Skip to main content
SpringerLink
Log in

Preservation of remnant with poor synovial coverage has no beneficial effect over remnant sacrifice in anterior cruciate ligament reconstruction

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

Abstract

Purpose

The purpose of the study was to evaluate the influence of synovial coverage of the remnant on clinical outcomes and graft healing in anterior cruciate ligament (ACL) reconstruction.

Methods

Seventy-five patients who underwent second-look arthroscopy after a single-bundle ACL reconstruction using autologous quadriceps tendon graft were included. The patients were divided into two groups according to whether the remnant was preserved (group P, n = 42) or sacrificed (group S, n = 33). Group P was further classified according to the degree of synovial coverage of the remnant on initial arthroscopic findings: group A (remnant fully covered with synovium, n = 15), group B (synovial coverage >50%, n = 15), and group C (coverage <50%, n = 12). Clinical outcomes including manual laxity tests, KT-2000 side-to-side difference, modified Lysholm score, Tegner activity score, and International Knee Documentation Committee score were evaluated pre-operatively and prior to the second-look arthroscopy. Graft tension, degrees of synovialization, and gross integrity were evaluated on second-look arthroscopic examination.

Results

There were no statistical differences in manual laxity tests, KT-2000 side-to-side difference, and clinical scores between groups P and S. In second-look arthroscopic examination, graft tension showed no difference between the two groups, but gross integrity and synovialization were significantly higher in group P (P = 0.032 and P = 0.008, respectively). In subgroup analysis, only group A showed higher grade regarding gross integrity and synovialization in comparison with group S (P = 0.007 and P < 0.001, respectively).

Conclusions

Preservation of remnant in ACL reconstruction showed no superiority concerning knee stability and clinical outcomes over remnant sacrificing at post-operative 1-year second-look arthroscopy. Preservation of remnant with good synovial coverage had a positive effect on graft synovialization and maintenance of graft integrity, but this effect was not observed in cases of a remnant with poor synovial coverage. When deciding whether to preserve the remnant or not, the degree of synovial coverage should be considered.

Level of evidence

III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Adravanti P, Dini F, de Girolamo L, Cattani M, Rosa RA (2017) Single-bundle versus double-bundle anterior cruciate ligament reconstruction: a prospective randomized controlled trial with 6-year follow-up. J Knee Surg. doi:10.1055/s-0037-1598176

    Article  PubMed  Google Scholar 

  2. Ahn JH, Wang JH, Lee YS, Kim JG, Kang JH, Koh KH (2011) Anterior cruciate ligament reconstruction using remnant preservation and a femoral tensioning technique: clinical and magnetic resonance imaging results. Arthroscopy 27:1079–1089

    Article  PubMed  Google Scholar 

  3. 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 21:19–24

    Article  PubMed  Google Scholar 

  4. Dhawan A, Gallo RA, Lynch SA (2016) Anatomic tunnel placement in anterior cruciate ligament reconstruction. J Am Acad Orthop Surg 24:443–454

    Article  PubMed  Google Scholar 

  5. Dhillon MS, Bali K, Vasistha RK (2010) Immunohistological evaluation of proprioceptive potential of the residual stump of injured anterior cruciate ligaments (ACL). Int Orthop 34:737–741

    Article  PubMed  PubMed Central  Google Scholar 

  6. Duchman KR, Lynch TS, Spindler KP (2017) Graft selection in anterior cruciate ligament surgery: Who gets what and why? Clin Sports Med 36:25–33

    Article  PubMed  Google Scholar 

  7. Fu W, Li Q, Tang X, Chen G, Zhang C, Li J (2016) Mesenchymal stem cells reside in anterior cruciate ligament remnants in situ. Int Orthop 40:1523–1530

    Article  PubMed  Google Scholar 

  8. Gao F, Zhou J, He C, Ding J, Lou Z, Xie Q et al (2016) A morphologic and quantitative study of mechanoreceptors in the remnant stump of the human anterior cruciate ligament. Arthroscopy 32:273–280

    Article  PubMed  Google Scholar 

  9. Guo L, Chen H, Luo JM, Yang L, Gu LC, Fu DJ (2016) An arthroscopic second-look study on the effect of remnant preservation on synovialization of bone-patellar tendon-bone allograft in anterior cruciate ligament reconstruction. Arthroscopy 32:868–877

    Article  PubMed  Google Scholar 

  10. Hong L, Li X, Zhang H, Liu X, Zhang J, Shen JW et al (2012) Anterior cruciate ligament reconstruction with remnant preservation: a prospective, randomized controlled study. Am J Sports Med 40:2747–2755

