1
|
Helal A, El-Gebaly O, Hamed H, Omran AM, ELForse E. Periosteal wrapping of the hamstring tendon autograft improves graft healing and prevents tunnel widening after anterior cruciate ligament anatomic reconstruction. Arch Orthop Trauma Surg 2024; 144:2711-2722. [PMID: 38748257 PMCID: PMC11211196 DOI: 10.1007/s00402-024-05356-9] [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: 11/04/2023] [Accepted: 04/28/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION The periosteum is a readily available tissue at the hamstring harvest site that could be utilized to enhance graft healing and prevent tunnel widening without additional cost or morbidity. This study aimed to compare graft healing using magnetic resonance imaging (MRI) and functional clinical outcome scores in a matched cohort of patients who underwent anterior cruciate ligament (ACL) reconstruction with hamstring autografts with or without periosteal augmentation. MATERIAL AND METHODS Forty-eight patients who underwent ACL reconstruction (ACLR) were prospectively enrolled: 25 with standard ACLR (ST-ACLR) and 23 with periosteal augmented grafts (PA-ACLR). The same surgical techniques, fixation methods, and postoperative protocol were used in both groups. Signal-to-noise quotient (SNQ), graft healing at the bone-graft interface, graft signal according to the Howell scale, and femoral tunnel widening were evaluated using MRI after 1 year of follow-up. International knee documentation score (IKDC), Lysholm, Tegner activity scale, and visual analog scale for pain were used for functional evaluation at a minimum of 2 years postoperative. RESULTS The mean SNQ of the proximal part of the graft was 9.6 ± 9.2 and 2.9 ± 3.3 for the ST-ACLR and PA-ACLR groups, respectively (P = 0.005). The mean femoral tunnel widening was 30.3% ± 18.3 and 2.3% ± 9.9 for the ST-ACLR, PA-ACLR groups, respectively (P < 0.001). Complete graft tunnel healing was observed in 65% and 28% of cases in the PA-ACLR and ST-ACLR groups, respectively. Both groups showed marked improvements in functional scores, with no statistically significant differences. CONCLUSION Periosteal wrapping of hamstring tendon autografts is associated with better graft healing and maturation and lower incidence of femoral tunnel widening based on MRI analysis 1 year after ACL reconstruction. However, patient-reported outcomes and measured laxity were similar between the two groups at 2 years follow up. TRIAL REGISTRATION Trail registration number: PACTR202308594339018, date of registration: 1/5/2023, retrospectively registered at the Pan African Clinical Trial Registry (pactr.samrc.ac.za) database.
Collapse
Affiliation(s)
- Ahmed Helal
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, Tanta, El-Gharbia Governorate, Egypt.
| | - Osama El-Gebaly
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, Tanta, El-Gharbia Governorate, Egypt
| | - Hany Hamed
- Department of Orthopaedics, Faculty of Medicine, Kafr El-Shaikh University, Kafr El Sheikh, Egypt
| | - Ali M Omran
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, Tanta, El-Gharbia Governorate, Egypt
| | - ElSayed ELForse
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, Tanta, El-Gharbia Governorate, Egypt
| |
Collapse
|
2
|
Zhang L, Lin J, Zhao X, Liu M, Hou Y, Zhang Y, Zhao J, Wang S. Robotic-assisted anatomic anterior cruciate ligament reconstruction: a comparative analysis of modified transtibial and anteromedial portal techniques in cadaveric knees. Front Bioeng Biotechnol 2024; 12:1360560. [PMID: 38511128 PMCID: PMC10953503 DOI: 10.3389/fbioe.2024.1360560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/07/2024] [Indexed: 03/22/2024] Open
Abstract
Introduction: This study employed surgical robot to perform anatomic single-bundle reconstruction using the modified transtibial (TT) technique and anteromedial (AM) portal technique. The purpose was to directly compare tunnel and graft characteristics of the two techniques. Methods: Eight cadaveric knees without ligament injury were used in the study. The modified TT and AM portal technique were both conducted under surgical robotic system. Postoperative data acquisition of the tunnel and graft characteristics included tibial tunnel position, tunnel angle, tunnel length and femoral tunnel-graft angle. Results: The mean tibial tunnel length of the modified TT technique was significantly shorter than in the AM portal technique (p < 0.001). The mean length of the femoral tunnel was significantly longer for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the tibial tunnel was significantly lower for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the femoral tunnel was significantly lower for the AM portal technique than for the modified TT technique (p < 0.001). The AM portal technique resulted in a graft bending angle that was significantly more angulated in the coronal (p < 0.001) and the sagittal planes (p < 0.001) compared with the modified TT technique. Discussion: Comparison of the preoperative planning and postoperative femoral tunnel positions showed that the mean difference of the tunnel position was 1.8 ± 0.4 mm. It suggested that the surgical navigation robot could make predictable tunnel position with high accuracy. The findings may support that the modified TT technique has benefits on femoral tunnel length and obliquity compared with AM portal technique. The modified TT technique showed a larger femoral tunnel angle in the coronal plane than the AM portal technique. Compared with the modified TT technique, the more horizontal trajectory of the femoral tunnel in the AM portal technique creates a shorter femoral tunnel length and a more acute graft bending angle.
