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MRI analysis of single-, double-, and triple-bundle anterior cruciate ligament grafts

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of the study was to evaluate the entire course of ACL grafts on coronal oblique MR images, focusing on differences in graft morphology and graft-to-tunnel healing among single-bundle (SB), double-bundle (DB), and triple-bundle (TB) reconstructions.

Methods

Eighty-three patients underwent anatomical ACL reconstruction using the semitendinosus tendon. SB reconstruction was performed on 20 patients, DB on 29 patients, and TB on 34 patients. The anteromedial-bundle (AMB) and posterolateral-bundle (PLB) images were extracted from coronal oblique images of grafts at 6 months to visualize their entire course. Signal intensity of grafts was measured independently in three regions: (1) intra-femoral tunnel region, (2) intra-articular region, and (3) intra-tibial tunnel region, followed by calculation of the signal-to-noise quotient (SNQ). To evaluate graft-to-tunnel healing, T2-weighted images were examined for the presence of a high signal-intensity lesion between the graft and bone tunnel around the tunnel aperture.

Results

AMB images showed that SB graft was thick throughout the entire course, while DB graft was thinner than SB graft. TB graft showed a fan shape approaching the tibial tunnels. The SNQ in the femoral tunnel of SB graft was significantly lower than in the DB and TB grafts. High signal-intensity lesions were frequently observed around the femoral tunnel aperture in PLB images of DB and TB grafts compared to SB grafts.

Conclusion

Gross morphology of TB grafts resembled that of the natural ACL. However, the graft-to-tunnel healing around the femoral tunnel seemed to be insufficient in PLB images of DB and TB compared to SB grafts.

Level of evidence

III.

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References

  1. Aglietti P, Giron F, Losco M, Cuomo P, Ciardullo A, Mondanelli N (2010) Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial. Am J Sports Med 38:25–34

    Article  PubMed  Google Scholar 

  2. Ahn JH, Choi SH, Wang JH, Yoo JC, Yim HS, Chang MJ (2011) Outcomes and second-look arthroscopic evaluation after double-bundle anterior cruciate ligament reconstruction with use of a single tibial tunnel. J Bone Joint Surg Am 93:1865–1872

    Article  PubMed  Google Scholar 

  3. Amiel D, Kleiner JB, Roux RD, Harwood FL, Akeson WH (1986) The phenomenon of “ligamentization”: anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res 4:162–172

    Article  CAS  PubMed  Google Scholar 

  4. Arai Y, Hara K, Takahashi T, Urade H, Minami G, Takamiya H, Kubo T (2008) Evaluation of the vascular status of autogenous hamstring tendon grafts after anterior cruciate ligament reconstruction in humans using magnetic resonance angiography. Knee Surg Sports Traumatol Arthrosc 16:342–347

    Article  PubMed  Google Scholar 

  5. Arnoczky SP, Tarvin GB, Marshall JL (1982) Anterior cruciate ligament replacement using patellar tendon. An evaluation of graft revascularization in the dog. J Bone Joint Surg Am 64:217–224

    CAS  PubMed  Google Scholar 

  6. Casagranda BU, Maxwell NJ, Kavanagh EC, Towers JD, Shen W, Fu FH (2009) Normal appearance and complications of double-bundle and selective-bundle anterior cruciate ligament reconstructions using optimal MRI techniques. AJR Am J Roentgenol 192:1407–1415

    Article  PubMed  Google Scholar 

  7. Edwards A, Bull AM, Amis AA (2007) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament: part 1: tibial attachment. Knee Surg Sports Traumatol Arthrosc 15:1414–1421

    Article  PubMed  Google Scholar 

  8. Fujimoto E, Sumen Y, Deie M, Yasumoto M, Kobayashi K, Ochi M (2004) Anterior cruciate ligament graft impingement against the posterior cruciate ligament: diagnosis using MRI plus three-dimensional reconstruction software. Magn Reson Imaging 22:1125–1129

    Article  PubMed  Google Scholar 

  9. Giron F, Aglietti P, Cuomo P, Mondanelli N, Ciardullo A (2005) Anterior cruciate ligament reconstruction with double-looped semitendinosus and gracilis tendon graft directly fixed to cortical bone: 5-year results. Knee Surg Sports Traumatol Arthrosc 13:81–91

