Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Knee Surgery, Sports Traumatology, Arthroscopy
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 5/2022

01-05-2022 | Magnetic Resonance Imaging | KNEE

Tibial slope, remnant preservation, and graft size are the most important factors affecting graft healing after ACL reconstruction

Authors: Ahmet Emin Okutan, Muhammet Kalkışım, Enes Gürün, Muhammet Salih Ayas, Osman Aynacı

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 5/2022

Login to get access

Abstract

Purpose

The aim of this study was to determine the anatomic, operative and biological factors that influenced graft healing after single-bundle anterior cruciate ligament (ACL) reconstruction.

Methods

One hundred fourteen consecutive patients who underwent anatomic single-bundle ACL reconstruction with quadrupled hamstring tendon autografts between 2016 and 2019 were retrospectively analyzed. Ninety-four patients met the inclusion criteria with minimum follow-up of 12 months. Patients were evaluated with multiple clinical measurements, including International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Lyshom Scores, and Marx activity scale. To evaluate graft healing, the signal-to-noise quotient (SNQ) was measured at intra-articular graft and intra-tunnel integration were evaluated on magnetic resonance imaging (MRI) at one year after surgery. Potential factors affecting graft healing, including age, sex, body mass index, time from injury to surgery, posterior tibial slope, lateral femoral condyle ratio, notch width index, meniscal injury, remnant preservation, tunnel aperture locations, graft size, graft bending angle, graft/remaining notch volume ratio were evaluated for their association with graft SNQ value by stepwise regression analysis.

Results

A total of 94 patients were evaluated with mean follow-up 28.5 ± 9 months. Univariate regression analysis showed that posterior tibial slope, notch width index, remnant preserving procedure, high femoral tunnel, anterior tibial tunnel, graft bending angle, and graft/remaining notch volume ratio significantly associated with graft SNQ values. Multivariate regression analysis showed that lateral tibial slope, remnant preservation, and graft/remaining notch volume ratio were independent factors correlated with graft SNQ values. Also, the graft SNQ values was weakly correlated with femoral tunnel integration and Marx activity scale at one year. There was no correlation between graft SNQ values and IKDC-SKF and Lysholm scores. There was no correlation between graft SNQ values and International Knee Documentation Committee and Lysholm scores.

Conclusions

Tibial slope, remnant preservation and graft/remaining notch volume ratio were significant independent associated factors of graft SNQ value at one year. The graft SNQ values were also weakly correlated with femoral tunnel integration and the Marx activity scale. These factors should be taken into account for ensuring the ideal graft healing and for the return to sport decision-making.