Collapse
Affiliation(s)
- Ling Zhang
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Jinpeng Lin
- Department of Orthopaedics, Guangdong Provincial Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuan Zhao
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Mingwei Liu
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Yao Hou
- Shanghai Droidsurg Medical Technology Co., Ltd., Shanghai, China
| | - Yu Zhang
- Department of Orthopaedics, Guangdong Provincial Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shaobai Wang
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| |
Collapse
|
3
|
Park SY, Cho JH, Ho JPY, Tu NT, Kim YB, Lee YS. Graft impingement increases anterior cruciate ligament graft signal more than acute graft bending angle: magnetic resonance imaging-based study in outside-in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:4379-4389. [PMID: 37351630 DOI: 10.1007/s00167-023-07491-z] [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: 02/21/2023] [Accepted: 06/12/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE In this study, the relationship between patient-specific geometric factors and tunnel placement in graft impingement was identified by using magnetic resonance imaging (MRI) signal intensity of anterior cruciate ligament (ACL) grafts. METHODS Ninety-two patients, who were treated between 2014 and 2020, were included retrospectively. These patients underwent primary remnant-preserving outside-in ACL reconstruction (ACLR) and were followed up with postoperative MRI at least one year after surgery. Plain radiographs and computed tomography (CT) were used to analyze tibial and femoral tunnel positions. Postoperative MRI was performed, at 32.8 ± 17.5 months after surgery, to evaluate the graft signal intensity, the ACL/posterior cruciate ligament (PCL) ratio (APR), ACL/muscle ratio (AMR), tunnel positions, and graft impingement. Clinical and stability outcomes were analyzed using the International Knee Documentation Committee (IKDC) subjective and objective scores, Lysholm scores, and side-to-side differences (SS-D). RESULTS The mean APR and AMR of the proximal third of the grafts were significantly lower than those of the middle third of the grafts (p = 0.017 and p = 0.045, respectively). Multivariate regression analysis showed that there was a negative association between the mean APR and AMR of entire intra-articular ACL graft and the distance from the anterior end of the intercondylar roof to the center of the tibial tunnel in the sagittal plane (p < 0.001 and p < 0.001, respectively) and the notch width index (p < 0.001 and p = 0.002, respectively). No significant correlations were found between tunneling and geometric factors, and clinical scores or SS-D. CONCLUSIONS Graft impingement on the anterior tibial tunnel relative to the end of the intercondylar roof and narrow notch was a more significant contributing factor on increased signal intensities of the ACL graft, compared with the acute femoral bending angle in remnant-preserving outside-in ACLR. Therefore, surgeons should focus on intercondylar notch anatomy during tibial tunnel placement to avoid roof impingement. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Seong Yun Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Joon Hee Cho
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Jade Pei Yuik Ho
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Nguyen Thanh Tu
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Yong Beom Kim
- Department of Orthopedic Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital Seoul, 59 Daesagwan-ro, Seoul, Yongsan-gu, South Korea
| | - Yong Seuk Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea.
| |
Collapse
|
4
|
Kim MJ, Moon SG, Kang JH, Lee DW. Usefulness of 3-Dimensional Computed Tomography Assessment of Femoral Tunnel after Anterior Cruciate Ligament Reconstruction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1716. [PMID: 37893436 PMCID: PMC10608529 DOI: 10.3390/medicina59101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
Positioning of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction is the most crucial factor for successful procedure. Owing to the inter-individual variability in the intra-articular anatomy, it can be challenging to obtain precise tunnel placement and ensure consistent results. Currently, the three-dimensional (3D) reconstruction of computed tomography (CT) scans is considered the best method for determining whether femoral tunnels are positioned correctly. Postoperative 3D-CT feedback can improve the accuracy of femoral tunnel placement. Precise tunnel formation obtained through feedback has a positive effect on graft maturation, graft failure, and clinical outcomes after surgery. However, even if femoral tunnel placement on 3D CT is appropriate, we should recognize that acute graft bending negatively affects surgical results. This review aimed to discuss the implementation of 3D-CT evaluation for predicting postoperative outcomes following ACL re-construction. Reviewing research that has performed 3D CT evaluations after ACL reconstruction can provide clinically significant evidence of the formation of ideal tunnels following anatomic ACL reconstruction.
Collapse
Affiliation(s)
- Min-Jeong Kim
- Department of Radiology, Incheon Sarang Hospital, Incheon 22135, Republic of Korea;
| | - Sung-Gyu Moon
- Department of Radiology, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea; (S.-G.M.); (J.-H.K.)
| | - Ji-Hee Kang
- Department of Radiology, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea; (S.-G.M.); (J.-H.K.)