    Article  PubMed  Google Scholar 

  10. Hamada M, Shino K, Horibe S, Mitsuoka T, Miyama T, Shiozaki Y, Mae T (2001) Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endoButton femoral fixation: a prospective study. Arthroscopy 17:801–807

    Article  CAS  PubMed  Google Scholar 

  11. Hantes ME, Zachos VC, Liantsis A, Venouziou A, Karantanas AH, Malizos KN (2009) Differences in graft orientation using the transtibial and anteromedial portal technique in anterior cruciate ligament reconstruction: a magnetic resonance imaging study. Knee Surg Sports Traumatol Arthrosc 17:880–886

    Article  PubMed  Google Scholar 

  12. Hara K, Mochizuki T, Sekiya I, Yamaguchi K, Akita K, Muneta T (2009) Anatomy of normal human anterior cruciate ligament attachments evaluated by divided small bundles. Am J Sports Med 37:2386–2391

    Article  PubMed  Google Scholar 

  13. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med 40:512–520

    Article  PubMed  Google Scholar 

  14. Iwahashi T, Shino K, Nakata K, Otsubo H, Suzuki T, Amano H, Nakamura N (2010) Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography. Arthroscopy 26:S13–S20

    Article  PubMed  Google Scholar 

  15. Iwahashi T, Shino K, Nakata K, Nakamura N, Yamada Y, Yoshikawa H, Sugamoto K (2008) Assessment of the “functional length” of the three bundles of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 16:167–174

    Article  PubMed  Google Scholar 

  16. Jansson KA, Karjalainen PT, Harilainen A, Sandelin J, Soila K, Tallroth K, Aronen HJ (2001) MRI of anterior cruciate ligament repair with patellar and hamstring tendon autografts. Skeletal Radiol 30:8–14

    Article  CAS  PubMed  Google Scholar 

  17. Mae T, Shino K, Matsumoto N, Hamada M, Yoneda M, Nakata K (2007) Anatomical two-bundle versus Rosenberg’s isometric bi-socket ACL reconstruction: a biomechanical comparison in laxity match pretension. Knee Surg Sports Traumatol Arthrosc 15:328–334

    Article  PubMed  Google Scholar 

  18. Mae T, Kuroda S, Matsumoto N, Yoneda M, Nakata K, Yoshikawa H, Shino K (2011) Migration of EndoButton after anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 27:1528–1535

    Article  PubMed  Google Scholar 

  19. Maeda A, Shino K, Horibe S, Nakata K, Buccafusca G (1996) Anterior cruciate ligament reconstruction with multistranded autogenous semitendinosus tendon. Am J Sports Med 24:504–509

    Article  CAS  PubMed  Google Scholar 

  20. Mellado JM, Calmet J, Olona M, Giné J, Saurí A (2004) Magnetic resonance imaging of anterior cruciate ligament tears: reevaluation of quantitative parameters and imaging findings including a simplified method for measuring the anterior cruciate ligament angle. Knee Surg Sports Traumatol Arthrosc 12:217–224

    Article  CAS  PubMed  Google Scholar 

  21. Muneta T, Koga H, Mochizuki T, Ju YJ, Hara K, Nimura A, Yagishita K, Sekiya I (2007) A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy 23:618–628

    Article  PubMed  Google Scholar 

  22. Muramatsu K, Hachiya Y, Izawa H (2008) Serial evaluation of human anterior cruciate ligament grafts by contrast-enhanced magnetic resonance imaging: comparison of allografts and autografts. Arthroscopy 24:1038–1044

    Article  PubMed  Google Scholar 

  23. Nebelung W, Becker R, Urbach D, Röpke M, Roessner A (2003) Histological findings of tendon-bone healing following anterior cruciate ligament reconstruction with hamstring grafts. Arch Orthop Trauma Surg 123:158–163

    CAS  PubMed  Google Scholar 

  24. Ntoulia A, Papadopoulou F, Ristanis S, Argyropoulou M, Georgoulis AD (2011) Revascularization process of the bone–patellar tendon–bone autograft evaluated by contrast-enhanced magnetic resonance imaging 6 and 12 months after anterior cruciate ligament reconstruction. Am J Sports Med 39:1478–1486

    Article  PubMed  Google Scholar 

  25. Otsubo H, Shino K, Nakamura N, Nakata K, Nakagawa S, Koyanagi M (2007) Arthroscopic evaluation of ACL grafts reconstructed with the anatomical two-bundle technique using hamstring tendon autograft. Knee Surg Sports Traumatol Arthrosc 15:720–728