    Article  PubMed  Google Scholar 

  11. Ju YJ, Muneta T, Yoshimura H, Koga H, Sekiya I (2008) Synovial mesenchymal stem cells accelerate early remodeling of tendon-bone healing. Cell Tissue Res 332:469–478

    Article  PubMed  Google Scholar 

  12. Kim MK, Lee SR, Ha JK, Ra HJ, Kim SB, Kim JG (2014) Comparison of second-look arthroscopic findings and clinical results according to the amount of preserved remnant in anterior cruciate ligament reconstruction. Knee 21:774–778

    Article  PubMed  Google Scholar 

  13. Kondo E, Yasuda K, Onodera J, Kawaguchi Y, Kitamura N (2015) Effects of remnant tissue preservation on clinical and arthroscopic results after anatomic double-bundle anterior cruciate ligament reconstruction. Am J Sports Med 43:1882–1892

    Article  PubMed  Google Scholar 

  14. Lee BI, Kim BM, Kho DH, Kwon SW, Kim HJ, Hwang HR (2016) Does the tibial remnant of the anterior cruciate ligament promote ligamentization? Knee 23:1133–1142

    Article  PubMed  Google Scholar 

  15. Lee BI, Kwon SW, Kim JB, Choi HS, Min KD (2008) Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. Arthroscopy 24:560–568

    Article  PubMed  Google Scholar 

  16. Lee JK, Lee S, Lee MC (2016) Outcomes of anatomic anterior cruciate ligament reconstruction: bone-quadriceps tendon graft versus double-bundle hamstring tendon graft. Am J Sports Med 44:2323–2329

    Article  PubMed  Google Scholar 

  17. Lee JK, Lee S, Seong SC, Lee MC (2014) Anatomic single-bundle ACL reconstruction is possible with use of the modified transtibial technique: a comparison with the anteromedial transportal technique. J Bone Joint Surg Am 96:664–672

    Article  PubMed  Google Scholar 

  18. Ma T, Zeng C, Pan J, Zhao C, Fang H, Cai D (2017) Remnant preservation in anterior cruciate ligament reconstruction versus standard techniques: a meta-analysis of randomized controlled trials. J Sports Med Phys Fit. doi:10.23736/S0022-4707.16.06832-8

    Article  Google Scholar 

  19. Nagai K, Araki D, Matsushita T, Nishizawa Y, Hoshino Y, Matsumoto T et al (2016) Biomechanical function of anterior cruciate ligament remnants: quantitative measurement with a 3-dimensional electromagnetic measurement system. Arthroscopy 32:1359–1366

    Article  PubMed  Google Scholar 

  20. Nakamae A, Ochi M, Deie M, Adachi N, Shibuya H, Ohkawa S et al (2014) Clinical outcomes of second-look arthroscopic evaluation after anterior cruciate ligament augmentation: comparison with single- and double-bundle reconstruction. Bone Joint J 96-B:1325–1332

    Article  PubMed  CAS  Google Scholar 

  21. Nakano N, Matsumoto T, Takayama K, Matsushita T, Araki D, Uefuji A et al (2015) Age-dependent healing potential of anterior cruciate ligament remnant-derived cells. Am J Sports Med 43:700–708

    Article  PubMed  Google Scholar 

  22. Naraoka T, Ishibashi Y, Tsuda E, Yamamoto Y, Kusumi T, Kakizaki I et al (2012) Time-dependent gene expression and immunohistochemical analysis of the injured anterior cruciate ligament. Bone Joint Res 1:238–244

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  23. Naraoka T, Kimura Y, Tsuda E, Yamamoto Y, Ishibashi Y (2017) Is remnant preservation truly beneficial to anterior cruciate ligament reconstruction healing? Am J Sports Med. doi:10.1177/0363546516682241363546516682241

    Article  PubMed  Google Scholar 

  24. Nguyen DT, Ramwadhdoebe TH, van der Hart CP, Blankevoort L, Tak PP, van Dijk CN (2014) Intrinsic healing response of the human anterior cruciate ligament: an histological study of reattached ACL remnants. J Orthop Res 32:296–301

    Article  PubMed  Google Scholar 

  25. Ohsawa T, Kimura M, Hagiwara K, Yorifuji H, Takagishi K (2012) Clinical and second-look arthroscopic study comparing 2 tibial landmarks for tunnel insertions during double-bundle ACL reconstruction with a minimum 2-year follow-up. Am J Sports Med 40:2479–2486