| | - Dhong-Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
| |
Collapse
|
5
|
Lee DW, Lee DH, Cho SI, Yang SJ, Kim WJ, Lee JK, Kim JG. Comparison of ACL and Anterolateral Ligament Reconstruction With Isolated ACL Reconstruction Using Hamstring Autograft: Outcomes in Young Female Patients With High-Grade Pivot Shift. Orthop J Sports Med 2023; 11:23259671231178048. [PMID: 37781636 PMCID: PMC10536865 DOI: 10.1177/23259671231178048] [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: 02/25/2023] [Accepted: 03/10/2023] [Indexed: 10/03/2023] Open
Abstract
Background Inferior return to sports (RTS) and functional outcomes have been reported in women after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis The purpose was to evaluate the results of combined ACLR and anterolateral ligament reconstruction (ALLR) in young women with a high-grade pivot shift (grade ≥2). It was hypothesized that combined ACLR and ALLR would result in better RTS and rotational stability than isolated ACLR. Study Design Cohort study; Level of evidence, 3. Methods Two groups were retrospectively evaluated and compared. Group I (n = 39; mean age, 31.1 ± 5.7 years) underwent isolated ACLR using hamstring autografts; group C (n = 39; mean age, 30.4 ± 6.1 years) underwent combined ACLR and ALLR. Subjective outcome measures included the International Knee Documentation Committee subjective form, Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI). Objective tests included a KT-2000 arthrometer stress test, a pivot-shift test, an isokinetic strength test, a Y-balance test, and a single-leg hop test. A postoperative questionnaire was administered to determine the rates and types of RTS, quality of sports performance, and reinjury and satisfaction rates. Subjective scores and clinical tests were performed at 2 years. Magnetic resonance imaging and second-look arthroscopy were conducted during the 1- and 2-year follow-ups, respectively. Results The mean follow-up for groups I and C were 30.4 ± 3.9 and 29.3 ± 3.5 months, respectively (P = .194). Patients in group C had better anteroposterior (P = .001) and rotational (P = .005) stability and higher ACL-RSI scores (P = .025) than those in group I. Group C had higher composite and posteromedial reach scores on the Y-balance test than group I (P = .014 and P = .010, respectively). A total of 26 (66.7%) patients in group C and 17 (43.6%) in group I returned to their prior level of sports (P = .040). Rerupture of the ACL graft and contralateral ACL rupture occurred in 2 (5.1%) and 2 (5.1%) patients in group I, respectively, compared with no rerupture or contralateral ACL rupture in group C. Conclusion Combined ACLR and ALLR in young women with a high-grade pivot shift was associated with better knee stability parameters, dynamic postural stability, and psychological readiness to RTS than isolated ACLR.
Collapse
Affiliation(s)
- Dhong Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Dong Hwan Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seung Ik Cho
- Sports Medical Center, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sang Jin Yang
- Department of Health and Exercise Management, Tongwon University, Gwangju-si, Gyeonggi-do, Republic of Korea
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan, Republic of Korea
| | - Joon Kyu Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jin Goo Kim
- Department of Orthopaedic Surgery, Myongji Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| |
Collapse
|
6
|
Lee DW, Lee DH, Moon SG, Kang JH, Woo YJ, Kim WJ. Femoral Tunnel Geometry and Graft Inclination Angles in Anterior Cruciate Ligament Reconstruction Using a Flexible Reamer System. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1031. [PMID: 37374234 DOI: 10.3390/medicina59061031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: The aim of this study is to investigate the femoral tunnel geometry (femoral tunsnel location, femoral graft bending angle, and femoral tunnel length) on three-dimensional (3D) computed tomography (CT) and graft inclination on magnetic resonance imaging (MRI) after anatomic anterior cruciate ligament (ACL) reconstruction using a flexible reamer system. Materials and Methods: A total of 60 patients who underwent anatomical ACL reconstruction (ACLR) using a flexible reamer system were retrospectively reviewed. One day after the ACLR procedure was performed, all patients underwent three-dimensional computed tomography (3D-CT) and magnetic resonance imaging (MRI). The femoral tunnel location, femoral graft bending angle, femoral tunnel length, and graft inclination were assessed. Results: In the 3D-CTs, the femoral tunnel was located at 29.7 ± 4.4% in the posterior to anterior (deep to shallow) direction and at 24.1 ± 5.9% in the proximal to distal (high to low) direction. The mean femoral graft bending angle was 113.9 ± 5.7°, and the mean femoral tunnel length was 35.2 ± 3.1 mm. Posterior wall breakage was observed in five patients (8.3%). In the MRIs, the mean coronal graft inclination was 69.2 ± 4.7°, and the mean sagittal graft inclination was 52.4 ± 4.6°. The results of this study demonstrated that a comparable femoral graft bending angle and longer femoral tunnel length were observed compared with the reported outcomes from previous studies that used the rigid reamer system. Conclusions: ACLR using a flexible reamer system allowed for an anatomic femoral tunnel location and a comparable graft inclination to that of the native ACL. In addition, it achieved a tolerable femoral graft bending angle and femoral tunnel length.
Collapse
Affiliation(s)
- Dhong-Won Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05029, Republic of Korea
| | - Dong-Hwan Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05029, Republic of Korea
| | - Sung-Gyu Moon
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05029, Republic of Korea
| | - Ji-Hee Kang
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05029, Republic of Korea
| | - Young-Je Woo
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05029, Republic of Korea
| | - Woo-Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan 31538, Republic of Korea
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Kawanishi Y, Kobayashi M, Yasuma S, Fukushima H, Kato J, Murase A, Takenaga T, Yoshida M, Kuroyanagi G, Kawaguchi Y, Nagaya Y, Murakami H, Nozaki M. An Analysis of the Femoral Drilling Angle to Avoid Tunnel Collision during Double-Bundle Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction on the Knee. J Knee Surg 2021; 36:483-490. [PMID: 34624908 DOI: 10.1055/s-0041-1736196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Concomitant anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has been reported as an effective technique for providing rotational control of the knee. However, the intraoperative risk of collision with an ACL tunnel during the drilling for the femoral ALL tunnel has been described. The purpose of this study was to investigate the various femoral drilling procedures to avoid tunnel collisions during combined double-bundle ACL and ALL reconstruction. Nine cadaveric knees were used in this study. ACL drilling was performed through the anteromedial portal to footprints of the posterolateral bundle at 120° (PL120) and 135° (PL135) knee flexion and the anteromedial bundle at 120° (AM120) and 135° (AM135) knee flexion. ALL drilling was performed at 0° (Cor0-ALL) and 30° (Cor30-ALL) coronal angles using a Kirschner wire (K-wire). The distance between the ALL footprint and ACL K-wire outlets, axial angles of ALL K-wires colliding with ACL K-wires, and distances from the ALL footprint to the collision point were measured. From these values, the safe zone, defined as the range of axial angles in which no collisions or penetrations occurred, was identified by simulation of tunnels utilized for reconstruction grafts in each drilling procedure. The point-to-point distance from the ALL footprint to the K-wire outlet was significantly greater in the AM120 than the AM135 (13.5 ± 3.1, 10.8 ± 3.2 mm; p = 0.048) and in the PL135 than the PL120 (18.3 ± 5.5, 16.1 ± 6.5 mm; p = 0.005) conditions, respectively. During an ACL drilling combination of PL135/AM120, a safe zone of > 45° in Cor30-ALL was identified. With a narrow safe zone during the PL135/AM120 combination only, the risk of femoral tunnel collisions in combined double-bundle ACL and ALL reconstruction is high. AM drilling at 120° and PL drilling at > 135° knee flexion, combined with ALL drilling at 30° coronal angle and > 45° axial angle, may reduce this risk.
