducted to elucidate the relationship between the percentage position of each tunnel and the graft signal intensity. RESULTS In the shallow tertile group, AMB signal intensity increased in the anterior position of the tibial tunnel (β = - 0.34; P = 0.025). In the intermediate and deep tertile groups, the tunnel position did not correlate with the signal intensity. CONCLUSIONS A more anterior tibial tunnel position increases AMB signal intensity in shallower femoral tunnel. Conversely, this correlation is attenuated for deeper femoral tunnels. Surgeons should pay attention to sagittal femoral tunnel position to create a more anterior tibial tunnel position. LEVEL OF EVIDENCE Level III.
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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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van Groningen B, van der Steen M, Janssen DM, van Rhijn LW, van der Linden AN, Janssen RP. Assessment of Graft Maturity After Anterior Cruciate Ligament Reconstruction Using Autografts: A Systematic Review of Biopsy and Magnetic Resonance Imaging studies. Arthrosc Sports Med Rehabil 2020; 2:e377-e388. [PMID: 32875303 PMCID: PMC7451875 DOI: 10.1016/j.asmr.2020.02.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/18/2020] [Indexed: 12/16/2022] Open
Abstract
Purpose The purpose of this investigation was to evaluate systematically the literature concerning biopsy, MRI signal to noise quotient (SNQ) and clinical outcomes in graft-maturity assessment after autograft anterior cruciate ligament reconstruction (ACLR) and their possible relationships. Methods The systematic review was reported and conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies through May 2019 evaluating methods of intra-articular ACL autograft maturity assessment were considered for inclusion. Eligible methods were histologic studies of biopsy specimens and conventional MRI studies reporting serial SNQ and/or correlation with clinical parameters. Results Ten biopsy studies and 13 imaging studies, with a total of 706 patients, met the inclusion criteria. Biopsy studies show that graft remodeling undergoes an early healing phase, a phase of remodeling or proliferation and a ligamentization phase as an ongoing process even 1 year after surgery. Imaging studies showed an initial increase in SNQ, peaking at approximately 6 months, followed by a gradual decrease over time. There is no evident correlation between graft SNQ and knee stability outcome scores at the short- and long-term follow-up after ACLR. Conclusions The remodeling of the graft is an ongoing process even 1 year after ACLR, based on human biopsy studies. MRI SNQ peaked at approximately 6 months, followed by a gradual decrease over time. Heterogeneity of the MRI methods and technical restrictions used in the current literature limit prediction of graft maturity and clinical and functional outcome measures by means of MRI graft SNQ after ACLR. Level of evidence Level IV, systematic review, including level III and IV studies.
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Affiliation(s)
- Bart van Groningen
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, the Netherlands
- Address correspondence to Bart van Groningen, M.D., Orthopaedic Center Máxima, Máxima Medical Center, PO Box 90052, 5600 PD Eindhoven, the Netherlands.
| | - M.C. van der Steen
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, the Netherlands
- Department of Orthopaedic Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Daan M. Janssen
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, the Netherlands
| | - Lodewijk W. van Rhijn
- Department of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Rob P.A. Janssen
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, the Netherlands
- Fontys University of Applied Sciences, Eindhoven, the Netherlands
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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张 培, 刘 泉, 樊 宗, 吴 敏, 朱 坤, 周 建, 项 平. [Effect of vascularized peroneus longus tendon graft reconstruction on anterior cruciate ligament insertion in rabbits]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:848-853. [PMID: 32666727 PMCID: PMC8180411 DOI: 10.7507/1002-1892.201912048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/08/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effect of vascularized peroneus longus tendon graft reconstruction on anterior cruciate ligament (ACL) insertion in rabbits. METHODS Eighty healthy New Zealand white rabbits were harvested to prepare ACL injury models and randomly divided into two groups ( n=40). The ACL was reconstructed with vascularized peroneus longus tendon graft in group A and peroneus longus tendon graft without blood supply in group B. The survival of animals and the healing of incision were observed after operation; the grafts were taken for gross and histological observations at 4, 8, and 16 weeks; the biomechanical test of the grafts was carried out to record the maximum tensile strength and incidence of ACL insertion rupture at 8 and 16 weeks. RESULTS All animals survived until the experiment completed. General observation showed that the tunnel was combined with grafts, the vascular infiltration was abundant, and no obvious boundary between the tunnel and grafts existed at 16 weeks in group A; there was still an obvious boundary between the tunnel and graft in group B. Histological observation showed that the collagen fibers between tendon and bone in group A increased gradually, the dense fiber connection was formed, and the "tidal-line" like structure similar to the normal ACL insertion was formed at 16 weeks; but the"tidal-line" like structure was not obvious in group B. Biomechanical test showed that there was no significant difference in the incidence of ACL insertion rupture at 8 and 16 weeks between group A and group B ( P=0.680; P=0.590), but the maximum tensile strength at 8 and 16 weeks were higher in group A than in group B ( t=18.503, P=0.001; t=25.391, P=0.001). CONCLUSION The vascularized peroneus longus tendon graft for ACL reconstruction can obviously promote the outcome of the ACL insertion.