    Article  PubMed  Google Scholar 

  26. Papalia R, Franceschi F, Vasta S, Di Martino A, Maffulli N, Denaro V (2012) Sparing the anterior cruciate ligament remnant: Is it worth the hassle? Br Med Bull 104:91–111

    Article  PubMed  Google Scholar 

  27. Papalia R, Franceschi F, Zampogna B, Tecame A, Maffulli N, Denaro V (2014) Surgical management of partial tears of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 22:154–165

    Article  PubMed  Google Scholar 

  28. Segawa Y, Muneta T, Makino H, Nimura A, Mochizuki T, Ju YJ et al (2009) Mesenchymal stem cells derived from synovium, meniscus, anterior cruciate ligament, and articular chondrocytes share similar gene expression profiles. J Orthop Res 27:435–441

    Article  PubMed  CAS  Google Scholar 

  29. Sonnery-Cottet B, Bazille C, Hulet C, Colombet P, Cucurulo T, Panisset JC et al (2014) Histological features of the ACL remnant in partial tears. Knee 21:1009–1013

    Article  PubMed  Google Scholar 

  30. Sonnery-Cottet B, Colombet P (2016) Partial tears of the anterior cruciate ligament. Orthop Traumatol Surg Res 102:S59–S67

    Article  PubMed  CAS  Google Scholar 

  31. Takahashi T, Kondo E, Yasuda K, Miyatake S, Kawaguchi Y, Onodera J et al (2016) Effects of remnant tissue preservation on the tendon graft in anterior cruciate ligament reconstruction: a biomechanical and histological study. Am J Sports Med 44:1708–1716

    Article  PubMed  Google Scholar 

  32. Tibor L, Chan PH, Funahashi TT, Wyatt R, Maletis GB, Inacio MC (2016) Surgical technique trends in primary ACL reconstruction from 2007 to 2014. J Bone Joint Surg Am 98:1079–1089

    Article  PubMed  Google Scholar 

  33. Tie K, Chen L, Hu D, Wang H (2016) The difference in clinical outcome of single-bundle anterior cruciate ligament reconstructions with and without remnant preservation: a meta-analysis. Knee 23:566–574

    Article  PubMed  Google Scholar 

  34. Tonin M, Saciri V, Veselko M, Rotter A (2001) Progressive loss of knee extension after injury. Cyclops syndrome due to a lesion of the anterior cruciate ligament. Am J Sports Med 29:545–549

    Article  PubMed  CAS  Google Scholar 

  35. Trocan I, Ceausu RA, Jitariu AA, Haragus H, Damian G, Raica M (2016) Healing potential of the anterior cruciate ligament remnant stump. In Vivo 30:225–230

    PubMed  Google Scholar 

  36. Wu B, Zhao Z, Li S, Sun L (2013) Preservation of remnant attachment improves graft healing in a rabbit model of anterior cruciate ligament reconstruction. Arthroscopy 29:1362–1371

    Article  PubMed  Google Scholar 

  37. Zhang S, Matsumoto T, Uefuji A, Matsushita T, Takayama K, Araki D et al (2015) Anterior cruciate ligament remnant tissue harvested within 3-months after injury predicts higher healing potential. BMC Musculoskelet Disord 16:390

    Article  PubMed  PubMed Central  CAS  Google Scholar 

Download references

Acknowledgements

This study was supported by grants from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute.

Author information

Authors and Affiliations

  1. Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea

    Bo Hyun Kim, Ki Woung Lee, Myung Chul Lee & Hyuk Soo Han

  2. Kangnam Sacred Heart Hospital, 1 Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea

    Joong Il Kim

  3. Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Republic of Korea

    Osung Lee

Authors
  1. Bo Hyun Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joong Il Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Osung Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ki Woung Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Myung Chul Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hyuk Soo Han
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

BHK collected data, performed statistical analysis, interpreted data, and drafted the manuscript. JIK participated in collection and interpretation of data. OL and KWL participated in data collection. MCL participated in the study design and performed all surgeries. HSH participated in the design of the study and proofread the manuscript as the corresponding author. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hyuk Soo Han.

Ethics declarations

Conflict of interest

The authors have no competing interests to declare.

Funding

This study was funded by the Ministry of Health and Welfare, Republic of Korea (HI14C3339).

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This retrospective study was conducted after the approval by the institutional review boards of Seoul National University Hospital.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kim, B.H., Kim, J.I., Lee, O. et al. 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, 2345–2352 (2018). https://doi.org/10.1007/s00167-017-4683-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-017-4683-7

Keywords

Search

Navigation