Collapse
Affiliation(s)
- Yusuke Kawanishi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Makoto Kobayashi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Sanshiro Yasuma
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Hiroaki Fukushima
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Jiro Kato
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Atsunori Murase
- Department of Orthopedic Surgery, Kasugai Joint & Sports Orthopedic Clinic, Kasugai, Aichi, Japan
| | - Tetsuya Takenaga
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Masahito Yoshida
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Gen Kuroyanagi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Yohei Kawaguchi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Yuko Nagaya
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| | - Masahiro Nozaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School, Mizuho-Cho Mizuho-Ku, Nagoya, Japan
| |
Collapse
|
12
|
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: 9] [Impact Index Per Article: 3.0] [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.
Collapse
|
13
|
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
Collapse
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
| |
Collapse
|
14
|
Zhang J, Ma Y, Pang C, Wang H, Jiang Y, Ao Y. No differences in clinical outcomes and graft healing between anteromedial and central femoral tunnel placement after single bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:1734-1741. [PMID: 32772135 DOI: 10.1007/s00167-020-06206-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical outcomes and graft healing after anterior cruciate ligament (ACL) reconstruction with anteromedial and central femoral tunnel placement. METHODS During 2016 and 2018, 110 consecutive patients underwent single bundle ACL reconstruction; 85 patients met the inclusion criteria, and each patient underwent 3D-CT within 1 week and MRI 1.5 years after the operation. The central point of the femoral tunnel and signal/noise quotient (SNQ) of three regions of interest (ROI) in the intra-articular graft were measured to analyse the tunnel position and graft healing extent. Clinical assessments, including functional scores, KT-2000 arthrometer measurements and pivot-shift tests, were evaluated at the 2-year follow-up. Patients were divided into two groups depending on the femoral tunnel position: the anteromedial position group (Group A) and the centre position group (Group B). RESULTS Seventy-one patients were available for the 2-year follow-up and MRI examination: 34 patients in Group A and 35 patients in Group B, and 2 patients were excluded for an eccentric tunnel position. No graft failure occurred, and compared with the preoperative assessment outcomes, the outcomes of both groups improved at the final follow-up. Group A was significantly better than Group B regarding the KT-2000 arthrometer measurements (P = 0.031). No significant differences were observed in terms of functional scores, pivot-shift test results, or the SNQ between groups. CONCLUSIONS No differences in clinical outcomes or graft healing were found between AM and central femoral tunnel placements in single bundle ACL reconstruction. Therefore, satisfactory clinical outcomes, knee stability and graft healing can be obtained for both femoral tunnel placements. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Jiahao Zhang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yong Ma
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Chaonan Pang
- Department of Radiology, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Haijun Wang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yanfang Jiang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yingfang Ao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
| |
Collapse
|
15
|
Yanagisawa S, Kimura M, Hagiwara K, Ogoshi A, Yoneyama T, Omae H, Miyamoto R, Chikuda H. A steep coronal graft bending angle is associated with bone tunnel enlargement of the posterolateral bundle after anterior cruciate ligament reconstruction. J Orthop Surg (Hong Kong) 2020; 28:2309499019888811. [PMID: 31829103 DOI: 10.1177/2309499019888811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The correlation between the graft bending angle (GBA) of the anteromedial bundle and posterolateral bundle after anterior cruciate ligament reconstruction (ACLR) and postoperative tunnel enlargement was evaluated. METHODS Two hundred fifty-eight patients (137 males, 121 females; mean age 27.3 years) who had undergone double-bundle ACLR were included. Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months postoperatively. The area of the tunnel aperture for femoral anteromedial tunnel (FAMT) and femoral posterolateral tunnel (FPLT) was measured; the area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The femoral tunnel angles were obtained with Cobb angle measurements. The femoral tunnel angle in the coronal plane was measured relative to the tibial plateau (coronal GBA). On the median value, the patients were divided into two groups in each of FAMT and FPLT; those with a coronal GBA of FAMT of ≥27° were classified as group A, while those with a coronal GBA of <27° were classified as group B, those with a coronal GBA of FPLT of ≥23° were classified as group C, while those with a coronal GBA of<23° were classified as group D. RESULTS Group A included 129 knees, while group B included 129 knees. Groups A and B did not significantly differ regarding FAMT enlargement. Group C included 133 knees, while group D included 125 knees. The percentage of FPLT enlargement in group C was significantly smaller than that in group D (p = 0.001). CONCLUSIONS A steep coronal GBA of the FPLT after ACLR results in greater FPLT enlargement. The present findings suggest that surgeons should avoid creating a steep GBA of the FPLT in the outside-in technique.