Level of evidence

Level IV.
Literature
1.
Bernhardson AS, Aman ZS, DePhillipo NN, Dornan GJ, Storaci HW, Brady AW, Nakama G, LaPrade RF (2019) Tibial slope and its effect on graft force in posterior cruciate ligament reconstructions. Am J Sports Med 47:1168–1174CrossRef
2.
3.
Chiba D, Yamamoto Y, Kimura Y, Sasaki S, Tsuda E, Ishibashi Y (2020) Combination of anterior tibial and femoral tunnels makes the signal intensity of antero-medial graft higher in double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc (Springer) 29:783–792CrossRef
4.
Claes S, Verdonk P, Forsyth R, Bellemans J (2011) The “ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med 39(11):2476–2483CrossRef
5.
Crain EH, Fithian DC, Paxton EW, Luetzow WF (2005) Variation in anterior cruciate ligament scar pattern: does the scar pattern affect anterior laxity in anterior cruciate ligament deficient knees? Arthroscopy 1:19–24CrossRef
6.
Elmansori A, Lording T, Dumas R, Elmajri K, Neyret P, Lustig S (2017) Proximal tibial bony and meniscal slopes are higher in ACL injured subjects than controls: a comparative MRI study. Knee Surg Sports Traumatol Arthrosc 25(5):1598–1605CrossRef
7.
Everhart JS, Best TM, Flanigan DC (2015) Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 23(3):752–762CrossRef
8.
Fu FH (2020) Pearls: individualized approach to ACL reconstruction—one size does not fit all. Clin Orthop Relat Res 478:1735–1737CrossRef
9.
Fu FH, Byrne KJ, Godshaw BM (2021) Editorial commentary: Remember the risk factors during individualized, anatomic, value-based anterior cruciate ligament reconstruction. Arthroscopy 37(1):206–208CrossRef
10.
Ge Y, Li H, Tao H, Hua Y, Chen J, Chen S (2015) Comparison of tendon-bone healing between autografts and allografts after anterior cruciate ligament reconstruction using magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 23:954–960CrossRef
11.
Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA (2014) Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL cohort study. J Bone Joint Surg Am 96(15):1233–1241CrossRef
12.
Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC (2018) Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surg Sports Traumatol Arthrosc 26:426–433CrossRef
13.
Kim BH, Il KJ, Lee O, Lee KW, Lee MC, Han HS (2018) Preservation of remnant with poor synovial coverage has no beneficial effect over remnant sacrifice in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26:2345–2352CrossRef
14.
Kim JH, Oh E, Yoon YC, Lee DK, Lee SS, Song SY, Wang JH (2020) The relationship between graft synovialization and graft revascularization after ACL reconstruction: assessment using dynamic contrast enhanced-MRI and second-look arthroscopy. Eur J Radiol 133:109346
15.
Lee BI, Kim BM, Kho D, Kwon SW, Kim HJ, Hwang HR (2016) Does the tibial remnant of the anterior cruciate ligament promote ligamentization? Knee 23:1133–1142
16.
Li H, Chen J, Li H, Wu Z, Chen S (2017) MRI-based ACL graft maturity does not predict clinical and functional outcomes during the first year after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 25:3171–3178CrossRef
17.
Li H, Chen S, Tao H, Li H, Chen S (2014) Correlation analysis of potential factors influencing graft maturity after anterior cruciate ligament reconstruction. Orthop J Sports Med 2:2325967114553552CrossRef
18.
Li H, Tao H, Cho S, Chen S, Yao Z, Chen S (2012) Difference in graft maturity of the reconstructed anterior cruciate ligament 2 years postoperatively: a comparison between autografts and allografts in young men using clinical and 3.0-T magnetic resonance imaging evaluation. Am J Sports Med 40:1519–1526CrossRef
19.
Li HY, Li HY, Wu ZY, Chen JW, Chen SY (2018) MRI-based tendon bone healing is related to the clinical functional scores at the first year after anterior cruciate ligament reconstruction with hamstring tendon autograft. Knee Surg Sports Traumatol Arthrosc 26:615–621CrossRef
20.
Ma R, Schär M, Chen T, Sisto M, Nguyen J, Voigt C, Deng XH, Rodeo SA (2018) Effect of dynamic changes in anterior cruciate ligament in situ graft force on the biological healing response of the graft-tunnel interface. Am J Sports Med 46:915–923CrossRef
21.
Maletis GB, Chen J, Inacio MCS, Funahashi TT (2016) Age-related risk factors for revision anterior cruciate ligament reconstruction: a cohort study of 21,304 patients from the Kaiser Permanente Anterior Cruciate Ligament Registry. Am J Sports Med 44:331–336CrossRef
22.
Maletis GB, Inacio MCS, Funahashi TT (2013) Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry. Am J Sports Med 41:2090–2098CrossRef
23.
Mayr R, Smekal V, Koidl C, Coppola C, Fritz J, Rudisch A, Kranewitter C, Attal R (2017) Tunnel widening after ACL reconstruction with aperture screw fixation or all-inside reconstruction with suspensory cortical button fixation: volumetric measurements on CT and MRI scans. Knee 24:1047–1054CrossRef
24.
Meredith SJ, Rauer T, Chmielewski TL, Fink C, Diermeier T, Rothrauff BB, Svantesson E, HamrinSenorski E, Hewett TE, Sherman SL, Lesniak BP (2020) Return to sport after anterior cruciate ligament injury: Panther symposium ACL injury return to sport consensus group. Knee Surg Sports Traumatol Arthrosc 28:2403–2414CrossRef
25.
