Evaluation parameters of graft maturation on second-look arthroscopy following anterior cruciate ligament reconstruction: a systematic review

Purpose To compare the midterm clinical outcomes of diferent meniscal surgeries in patients undergoing anatomic doublebundle anterior cruciate ligament reconstruction (DB-ACLR) with eight strands of hamstring (HT8) autografts and explore the potential predictive risk factors for residual knee laxity. Methods From 2010 to 2017, a total of 410 patients who underwent anatomic trans-tibial DB-ACLR with HT8 autografts (169 patients without meniscal surgery, 105 patients with meniscal repair, and 136 patients with meniscal resection) were included in this study. The equivalent graft diameter was introduced to make the total graft size of DB-ACLR comparable with that of single-bundle ACLR and calculated as the square root of the quadratic sum of the diameter for each bundle. Residual laxity was deined as excessive anterior tibial translation or residual pivot shift at any follow-up visit, while graft rupture was conirmed by second-look arthroscopy or magnetic resonance imaging. ResultsThe mean follow-up period was 8.3 ± 2.2 years. The mean equivalent graft diameter was 9.9 ± 0.7 mm. Graft rupture was conirmed in 16 (3.9%) patients, while residual laxity was detected in 72 (17.6%) patients (34 [25.0%] in the meniscal resection group vs. 22 [13.0%] in the no meniscal surgery group, p = 0.021). In the multivariate logistic regression analysis, high-grade preoperative knee laxity (odds ratio OR 2.04, p = 0.020), equivalent graft diameter < 9 mm (OR 3.31 compared with 9-10 mm, p = 0.012; OR 3.28 compared with ≥ 10 mm, p = 0.019), and meniscal resection (OR 1.94 compared with no meniscal surgery, p = 0.045) were associated with residual laxity. Conclusion During a midterm follow-up, meniscal resection increased the risk of residual knee laxity even in patients undergoing anatomic DB-ACLR with HT8 autografts. Increasing the hamstring graft diameter and preserving the menisci are important strategies for ACLR to restore knee stability. Level of evidence Level III.

Section: Methodsmentioning

confidence: 99%

“…For arthroibrosis, symptomatic meniscal tears, and demands for ACL revision surgery, the second-look arthroscopy may be performed earlier if requested. Two independent surgeons evaluated both AMB and PLB grafts respectively with regard to graft continuity, graft tension, and synovial coverage [41].…”

Section: Second-look Arthroscopymentioning

confidence: 99%

Meniscal resection increases the risk of residual knee laxity even in patients undergoing anatomic double-bundle anterior cruciate ligament reconstruction with eight strands of hamstring autografts

et al. 2022

“…The hind limb was dissected to examine graft maturation. A scoring system was devised based on parameters used at second-look arthroscopy [ 9 ]. A category for synovial sealing at the tunnel apertures was added based on a previously reported scoring system [ 25 ].…”

Section: Methodsmentioning

confidence: 99%

Mesenchymal stromal cells and platelet-rich plasma promote tendon allograft healing in ovine anterior cruciate ligament reconstruction

Hexter

Sanghani-Kerai

Heidari

et al. 2020

Purpose The effect of bone marrow mesenchymal stromal cells (BMSCs) and platelet-rich plasma (PRP) on tendon allograft maturation in a large animal anterior cruciate ligament (ACL) reconstruction model was reported for the first time. It was hypothesised that compared with non-augmented ACL reconstruction, BMSCs and PRP would enhance graft maturation after 12 weeks and this would be detected using magnetic resonance imaging (MRI). Methods Fifteen sheep underwent unilateral tendon allograft ACL reconstruction using aperture fixation and were randomised into three groups (n = 5). Group 1 received 10 million allogeneic BMSCs in 2 ml fibrin sealant; Group 2 received 12 ml PRP in a plasma clot injected into the graft and bone tunnels; and Group 3 (control) received no adjunctive treatment. At autopsy at 12 weeks, a graft maturation score was determined by the sum for graft integrity, synovial coverage and vascularisation, graft thickness and apparent tension, and synovial sealing at tunnel apertures. MRI analysis (n = 2 animals per group) of the signal–noise quotient (SNQ) and fibrous interzone (FIZ) was used to evaluate intra-articular graft maturation and tendon–bone healing, respectively. Spearman’s rank correlation coefficient (r) of SNQ, autopsy graft maturation score and bone tunnel diameter were analysed. Results The BMSC group (p = 0.01) and PRP group (p = 0.03) had a significantly higher graft maturation score compared with the control group. The BMSC group scored significantly higher for synovial sealing at tunnel apertures (p = 0.03) compared with the control group. The graft maturation score at autopsy significantly correlated with the SNQ (r = − 0.83, p < 0.01). The tunnel diameter of the femoral tunnel at the aperture (r = 0.883, p = 0.03) and mid-portion (r = 0.941, p = 0.02) positively correlated with the SNQ. Conclusions BMSCs and PRP significantly enhanced graft maturation, which indicates that orthobiologics can accelerate the biologic events in tendon allograft incorporation. Femoral tunnel expansion significantly correlated with inferior maturation of the intra-articular graft. The clinical relevance of this study is that BMSCs and PRP enhance allograft healing in a translational model, and biological modulation of graft healing can be evaluated non-invasively using MRI.