Collapse
Affiliation(s)
- Shinya Yanagisawa
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Masashi Kimura
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Keiichi Hagiwara
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Atsuko Ogoshi
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Tomotaka Yoneyama
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Hiroaki Omae
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Ryosuke Miyamoto
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Gunma, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| |
Collapse
|
16
|
Lee DW, Jang HG, Lee YJ, Moon SG, Kim NR, Kim JG. Effect of atelocollagen on the healing status after medial meniscal root repair using the modified Mason-Allen stitch. Orthop Traumatol Surg Res 2020; 106:969-975. [PMID: 32753355 DOI: 10.1016/j.otsr.2020.03.022] [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] [Received: 10/03/2019] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Addition of collagen during medial meniscal root repair (MMRR) may improve meniscal root healing minimising fibrous scar tissue formation. The purpose of this study was to verify the effect of atelocollagen on MMRR using the modified Mason-Allen stitch when compared with that of the conventional pullout repair by assessing the clinical and radiological outcomes. HYPOTHESIS It was hypothesised that atelocollagen would enhance the healing effect on the meniscal root following MMRR. Moreover, we presumed that MMRR with atelocollagen application might reduce meniscal extrusion by promoting healing. MATERIALS AND METHODS A total of 47 patients who underwent MMRR using the modified Mason-Allen stitch between 2015 and 2016 were included, and they were divided into group A (atelocollagen application; n=25) and group R (MMRR without atelocollagen application; n=22). The postoperative clinical outcomes, radiological outcomes, and meniscal root healing and medial compartment cartilage status on follow-up magnetic resonance imaging (MRI) were compared between the two groups. RESULTS Mean follow-up duration was 26.4±4.8 months in group A and 27.1±5.2 months in group R (p=0.598). Mean duration from surgery to follow-up MRI was 12.5±1.4 months in group A and 12.7±1.2 months in group R (p=0.604). The subjective knee scores improved significantly in both groups at the last follow-up (all, p<0.001). The Kellgren-Lawrence (K-L) grade progressed in 16% and 22.7% in group A and group R, respectively (p=0.351). Follow-up MRI showed progression of cartilage loss in the medial compartment in 28% and 40.9% in group A and group R, respectively (p=0.355). In terms of meniscal root healing, 18 (72%) and 12 (54.5%) patients had complete healing, and 6 (24%) and 8 (36.4%) patients had partial healing in groups A and R, respectively. The mean value of the intra-meniscal signal intensity (IMSI) of the meniscal root based on MRI in group A was significantly lower than that in group R (p<0.001). The medial meniscal extrusion in groups A and R decreased by 0.2±0.1mm and 0.1±0.3mm following MMRR without significant differences (p=0.056 and p=0.229, respectively). The IMSI presented significant negative correlations with the root healing status and significant positive correlations with K-L grade progression (p<0.05). DISCUSSION Atelocollagen application during MMRR yielded lower IMSIs, suggesting better healing, than did conventional pullout root repair. However, this technique could not demonstrate beneficial effects on meniscal extrusion. LEVEL OF EVIDENCE III, retrospective case-control study.
Collapse
Affiliation(s)
- Dhong Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Centre, Seoul, Korea
| | - Han Gil Jang
- Department of Orthopaedic Surgery, KonKuk University Medical Centre, Seoul, Korea
| | - Young Jun Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Centre, Seoul, Korea
| | - Sung Gyu Moon
- Department of Radiology, KonKuk University Medical Centre, Seoul, Korea
| | - Na Ra Kim
- Department of Radiology, KonKuk University Medical Centre, Seoul, Korea
| | - Jin Goo Kim
- Department of Orthopaedic Surgery, Myongji Hospital, Goyang-si, Gyeonggi-do, Korea.
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
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.
Collapse
|
19
|
Zhang S, Liu S, Yang L, Chen S, Chen S, Chen J. Morphological Changes of the Femoral Tunnel and Their Correlation With Hamstring Tendon Autograft Maturation up to 2 Years After Anterior Cruciate Ligament Reconstruction Using Femoral Cortical Suspension. Am J Sports Med 2020; 48:554-564. [PMID: 31967861 DOI: 10.1177/0363546519898136] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Graft healing within the femoral tunnel after anterior cruciate ligament reconstruction (ACLR) using suspensory fixation could be reflected in graft maturation and tunnel morphological changes. However, the correlation between graft maturation and femoral tunnel changes remains unclear. PURPOSE To quantitatively evaluate femoral tunnel morphological changes and graft maturation and to analyze their correlation after ACLR using femoral cortical suspension. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent single-bundle ACLR with a hamstring tendon autograft using femoral cortical suspension were included. Preoperative and postoperative (at 6, 12, and 24 months) knee function were evaluated using KT-1000 arthrometer testing, the Lysholm knee scoring scale, and the International Knee Documentation Committee (IKDC) questionnaire. At 1 day, 6 months, 12 months, and 24 months after ACLR, 3-dimensional magnetic resonance imaging was performed to observe the morphology of the femoral tunnel and to evaluate graft maturation using the graft signal/noise quotient (SNQ). The Pearson product moment correlation coefficients (r) of femoral tunnel radii versus clinical outcomes and graft SNQs at last follow-up were analyzed. RESULTS A total of 22 patients completed full follow-up. KT-1000 arthrometer, Lysholm, and IKDC scores improved over time postoperatively, but no significant improvement was seen after 12 months (P < .05). The radius of the tunnel containing the graft and the SNQs of the femoral intraosseous graft and intra-articular graft were the highest at 6 months, and they decreased by 24 months but remained higher than their 1-day postoperative values (P < .05). Expansion mainly occurred at the anteroinferior wall of the femoral tunnel. The tunnel aperture radius was positively correlated with SNQs of the intraosseous graft (r = 0.591; P < .05) and intra-articular graft (r = 0.359; P < .05) but not with clinical outcomes. CONCLUSION After ACLR using suspensory fixation, morphological changes of the femoral tunnel were mainly observed in the part of the tunnel containing the graft, which expanded at 6 months and reduced by 24 months. Expansion mainly occurred at the anteroinferior wall of the femoral tunnel. Femoral tunnel expansion was correlated with inferior graft maturation but not with clinical outcomes.