Mochizuki Y, Kaneko T, Kawahara K, Toyoda S, Kono N, Hada M, Ikegami H, Musha Y (2018) The quadrant method measuring four points is as a reliable and accurate as the quadrant method in the evaluation after anatomical double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 26:2389–2394CrossRef
26.
Naraoka T, Kimura Y, Tsuda E, Yamamoto Y, Ishibashi Y (2017) Is Remnant preservation truly beneficial to anterior cruciate ligament reconstruction healing? Clinical and magnetic resonance imaging evaluations of remnant-preserved reconstruction. Am J Sports Med 45:1049–1058CrossRef
27.
Offerhaus C, Albers M, Nagai K, Arner JW, Höher J, Musahl V, Fu FH (2018) Individualized anterior cruciate ligament graft matching. In vivo comparison of cross-sectional areas of hamstring, patellar, and quadriceps tendon grafts and ACL insertion area. Am J Sports Med 46:2646–2652CrossRef
28.
Orsi AD, Canavan PK, Vaziri A, Goebel R, Kapasi OA, Nayeb-Hashemi H (2017) The effects of graft size and insertion site location during anterior cruciate ligament reconstruction on intercondylar notch impingement. Knee 24:525–535CrossRef
29.
Oshima T, Putnis S, Grasso S, Klasan A, Parker DA (2020) Graft size and orientation within the femoral notch affect graft healing at 1 year after anterior cruciate ligament reconstruction. Am J Sports Med 48:99–108CrossRef
30.
Pfeiffer TR, Burnham JM, Hughes JD, Kanakamedala AC, Herbst E, Popchak A, Shafizadeh S, Irrgang JJ, Debski RE, Musahl V (2018) An increased lateral femoral condyle ratio is a risk factor for anterior cruciate ligament injury. J Bone Joint Surg 100:857–864CrossRef
31.
Putnis S, Neri T, Grasso S, Linklater J, Fritsch B, Parker D (2020) ACL hamstring grafts fixed using adjustable cortical suspension in both the femur and tibia demonstrate healing and integration on MRI at one year. Knee Surg Sports Traumatol Arthrosc 28:906–914CrossRef
32.
Sabzevari S, Shaikh H, Marshall B, Zhu J, Linde MA, Smolinski P, Fu FH (2020) The femoral posterior fan-like extension of the ACL insertion increases the failure load. Knee Surg Sports Traumatol Arthrosc 28:1113–1118CrossRef
33.
Smith A, Noyes FR (2019) What is the scientific basis for knee ligament healing and maturation to restore biomechanical properties and a return to sport? In: Noyes F, Barber-Westin S (eds) Return to sport after ACL reconstruction and other knee operations. Springer, New York. https://​doi.​org/​10.​1007/​978-3-030-22361-8_​7
34.
Takahashi T, Kondo E, Yasuda K, Miyatake S, Kawaguchi Y, Onodera J, Kitamura N (2016) Effects of remnant tissue preservation on the tendon graft in anterior cruciate ligament reconstruction. Am J Sports Med 44:1708–1716CrossRef
35.
Tan SHS, Lau BPH, Khin LW, Lingaraj K (2016) The importance of patient sex in the outcomes of anterior cruciate ligament reconstructions. Am J Sports Med 44:242–254CrossRef
36.
Van Dyck P, Zazulia K, Smekens C, Heusdens CHW, Janssens T, Sijbers J (2019) Assessment of anterior cruciate ligament graft maturity with conventional magnetic resonance imaging: a systematic literature review. Orthop J Sports Med 7(6):2325967119849012PubMedPubMedCentral
37.
Van Groningen B, van der Steen MC, Janssen DM, van Rhijn LW, van der Linden AN, Janssen RPA (2020) 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 2:e377–e388CrossRef
38.
Ziegler CG, DePhillipo NN, Kennedy MI, Dekker TJ, Dornan GJ, LaPrade RF (2021) Beighton score, tibial slope, tibial subluxation, quadriceps circumference difference, and family history are risk factors for anterior cruciate ligament graft failure: a retrospective comparison of primary and revision anterior cruciate ligament reconstructions. Arthroscopy 37:195–205CrossRef
Metadata
Title
Tibial slope, remnant preservation, and graft size are the most important factors affecting graft healing after ACL reconstruction
Authors
Ahmet Emin Okutan
Muhammet Kalkışım
Enes Gürün
Muhammet Salih Ayas
Osman Aynacı
Publication date
01-05-2022
Publisher
Springer Berlin Heidelberg
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 5/2022
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-021-06660-2

Other articles of this Issue 5/2022

Knee Surgery, Sports Traumatology, Arthroscopy 5/2022 Go to the issue

KNEE

Derotational distal femoral osteotomy yields satisfactory clinical outcomes in pathological femoral rotation with failed medial patellofemoral ligament reconstruction

KNEE

Revision ACL reconstruction has higher incidence of 30-day hospital readmission, reoperation, and surgical complications relative to primary procedures

KNEE

Good healing potential of patellar chondral defects after all-arthroscopic autologous chondrocyte implantation with spheroids: a second-look arthroscopic assessment

KNEE

Bone-patellar tendon–bone autograft maturation is superior to double-bundle hamstring tendon autograft maturation following anatomical anterior cruciate ligament reconstruction

KNEE

Severe bicompartmental bone bruise is associated with rotatory instability in anterior cruciate ligament injury

KNEE

Transpatellar bone tunnels perforating the lateral or anterior cortex increase the risk of patellar fracture in MPFL reconstruction: a finite element analysis and survey of the International Patellofemoral Study Group