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Affiliation(s)
- 培 张
- 蚌埠医学院第一附属医院骨科(安徽蚌埠 233000)Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
| | - 泉 刘
- 蚌埠医学院第一附属医院骨科(安徽蚌埠 233000)Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
| | - 宗庆 樊
- 蚌埠医学院第一附属医院骨科(安徽蚌埠 233000)Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
| | - 敏 吴
- 蚌埠医学院第一附属医院骨科(安徽蚌埠 233000)Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
| | - 坤 朱
- 蚌埠医学院第一附属医院骨科(安徽蚌埠 233000)Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
| | - 建生 周
- 蚌埠医学院第一附属医院骨科(安徽蚌埠 233000)Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
- 蚌埠医学院第一附属医院组织移植安徽省重点实验室(安徽蚌埠 233000)Key Laboratory of Tissue and Transplant in Anhui Province, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
| | - 平 项
- 蚌埠医学院第一附属医院骨科(安徽蚌埠 233000)Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui, 233000, P.R.China
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23
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Anterior cruciate ligament grafts display differential maturation patterns on magnetic resonance imaging following reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2020; 28:2124-2138. [PMID: 31520146 PMCID: PMC7067650 DOI: 10.1007/s00167-019-05685-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE The appearance of anterior cruciate ligament (ACL) grafts on magnetic resonance imaging (MRI) is related to graft maturity and mechanical strength after ACL reconstruction (ACLR). Accordingly, the purpose of this review was to quantitatively analyze reports of serial MRI of the ACL graft during the first year following ACLR; the hypothesis tested was that normalized MRI signal intensity would differ significantly by ACL graft type, graft source, and postoperative time. METHODS PubMed, Scopus, and CINAHL were searched for all studies published prior to June 2018 reporting MRI signal intensity of the ACL graft at multiple time points during the first postoperative year after ACLR. Signal intensity values at 6 and 12 months post-ACLR were normalized to initial measurements and analyzed using a least-squares regression model to study the independent variables of postoperative time, graft type, and graft source on the normalized MRI signal intensity. RESULTS An effect of graft type (P = 0.001) with interactions of graft type * time (P = 0.012) and graft source * time (P = 0.001) were observed. Post hoc analyses revealed greater predicted normalized MRI signal intensity of patellar tendon autografts than both hamstring (P = 0.008) and hamstring with remnant preservation (P = 0.001) autografts at postoperative month 12. CONCLUSION MRI signal varies with graft type, graft source, and time after ACLR. Enhanced graft maturity during the first postoperative year was associated with hamstring autografts, with and without remnant preservation. Serial MRI imaging during the first postoperative year may be clinically useful to identify biologically or mechanically deficient ACL grafts at risk for failure. LEVEL OF EVIDENCE IV.
