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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

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

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.

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Authors and Affiliations

  1. 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

    Seong Yun Park, Joon Hee Cho, Jade Pei Yuik Ho, Nguyen Thanh Tu & Yong Seuk Lee

  2. Department of Orthopedic Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital Seoul, 59 Daesagwan-ro, Seoul, Yongsan-gu, South Korea

    Yong Beom Kim

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Contributions

SYP, YBK, and YSL participated in study design and drafted the manuscript, SYP and JPYH performed the statistical analysis, SYP, JHC, and Nguyen collected the data and contributed to performing statistical analysis, SYP, YBK, and YSL conceived of the study, participated in coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.

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Correspondence to Yong Seuk Lee.

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Institutional Review Board approval was obtained before performing the study (IRB NO: B-2208-774-103).

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Park, S.Y., Cho, J.H., Ho, J.P.Y. et al. 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 31, 4379–4389 (2023). https://doi.org/10.1007/s00167-023-07491-z

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