    Article  PubMed  Google Scholar 

  26. Purnell ML, Larson AI, Clancy W (2008) Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 36:2083–2090

    Article  PubMed  Google Scholar 

  27. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF (1993) Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 75:1795–1803

    CAS  PubMed  Google Scholar 

  28. Samuelsson K, Andersson D, Karlsson J (2009) Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials. Arthroscopy 25:1139–1174

    Article  PubMed  Google Scholar 

  29. Sasaki N, Ishibashi Y, Tsuda E, Yamamoto Y, Maeda S, Mizukami H, Toh S, Yagihashi S, Tonosaki Y (2012) The femoral insertion of the anterior cruciate ligament: discrepancy between macroscopic and histological observations. Arthroscopy 28:1135–1146

    Article  PubMed  Google Scholar 

  30. Sastre S, Popescu D, Núñez M, Pomes J, Tomas X, Peidro L (2010) Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 18:32–36

    Article  PubMed  Google Scholar 

  31. Shino K, Mae T, Maeda A, Miyama T, Shinjo H, Kawakami H (2002) Graft fixation with predetermined tension using a new device, the double spike plate. Arthroscopy 18:908–911

    Article  PubMed  Google Scholar 

  32. Shino K, Nakata K, Nakamura N, Mae T, Ohtsubo H, Iwahashi T, Nakagawa S (2005) Anatomic anterior cruciate ligament reconstruction using two double-looped hamstring tendon grafts via twin femoral and triple tibial tunnels. Oper Tech Orthop 15:130–134

    Article  Google Scholar 

  33. Staeubli HU, Adam O, Becker W, Burgkart R (1999) Anterior cruciate ligament and intercondylar notch in the coronal oblique plane: anatomy complemented by magnetic resonance imaging in cruciate ligament-intact knees. Arthroscopy 15:349–359

    Article  CAS  PubMed  Google Scholar 

  34. Tanaka Y, Shiozaki Y, Yonetani Y, Kanamoto T, Tsujii A, Horibe S (2011) MRI analysis of the attachment of the anteromedial and posterolateral bundles of anterior cruciate ligament using coronal oblique images. Knee Surg Sports Traumatol Arthrosc 19:S54–S59

    Article  PubMed  Google Scholar 

  35. Tanaka Y, Shino K, Horibe S, Nakamura N, Nakagawa S, Mae T, Otsubo H, Suzuki T, Nakata K (2012) Triple-bundle ACL grafts evaluated by second-look arthroscopy. Knee Surg Sports Traumatol Arthrosc 20:95–101

    Article  PubMed  Google Scholar 

  36. Tsuda E, Ishibashi Y, Tazawa K, Sato H, Kusumi T, Toh S (2006) Pretibial cyst formation after anterior cruciate ligament reconstruction with a hamstring tendon autograft. Arthroscopy 22:691

    Article  PubMed  Google Scholar 

  37. Weiler A, Peters G, Mäurer J, Unterhauser FN, Südkamp NP (2001) Biomechanical properties and vascularity of an anterior cruciate ligament graft can be predicted by contrast-enhanced magnetic resonance imaging. A two-year study in sheep. Am J Sports Med 29:751–761

    CAS  PubMed  Google Scholar 

  38. White LM, Kramer J, Recht MP (2005) MR imaging evaluation of the postoperative knee: ligaments, menisci, and articular cartilage. Skeletal Radiol 34:431–452

    Article  PubMed  Google Scholar 

  39. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL (2002) Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 30:660–666

    PubMed  Google Scholar 

  40. Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama H, Minami A (2004) Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 20:1015–1025

    Article  PubMed  Google Scholar 

  41. Yoon KH, Bae DK, Cho SM, Park SY, Lee JH (2009) Standard anterior cruciate ligament reconstruction versus isolated single-bundle augmentation with hamstring autograft. Arthroscopy 25:1265–1274

    Article  PubMed  Google Scholar 

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Correspondence to Yoshinari Tanaka.

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Tanaka, Y., Yonetani, Y., Shiozaki, Y. et al. MRI analysis of single-, double-, and triple-bundle anterior cruciate ligament grafts. Knee Surg Sports Traumatol Arthrosc 22, 1541–1548 (2014). https://doi.org/10.1007/s00167-013-2557-1

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  • DOI: https://doi.org/10.1007/s00167-013-2557-1

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