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Oshima T, Putnis S, Grasso S, Klasan A, Parker DA. Graft Size and Orientation Within the Femoral Notch Affect Graft Healing at 1 Year After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2020; 48:99-108. [PMID: 31730373 DOI: 10.1177/0363546519885104] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The combined influence of anatomic and operative factors affecting graft healing after anterior cruciate ligament (ACL) reconstruction within the femoral notch is not well understood. PURPOSE To determine the influence of graft size and orientation in relation to femoral notch anatomy, with the signal/noise quotient (SNQ) of the graft used as a measure of graft healing after primary single-bundle ACL reconstruction. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 98 patients with a minimum 2-year follow-up after primary single-bundle ACL reconstruction with hamstring tendon autografts were included. Graft healing was evaluated at 1 year on magnetic resonance imaging (MRI) scan as the mean SNQ measured from 3 regions situated at sites at the proximal, middle, and distal graft. Patient characteristics, chondropenia severity score, tunnel sizes, tunnel locations, graft bending angle (GBA), graft sagittal angle, posterior tibial slope (PTS), graft length, graft volume, femoral notch volume, and graft-notch volume ratio (measured using postoperative 3-T high-resolution MRI) were evaluated to determine any association with 1-year graft healing. The correlation between 1-year graft healing and clinical outcome at minimum 2 years was also assessed. RESULTS There was no significant difference in mean SNQ between male and female patients (P > .05). Univariate regression analysis showed that a low femoral tunnel (P = .005), lateral tibial tunnel (P = .009), large femoral tunnel (P = .011), large tibial tunnel (P < .001), steep lateral PTS (P = .010), steep medial PTS (P = .004), acute graft sagittal angle (P < .001), acute GBA (P < .001), large graft volume (P = .003), and high graft-notch volume ratio (P < .001) were all associated with higher graft SNQ values. A multivariate regression analysis showed 2 significant factors: a large graft-notch volume ratio (P = .001) and an acute GBA (P = .004). The 1-year SNQ had a weak correlation with 2-year Tegner Activity Scale score (r = 0.227; P = .026) but no other clinical findings, such as International Knee Documentation Committee subjective and Lysholm scores and anterior tibial translation side-to-side difference. CONCLUSION The 1-year SNQ value had a significant positive association with graft-notch volume ratio and GBA. Both graft size and graft orientation appeared to have a significant influence on graft healing as assessed on 1-year high-resolution MRI scan.
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Affiliation(s)
- Takeshi Oshima
- Sydney Orthopaedic Research Institute, Sydney, Australia.,Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Sven Putnis
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | - Samuel Grasso
- Sydney Orthopaedic Research Institute, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Antonio Klasan
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | - David Anthony Parker
- Sydney Orthopaedic Research Institute, Sydney, Australia.,University of Sydney, Sydney, Australia
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25
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Li H, Liu S, Sun Y, Li H, Chen S, Chen J. Influence of Graft Bending Angle on Graft Maturation, the Femoral Tunnel, and Functional Outcomes by 12 Months After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2019; 7:2325967119882663. [PMID: 31807603 PMCID: PMC6880034 DOI: 10.1177/2325967119882663] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: The graft bending angle (GBA), the angle between the femoral bone tunnel and
the line connecting the femoral and tibial tunnel apertures, has been proven
to influence stress within the graft and could be an important factor in
graft healing within the joint and bone tunnel. However, the influence of
the GBA on functional outcomes, particularly on return to sports (RTS), is
rarely reported. Purpose/Hypothesis: The purpose of this study was to investigate the influence of the GBA on
graft maturation, the femoral tunnel, and functional outcomes at 12 months
after anterior cruciate ligament reconstruction (ACLR). We hypothesized that
a greater GBA might be related to bone tunnel widening, poor graft healing,
and inferior functional outcomes after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 43 consecutive patients who underwent unilateral ACLR with
hamstring tendon autografts participated in this study. Their knees were
evaluated using functional scores (International Knee Documentation
Committee [IKDC] score, Lysholm knee activity score, Tegner activity scale,
RTS) and the anterior tibial translation side-to-side difference (ATTD), as
measured using a KT-1000 arthrometer and 3.0-T magnetic resonance imaging
(MRI), at 12 months after surgery. Based on MRI, the signal/noise quotient
(SNQ) of the graft, the GBA, and the femoral tunnel diameter were
measured. Results: The mean GBA was 56° (range, 41°-69°). The GBA had a significant positive
correlation with the SNQ (rho, 0.45; P = .003) and bone
tunnel diameter (rho, 0.35; P = .02), but it had no
significant correlation with any functional scores. Patients were divided
into 3 groups based on GBA values: low GBA (LGBA; 40° < GBA ≤ 50°),
middle GBA (MGBA; 50° < GBA ≤ 60°), and high GBA (HGBA; 60° < GBA ≤
70°). The HGBA group had a significantly higher mean SNQ than both the LGBA
(P = .01) and MGBA groups (P = .02).