Collapse
Affiliation(s)
- Shurong Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
| | - Shaohua Liu
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
| | - Liqin Yang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Shuang Chen
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Sports Medicine Institute, Fudan University, Shanghai, China
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Saito M, Nakajima A, Sonobe M, Takahashi H, Akatsu Y, Inaoka T, Iwasaki J, Morikawa T, Watanabe A, Aoki Y, Sasho T, Nakagawa K. Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique. Knee Surg Sports Traumatol Arthrosc 2019; 27:2468-2477. [PMID: 30374576 DOI: 10.1007/s00167-018-5240-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel. METHODS Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups. RESULTS There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004). CONCLUSION There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.
Collapse
Affiliation(s)
- Masahiko Saito
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan.
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Tsutomu Inaoka
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
| | - Junichi Iwasaki
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Tsuguo Morikawa
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba, 260-8670, Japan
| | - Koichi Nakagawa
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
| |
Collapse
|
22
|
Comparison of Modified Transtibial and Outside-In Techniques in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy 2018; 34:2857-2870. [PMID: 30197202 DOI: 10.1016/j.arthro.2018.05.041] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 05/20/2018] [Accepted: 05/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the bending angle of anterior cruciate ligament (ACL) graft at femoral tunnel, graft maturation, and tunnel positions and the clinical outcomes of the modified transtibial (mTT) and outside-in (OI) techniques. METHODS Patients who met the inclusion criteria were divided into the mTT group (n = 50) and the OI group (n = 50). Using 3-dimensional computed tomography (3-D CT), tunnel placement and femoral tunnel bending angle were analyzed. The 3.0-T magnetic resonance imaging (MRI) was used to assess the graft signal intensity (indicative of maturation) with signal/noise quotient (SNQ). Graft tension and synovialization were evaluated with second-look arthroscopy in all cases. Clinical and functional tests were completed at 36 months of follow-up. RESULTS When tunnel placements were analyzed using the quadrant method, no significant differences were found between the mTT group and the OI group. The femoral graft bending angle was reduced in the mTT group, and the total mean of SNQ values and mean SNQ values at the femoral intraosseous and proximal graft of the mTT group were significantly lower than in the OI group (P < .001), respectively. The femoral graft bending angle on the coronal and axial planes showed moderate-to-strong correlation with the SNQ values at the femoral intraosseous and proximal graft. Second-look arthroscopy revealed better synovialization in the mTT group than in the OI group (P = .040), with no significant difference in graft tension between the 2 groups (P = .328). CONCLUSIONS Anatomic tunnel placements did not vary between the mTT group and the OI group. However, the mTT group had more benefits in femoral graft bending angle and showed higher graft maturity and better synovial coverage than the OI group, although there were no significant differences in clinical outcomes. The acute femoral graft bending angle might negatively affect the maturation of proximal graft. LEVEL OF EVIDENCE: Level III, retrospective comparative study.
Collapse
|
23
|
Sheean AJ, Musahl V. Editorial Commentary: Does "No Difference" Really Mean "No Difference"? Not All Anterior Cruciate Ligament Transtibial Drilling Techniques Are Created Equal. Arthroscopy 2018; 34:2871-2873. [PMID: 30286885 DOI: 10.1016/j.arthro.2018.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 02/02/2023]
Abstract
Despite the preponderance of biomechanical data suggesting that independent femoral tunnel drilling results in more favorable knee kinematics and superior anterior cruciate ligament footprint restoration when compared with transtibial tunnel drilling, equivalent clinical outcomes associated with both techniques continue to be reported. However, readers could contemplate the meaning of "clinical equivalence" and, perhaps, find themselves wanting better ways to detect differences between surgical techniques.
