Hamstring grafts for anterior cruciate ligament reconstruction show better magnetic resonance features when tibial insertion is preserved

Grassi, Alberto; Casali, Marco; Macchiarola, Luca; Lucidi, Gian Andrea; Cucurnia, Ilaria; Filardo, Giuseppe; Lopomo, N.; Zaffagnini, Stefano

doi:10.1007/s00167-020-05948-z

Cited by 14 publications

(17 citation statements)

References 43 publications

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“…Our findings with an aST graft are consistent with results of attached hamstring grafts. 20,28,46 However, our SNQ values cannot be compared with those of other studies as this parameter is highly dependent on the MRI system and software used. The same goes for all MRI criteria using graft signals.…”

Section: Discussionmentioning

confidence: 99%

“…In a randomized controlled study, Liu et al 28 found that the mean intra-articular SNQ was significantly lower at 6 months (14.9 vs 25.6; P = .002) and 12 months (12.6 vs 18.3; P = .02) after ACL reconstruction. Recently, Grassi et al 20 compared the mean SNQ of the graft inside the tibial tunnel at 18 months between single-strand attached hamstring tendons with lateral reconstruction and a standard 4-bundle hamstring graft. The results also favored the distally attached technique with a lower mean SNQ value (0.15 vs 1.61; P = .015).…”

Section: Discussionmentioning

confidence: 99%

“…This is consistent with published studies of hamstring grafts. 20,21,28,41,46,47,54,57 It is difficult to show a statistically significant difference in the functional outcomes between different techniques because the results are so good with these techniques to start with. 4,30,34,49 Putnis et al 45 showed an association between a high signal intensity ratio (SIR) on MRI scans at 1 year and the graft retear rate.…”

Section: Discussionmentioning

confidence: 99%

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Preserving the Semitendinosus Distal Attachment Is Associated With Improved Graft Remodeling After ACL Reconstruction

Cavaignac

Vari²,

Marot

et al. 2023

Am J Sports Med

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Background: The semitendinosus (ST) tendon can be used by itself as a graft for anterior cruciate ligament (ACL) reconstruction. An increasing number of these procedures are being done while preserving the ST's tibial attachment, but there are no data on the remodeling of an attached ST (aST) graft. Purpose: To compare graft remodeling on magnetic resonance imaging (MRI) scans at 1 year after ACL reconstruction between standard free ST graft and aST graft. Study design: Cohort study; Level of evidence, 3. Methods: This prospective study enrolled 180 patients who were undergoing ACL reconstruction: 90 with the ST graft and 90 with the aST graft. The analysis was performed 1 year after the surgery. The main endpoint was the signal-to-noise quotient (SNQ) on MRI scans (T1-weighted sequence). The secondary endpoints were tibial tunnel widening (TTW), graft maturation (Howell classification), retear rate, new surgery rate, Simple Knee Value, Lysholm score, International Knee Documentation Committee (IKDC) score, postoperative Tegner score, difference between pre- and postoperative Tegner scores, ACL–Return to Sport after Injury (ACL-RSI), return-to-sports rate, and time to return to sports. Results: The mean adjusted SNQ was 1.18 (95% CI, 0.72-1.65) in the aST group and 3.88 (95% CI, 3.42-4.34) in the ST group ( P < .001). The new surgery rate was 2.2% in the aST group and 10% in the ST group ( P = .029). The median Lysholm score was significantly higher in the aST group (99; interquartile range [IQR], 95-100) than in the ST group (95; IQR, 91-99) ( P = .004). The mean time to return to sports was significantly shorter in the aST group (248.73 ± 141.62 days) than the ST group (317.23 ± 144.69 days) ( P = .002). No statistically significant difference was found between groups in the TTW ( P = .503), Howell graft maturity grade ( P = .149), retear rate ( P > .999), Simple Knee Value ( P = .061), postoperative Tegner score ( P = .320), pre- to postoperative difference in Tegner score ( P = .317), ACL-RSI ( P = .097), IKDC score ( P = .621), and return-to-sports rate ( P > .999). Conclusion: At 1 year postoperatively, remodeling of an ST graft assessed using MRI is better when its distal attachment is left intact.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Preserving the Semitendinosus Distal Attachment Is Associated With Improved Graft Remodeling After ACL Reconstruction

Cavaignac

Vari²,

Marot

et al. 2023

Am J Sports Med

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“…On the contrary, the integration of the graft in the tibial tunnel did not differ significantly between both groups. Similarly, a pedunculated hamstring "over-the-top" reconstruction combined with lateral plasty showed significantly better intraarticular features of the graft compared to the conventional hamstring reconstructions [28]. Moreover, the authors also confirmed significantly lower tibial tunnel enlargement in the pedunculated group.…”

Section: Preservation Of Hamstrings Tibial Insertionmentioning

confidence: 77%

Maturation of Anterior Cruciate Ligament Graft—Possibilities of Surgical Enhancement: What Do We Know So Far?

