J Korean Orthop Assoc.  2015 Dec;50(6):501-512. 10.4055/jkoa.2015.50.6.501.

Comparison of Magnetic Resonance Imaging of Remnant Preserving versus Remnant Sacrificing Technique after Anterior Cruciate Ligament Reconstruction; Clinical Results and Second-Look Arthroscopic Findings: Pilot Study

• Lee BI
• Kim BM
• Kho DH
• Kwon SW
• Kim HB

• KMID: 2185091
• DOI: http://doi.org/10.4055/jkoa.2015.50.6.501

Abstract

PURPOSE
The purpose of this study was to clarify the difference between the remnant-preserving and remnant-sacrificing techniques in anterior cruciate ligament (ACL) reconstruction using stress test, functional score, 2nd look arthroscopy and magnetic resonance imaging (MRI).
MATERIALS AND METHODS
Among 66 patients having anatomical ACL reconstruction with the fourstrand hamstring autograft using outside-in technique (FlipCutter(R)) for the femoral tunnel from April 2012 to April 2014, 23 patients who underwent 2nd look arthroscopy and MRI were included. The remnant-preserving group included 12 patients and the remnant-sacrificing group included 11 patients. The two groups were compared and analyzed with regard to stability (Stress test using GNRB(R), pivot shift test), functional assessment (International Knee Documentation Committee [IKDC] scale, Lysholm score, one leg hoop test), and the result of second-look arthroscopy and signal to noise quotient (SNQ) ratio of the graft in MRI.
RESULTS
The two groups did not differ significantly in the stability test, IKDC scale, and Lysholm test. The remnant-preserving group showed significant improvement in one leg hoop test compared with the remnant-sacrificing group (p<0.05). The SNQ ratio of the grafted tendon in the remnant-preserving group was significantly lower than those in the remnant-sacrificing group in all regions (p<0.05). In second-look arthroscopy, no significant difference in tension, synovialization, and status of the bundle was observed between the two groups. The grade of synovialization and the status of the bundle in second-look arthroscopy did not influence the signal intensity of the graft in MRI (p>0.05).
CONCLUSION
More than 12 months after surgery, the graft of the remnant-preserving group showed lower signal intensity compared to that of the remnant-sacrificing group by MRI evaluation. The remnant preserving technique has biological difference compared with the remnant sacrificing technique in human study.

Keyword

anterior cruciate ligament; anterior cruciate ligament reconstruction; remnant preserving technique; ligamentization; magnetic resonance imaging

MeSH Terms

Anterior Cruciate Ligament Reconstruction*
Anterior Cruciate Ligament*
Arthroscopy
Autografts
Exercise Test
Humans
Knee
Leg
Magnetic Resonance Imaging*
Noise
Pilot Projects*
Tendons
Transplants

Figure

• 

  Figure 1 Passage of grafted tendon. Leading sutures lay inside the anterior cruciate ligament (ACL) stump; pictorial description (A), arthroscopic finding (B). After the grafted tendon was passed, it lay inside the center of the ACL stump with circular synovial coverage of its major part.

• 

  Figure 2 Findings of a second look arthroscopy. Tensions of reconstructed grafts were evaluated subjectively with meticulous probing and it was graded as good, fair, and poor. Good tension was graded if tautness was felt. Fair was graded if the tension was slightly lax, but acceptable. Poor was graded if there was no firm tension. Synovial coverage of the reconstructed graft was graded as 'good' when the synovium covered the entire lengths of the graft, 'fair' when synovial coverage was incomplete, and 'poor' when the synovium covered less than half the lengths of the graft. Status of the fiber bundle was designated as 'good' in case where we could not see the fiber of the graft, 'fair' in case where we could see the fiber but it was not ruptured, 'poor' in case where we could see the fiber but it was ruptured.

• 

  Figure 3 Postoperative sagittal oblique plan, proton density magnetic resonance image of the knee shows the positions of the 5 regions of interest, which included a distal third (1), middle third (2), proximal third (3), quadriceps tendon (4), and 2 cm anterior to the patellar tendon (5).

• 

  Figure 4 Comparison of second look arthroscopic findings between the remnant preserving group and the remnant sacrificing group. (A, B) Second look arthroscopy in the remnant sacrificing group showed thin, pale and hypovascular synovial membrane. (C, D) Second look arthroscopy in the remnant preserving group showed thick and hypervascular synovial membrane like normal synovial membrane of the anterior cruciate ligament.

• 

  Figure 5 Comparison of magnetic resonance imaging (MRI) findings. Sagittal oblique proton density MRI image showed low signal intensity in the graft of the remnant sacrificing group (A) and the remnant preserving group (B). The signal intensity in the remnant preserving group was lower than the signal intensity in the remnant sacrificing group. The remnant tissue of the anterior cruciate ligament was observed in the remnant preserving group.

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