Collapse
|
24
|
Chen L, Wu Y, Lin G, Wei P, Ye Z, Wang Y, Ren T. Graft bending angle affects allograft tendon maturity early after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:3048-3054. [PMID: 29574546 DOI: 10.1007/s00167-018-4910-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/20/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this study was to clarify the association of the anterior cruciate ligament (ACL) graft bending angle and graft maturity of autograft and allograft tendons using high-resolution MRI. METHODS Patients with unilateral ACL reconstruction were invited to participate in this study, and they were examined using a 3.0-T MRI scan at 3, 6 and 12 months after the operation. Anatomic single-bundle ACL reconstruction was performed on 48 patients using the trans-portal technique, including 28 with autograft hamstring tendons and 20 with allograft tendons. To evaluate graft healing, the signal/noise quotient (SNQ) was measured in four regions of interest (ROIs) of the femoral tunnel, proximal, midsubstance and distal ACL grafts. The graft bending angle was defined as the angle between the femoral bone tunnel and the line connecting the femoral and tibial tunnel apertures. Graft SNQ and graft bending angle were assessed at 3, 6 and 12 months postoperatively, and the association between SNQ and the average graft bending angle was analyzed. RESULTS Generally, the mean graft bending angle of this cohort increased gradually with time. The SNQ value of each graft region increased from 3 to 6 months and then decreased from 6 to 12 months. In the whole cohort, the graft bending angle had a significant positive association with graft SNQ in the femoral tunnel or proximal site. In the allograft subgroup, the graft bending angle had a significant positive association with the graft SNQ in the femoral tunnel or proximal site at 6 months after surgery, while there was no association between the graft bending angle and SNQ at 12 months. In the autograft subgroup, the graft bending angle had a significant positive association with graft SNQ in the femoral tunnel or proximal site at 12 months after surgery. CONCLUSION Generally, the graft bending angle was correlated with a high signal intensity of the proximal graft in the early postoperative period for allograft tendons and in the late postoperative period for allograft tendons. This suggests that the biomechanical effect from the graft bending angle on graft healing may be different for allografts and autografts after ACL reconstruction. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Linhai Chen
- Medical college, Ningbo University, Ningbo, Zhejiang, People's Republic of China
| | - Yibing Wu
- Medical college, Ningbo University, Ningbo, Zhejiang, People's Republic of China
| | - Guanghao Lin
- Medical college, Ningbo University, Ningbo, Zhejiang, People's Republic of China
| | - Peng Wei
- Department of Repair and Reconstruction Surgery, Ningbo First hospital, 247 Renmin Road, Ningbo, Zhejiang, People's Republic of China.
| | - Zaohui Ye
- Department of Repair and Reconstruction Surgery, Ningbo First hospital, 247 Renmin Road, Ningbo, Zhejiang, People's Republic of China
| | - Yangjian Wang
- Department of Repair and Reconstruction Surgery, Ningbo First hospital, 247 Renmin Road, Ningbo, Zhejiang, People's Republic of China
| | - Tiantian Ren
- Department of Repair and Reconstruction Surgery, Ningbo First hospital, 247 Renmin Road, Ningbo, Zhejiang, People's Republic of China
| |
Collapse
|
25
|
Optimal Condition to Create Femoral Tunnel Considering Combined Influence of Knee Flexion and Transverse Drill Angle in Anatomical Single-Bundle ACL Reconstruction Using Medial Portal Technique: 3D Simulation Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2643247. [PMID: 30112370 PMCID: PMC6077681 DOI: 10.1155/2018/2643247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 07/02/2018] [Indexed: 01/10/2023]
Abstract
There has been no previous study using three-dimensional (3D) measurement on femoral tunnel characteristics according to the combined influence of various flexion angles of knee and transverse drill angles in single-bundle ACL reconstruction with transportal technique. The purpose of this study was to determine optimal condition of knee flexion angle and transverse drill angle to create secure femoral tunnel in single-bundle ACL reconstruction with transportal technique considering tunnel length, tunnel wall breakage, and graft bending angle. This study was conducted using simulation of 3D computed tomography of thirty subjects. Three variables of femoral tunnel changed according to combined influence of four flexion angles of knee and three transverse drill angles were measured: tunnel length, wall breakage, and graft bending angle. There was no case of short femoral tunnel less than 25 mm at 120° and 130° of flexion. There was no case of breakage of femoral tunnel at 120° of flexion with maximum transverse drill angle (MTA) and MTA-10° and at 130° of flexion. Considering effect on graft bending angle, decrease of flexion angle and transverse drill angle could be appropriate in creating femoral tunnel. Increased flexion angle and transverse drill angle secured femoral tunnel having sufficiently long length without wall breakage. However, avoiding excessive flexion angle and maximum transverse drill angle could be recommended because they tended to cause more acute graft bending angle.