Ebisz¹,

Góralczyk

Mostowy

et al. 2021

Applied Sciences

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The purpose of this study is to review the surgical methods of enhancing anterior cruciate ligament (ACL) graft maturation. Several methods of ACL maturation enhancement were identified through research of the literature available in the PubMed database. ACL remnant preservation was the most extensively investigated technique. ACL reconstruction with a pedunculated hamstring graft provides superior revascularization of the graft along with higher mechanical strength. The usage of a graft enveloped with a periosteum was proposed to enhance the tendon-bone unit formation, and consequently, to prevent the bone tunnel widening. The muscle tissue on the graft is a potential source of stem cells. However, an excessive amount may weaken whole graft strength despite its enhanced remodeling. Similarly, amniotic tissue may augment the ACL reconstruction with stem cells and growth factors. Despite the existence of several surgical techniques that utilize amnion, the outcomes of these augmentation methods are lacking. Lastly, the intra-articular transplantation of the synovium on the surface of an ACL was proposed to augment the graft with synovial tissue and blood vessels. In conclusion, diverse approaches are being developed in order to enhance the maturation of an ACL reconstruction graft. Although these approaches have their foundation in on well-established scientific research, their outcomes are still equivocal. Clinical trials of high quality are needed to evaluate their utility in clinical practice.

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“…15 The concept that the blood supply at the tibial aperture is important for overall graft healing is supported by evidence that hamstring tendon grafts show less high-signal fluid on MRI at 4 and 18 months when the tibial pes anserinus insertion is preserved and that by 18 months the tibial tunnel area is reduced alongside lower graft signal. 6 In a further study directly comparing distal hamstring attachment sparing or detachment, serial MRI measurements revealed a significant increase in graft signal at 6 and 12 months for detached grafts. Interestingly and importantly, this effect was not evident on the 24-month MRI scan in either cohort, suggesting significant changes in the graft throughout this time period.…”

Section: Discussionmentioning

confidence: 88%

Magnetic Resonance Imaging Assessment of Hamstring Graft Healing and Integration 1 and Minimum 2 Years after ACL Reconstruction

et al. 2022

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Background: An increase has been seen in the number of studies of anterior cruciate ligament reconstruction (ACLR) that use magnetic resonance imaging (MRI) as an outcome measure and proxy for healing and integration of the reconstruction graft. Despite this, the MRI appearance of a steady-state graft and how long it takes to achieve such an appearance have not yet been established. Purpose: To establish whether a hamstring tendon autograft for ACLR changes in appearance on MRI scans between 1 and 2 years and whether this change affects a patient’s ability to return to sports. Study Design: Case series; Level of evidence, 4. Methods: Patients with hamstring tendon autograft ACLR underwent MRI and clinical outcome measures at 1 year and at a final follow-up of at least 2 years. MRI graft signal was measured at multiple regions of interest using oblique reconstructions both parallel and perpendicular to the graft, with lower signal indicative of better healing and expressed as the signal intensity ratio (SIR). Changes in tunnel aperture areas were also measured. Clinical outcomes were side-to-side anterior laxity and patient-reported outcome measures (PROMs). Results: A total of 42 patients were included. At 1 year, the mean SIR for the graft was 2.7 ± 1.2. Graft SIR of the femoral aperture was significantly higher than that of the tibial aperture (3.4 ± 1.3 vs 2.6 ± 1.8, respectively; P = .022). Overall, no significant change was seen on MRI scans after 2 years; a proximal graft SIR of 1.9 provided a sensitivity of 96% to remain unchanged. However, in the 6 patients with the highest proximal graft SIR (>4) at 1 year, a significant reduction in signal was seen at final follow-up ( P = .026), alongside an improvement in sporting level. A significant reduction in aperture area was also seen between 1 and 2 years (tibial, –6.3 mm2, P < .001; femoral, –13.3 mm2, P < .001), which was more marked in the group with proximal graft SIR >4 at 1 year and correlated with a reduction in graft signal. The patients had a high sporting level; the median Tegner activity score was 6 (range, 5-10), and a third of patients scored either 9 or 10. Overall, PROMs and knee laxity were not associated with MRI appearance. Conclusion: In the majority of patients, graft SIR on MRI did not change significantly after 1 year, and a proximal graft SIR <2 was a sensitive indicator for a stable graft signal, implying healing. Monitoring is proposed for patients who have a high signal at 1 year (proximal graft SIR >4), because a significant reduction in signal was seen in the second year, indicative of ongoing healing, alongside an improvement in sporting level. A reduction in tunnel aperture area correlated with a reduction in graft SIR, suggesting this could also be a useful measure of graft integration.

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Hamstring grafts for anterior cruciate ligament reconstruction show better magnetic resonance features when tibial insertion is preserved

Cited by 14 publications

References 43 publications

Preserving the Semitendinosus Distal Attachment Is Associated With Improved Graft Remodeling After ACL Reconstruction

Preserving the Semitendinosus Distal Attachment Is Associated With Improved Graft Remodeling After ACL Reconstruction

Maturation of Anterior Cruciate Ligament Graft—Possibilities of Surgical Enhancement: What Do We Know So Far?

Magnetic Resonance Imaging Assessment of Hamstring Graft Healing and Integration 1 and Minimum 2 Years after ACL Reconstruction

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