“…According to second‐look arthroscopic reports comparing BTB and HT [2, 23, 31], Ahn et al found that HT showed better synovial coverage than BTB, and Mae et al demonstrated that BTB was significantly superior to HT in anatomical ACLR. Kim et al reported no significant difference between the two groups in a systematic review, although all studies reported that there was no correlation between second‐look findings and patient‐reported outcomes.…”

Section: Introductionmentioning

confidence: 99%

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

Fukuda

Ogura

Asai

et al. 2021

Purpose The primary purpose of this study was to evaluate the second-look arthroscopic indings 1 year postoperatively and magnetic resonance imaging (MRI) indings 2 years after anterior cruciate ligament reconstruction (ACLR) using bonepatellar tendon-bone autograft (BTB) or hamstring tendon autograft (HT). Secondary purpose included clinical results from physical examination, including range of motion, Lachman test, pivot shift test, and knee anterior laxity evaluation, and the clinical score for subjective evaluations at 2 years after surgery. Methods Between 2015 and 2018, 75 patients with primary ACL injuries were divided into either the BTB group (n = 30) or HT group (n = 45). When using HT, an anatomical double-bundle ACLR was performed. BTB was indicated for athletes with suicient motivation to return to sporting activity. Graft maturation on second-look arthroscopy was scored in terms of synovial coverage and revascularization. All participants underwent postoperative MRI evaluation 2 years postoperatively. The signal intensity (SI) characteristics of the reconstructed graft were evaluated using oblique axial proton density-weighted MR imaging (PDWI) perpendicular to the grafts. The signal/noise quotient (SNQ) was calculated to quantitatively determine the normalized SI. For clinical evaluation, the Lachman test, pivot shift test, KT-2000 evaluation, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were used. Results Arthroscopic indings showed that the graft maturation score in the BTB group (3.6 ± 0.7) was signiicantly greater than that in the anteromedial bundle (AMB; 2.9 ± 0.2, p = 0.02) and posterolateral bundle (PLB; 2.0 ± 0.9, p = 0.001) in the HT group. The mean MRI-SNQs were as follows: BTB, 2.3 ± 0.5; AMB, 2.9 ± 0.9; and PLB, 4.1 ± 1.1. There were signiicant diferences between BTB, AMB, and PLB (BTB and AMB: p = 0.04, BTB and PLB: p = 0.003, AMB and PLB: p = 0.03). Second-look arthroscopic maturation score and MRI-SNQ value signiicantly correlated for BTB, AMB, and PLB. No signiicant diferences were detected in clinical scores. There was a signiicant diference (p = 0.02) in the knee laxity evaluation (BTB: 0.9 ± 1.1 mm; HT: 2.0 ± 1.9 mm). Conclusion BTB maturation is superior to that of double-bundle HT based on morphological and MRI evaluations following anatomical ACLR, although no signiicant diferences were found in clinical scores. Regarding clinical relevance, the advantages of BTB may help clinicians decide on using the autograft option for athletes with higher motivation to return to sporting activity because signiicant diferences were observed in morphological evaluation, MRI assessment, and knee anterior laxity evaluation between BTB and double-bundle HT. Level of evidence Level IV.