Collapse
|
26
|
Hiramatsu K, Mae T, Tachibana Y, Nakagawa S, Shino K. Contact area between femoral tunnel and interference screw in anatomic rectangular tunnel ACL reconstruction: a comparison of outside-in and trans-portal inside-out techniques. Knee Surg Sports Traumatol Arthrosc 2018; 26:519-525. [PMID: 29058021 DOI: 10.1007/s00167-017-4732-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/25/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE The purpose of this study was to compare the femoral tunnel length, the femoral graft bending angle at the femoral tunnel aperture, and the contact area between the femoral tunnel wall and an interference screw used for fixation in anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction (ART ACLR). METHODS The study included 149 patients with primary ACL injury who underwent ART ACLR. Preoperatively, flexion angle of the index knee was checked under general anaesthesia. Those of less than 130° of passive flexion were assigned to the outside-in (OI) technique (78 patients), while the others to the trans-portal inside-out (TP) technique (71 patients). The patients underwent computed tomography with multiplanar reconstruction at 3-5 weeks post-operatively. Femoral tunnel length, graft bending angle, and contact ratio between the IFS and femoral tunnel were assessed. P < 0.05 was considered statistically significant. RESULTS The femoral tunnel length in the OI technique was significantly longer than that in the TP technique (P < 0.001). The femoral graft bending angle in the OI technique was significantly more acute than that in the TP technique (P < 0.001). The contact ratio in the OI technique was significantly larger than that in the TP technique at every point in the femoral tunnel (P < 0.001). CONCLUSIONS The OI technique resulted in a more acute femoral graft bending angle, longer mean femoral tunnel length, and larger contact ratio than the TP technique after ART ACLR. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
Collapse
Affiliation(s)
- Kunihiko Hiramatsu
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yuta Tachibana
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Shigeto Nakagawa
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Konsei Shino
- Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| |
Collapse
|
27
|
Choi CH, Kim SJ, Chun YM, Kim SH, Lee SK, Eom NK, Jung M. Influence of knee flexion angle and transverse drill angle on creation of femoral tunnels in double-bundle anterior cruciate ligament reconstruction using the transportal technique: Three-dimensional computed tomography simulation analysis. Knee 2018; 25:99-108. [PMID: 28978459 DOI: 10.1016/j.knee.2017.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/19/2017] [Accepted: 09/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to find appropriate flexion angle and transverse drill angle for optimal femoral tunnels of anteromedial (AM) bundle and posterolateral (PL) bundle in double-bundle ACL reconstruction using transportal technique. METHODS Thirty three-dimensional knee models were reconstructed. Knee flexion angles were altered from 100° to 130° at intervals of 10°. Maximum transverse drill angle (MTA), MTA minus 10° and 20° were set up. Twelve different tunnels were determined by four flexion angles and three transverse drill angles for each bundle. Tunnel length, wall breakage, inter-tunnel communication and graft-bending angle were assessed. RESULTS Mean tunnel length of AM bundle was >30mm at 120° and 130° of flexion in all transverse drill angles. Mean tunnel length of PL bundle was >30mm during every condition. There were ≥1 cases of wall breakage except at 120° and 130° of flexion with MTA for AM bundle. There was no case of wall breakage for PL bundle. Considering inter-tunnel gap of >2mm without communication and obtuse graft-bending angle, 120° of flexion and MTA could be recommended as optimal condition for femoral tunnels of AM and PL bundles. CONCLUSION Flexion angle and transverse drill angle had combined effect on femoral tunnel in double-bundle ACL reconstruction using transportal technique. Achieving flexion angle of 120° and transverse drill angle close to the medial femoral condyle could be recommended as optimal condition for femoral tunnels of AM and PL bundles to avoid insufficient tunnel length, wall breakage, inter-tunnel communication and acute graft-bending angle.
Collapse
Affiliation(s)
- Chong Hyuk Choi
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Jae Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su-Keon Lee
- Department of Orthopaedic Surgery, Gwangmyung Sungae Hospital, Gyeonggi, Republic of Korea
| | - Nam-Kyu Eom
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
28
|
Tashiro Y, Gale T, Sundaram V, Nagai K, Irrgang JJ, Anderst W, Nakashima Y, Tashman S, Fu FH. The Graft Bending Angle Can Affect Early Graft Healing After Anterior Cruciate Ligament Reconstruction: In Vivo Analysis With 2 Years' Follow-up. Am J Sports Med 2017; 45:1829-1836. [PMID: 28402758 DOI: 10.1177/0363546517698676] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A high graft bending angle (GBA) after anterior cruciate ligament (ACL) reconstruction has been suggested to cause stress on the graft. Nevertheless, evidence about its effect on graft healing in vivo is limited. HYPOTHESIS The signal intensity on magnetic resonance imaging (MRI) would be higher in the proximal region of the ACL graft, and higher signals would be correlated to a higher GBA. STUDY DESIGN Descriptive laboratory study. METHODS Anatomic single-bundle ACL reconstruction was performed on 24 patients (mean age, 20 ± 4 years) using the transportal technique. A quadriceps tendon autograft with a bone plug was harvested. To evaluate graft healing, the signal/noise quotient (SNQ) was measured in 3 regions of interest (ROIs) of the proximal, midsubstance, and distal ACL graft using high-resolution MRI (0.45 × 0.45 × 0.70 mm), with decreased signals suggesting improved healing. Dynamic knee motion was examined during treadmill walking and running to assess the in vivo GBA. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors at each motion frame, based on tibiofemoral kinematics determined from dynamic stereo X-ray analysis. Graft healing and GBAs were assessed at 6 and 24 months postoperatively. Repeated-measures analysis of variance was used to compare the SNQ in the 3 ROIs at 2 time points. Pearson correlations were used to analyze the relationship between the SNQ and mean GBA during 0% to 15% of the gait cycle. RESULTS The SNQ of the ACL graft in the proximal region was significantly higher than in the midsubstance ( P = .022) and distal regions ( P < .001) at 6 months. The SNQ in the proximal region was highly correlated with the GBA during standing ( R = 0.64, P < .001), walking ( R = 0.65, P = .002), and running ( R = 0.54, P = .015) but not in the other regions. At 24 months, signals in the proximal and midsubstance regions decreased significantly compared with 6 months ( P < .001 and P = .008, respectively), with no difference across the graft area. CONCLUSION The signal intensity was highest in the proximal region and lowest in the distal region of the reconstructed graft at 6 months postoperatively. A steep GBA was significantly correlated with high signal intensities of the proximal graft in this early period. A steep GBA may negatively affect proximal graft healing after ACL reconstruction.
Collapse
Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vani Sundaram
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kanto Nagai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|