It also had a greater mean tunnel diameter than the LGBA group
(P = .04). There was no significant difference in IKDC
scores, Lysholm scores, ATTD, Tegner scores, or rates of RTS among
groups. Conclusion: The GBA did not affect functional outcomes at 12 months after ACLR, although
it affected the SNQ of the graft and the femoral tunnel diameter.
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Affiliation(s)
- Hong Li
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shaohua Liu
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yaying Sun
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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26
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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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Hofbauer M, Soldati F, Szomolanyi P, Trattnig S, Bartolucci F, Fu F, Denti M. Hamstring tendon autografts do not show complete graft maturity 6 months postoperatively after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:130-136. [PMID: 30008057 PMCID: PMC6510818 DOI: 10.1007/s00167-018-5033-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/22/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE In this prospective, double-center cohort study, we aim to assess how the anterior cruciate ligament (ACL) signal intensity on magnetic resonance imaging (MRI) potentially varies between a group of patients with anatomic ACL reconstruction using autogenous hamstring grafts 6 months postoperatively and a healthy ACL control group, and how MRI-based graft signal intensity is related to knee laxity. METHODS Sixty-two consecutive patients who underwent ACL reconstruction using quadrupled hamstring tendon autograft were prospectively invited to participate in this study, and they were evaluated with MRI after 6 months of follow-up. 50 patients with an MRI of their healthy ACL (Clinica Luganese, Lugano, Switzerland) and 12 patients of their contralateral healthy knee (Department of Orthopaedic and Trauma Surgery, Medical University of Vienna, Austria) served as the control group. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in three regions of interest (ROIs) of the proximal, mid-substance and distal ACL graft and the healthy ACL. KT-1000 findings were obtained 6 months postoperatively in the ACL reconstruction group. Statistical analysis was independently performed to outline the differences in the two groups regarding ACL intensity and the correlation between SNQ and KT-1000 values. RESULTS There was a significant difference in the mean SNQ between the reconstructed ACL grafts and the healthy ACLs in the proximal and mid-substance regions (p = 0.001 and p = 0.004). The distal region of the reconstructed ACL showed a mean SNQ similar to the native ACL (n.s). Patients with a KT-1000 between 0 and 1 mm showed a mean SNQ of 0.1; however, a poor correlation was found between the mean SNQ and KT-1000 findings, probably due to the small sample size of patients with higher laxity. CONCLUSION After 6 months of follow-up, hamstring tendon autografts for anatomic ACL reconstruction do not show equal MRI signal intensity compared to a healthy ACL and should therefore be considered immature or at least not completely healed even if clinical laxity measurement provides good results. However, in the case of a competitive athlete, who is clinically stable and wants to return to sports at 6 months, performing an MRI to confirm the stage of graft healing might be an option. LEVEL OF EVIDENCE Prospective, comparative study II.
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Affiliation(s)
- Marcus Hofbauer
- Department of Orthopaedic and Trauma Surgery, Medical University of Vienna, Waehringerguertel 18-20, 1090, Vienna, Austria.
| | | | - Pavol Szomolanyi
- Centre of Excellence "High-field Magnetic Resonance (MR)", Medical University Vienna, Vienna, Austria
| | - Siegfried Trattnig
- Centre of Excellence "High-field Magnetic Resonance (MR)", Medical University Vienna, Vienna, Austria
| | | | - Freddie Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matteo Denti
- IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
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