Korean J Radiol.  2016 Dec;17(6):919-930. 10.3348/kjr.2016.17.6.919.

Postoperative Evaluation after Anterior Cruciate Ligament Reconstruction: Measurements and Abnormalities on Radiographic and CT Imaging

• Kim M
• Choi YS
• Kim H
• Choi NH

• KMID: 2466289
• DOI: http://doi.org/10.3348/kjr.2016.17.6.919

Abstract

Reconstruction of a ruptured anterior cruciate ligament (ACL) is a well-established procedure for repair of ACL injury. Despite improvement of surgical and rehabilitation techniques over the past decades, up to 25% of patients still fail to regain satisfactory function after an ACL reconstruction. With development of CT imaging techniques for reducing metal artifacts, multi-planar reconstruction, and three-dimensional reconstruction, early post-operative imaging is increasingly being used to provide immediate feedback to surgeons regarding tunnel positioning, fixation, and device placement. Early post-operative radiography and CT imaging are easy to perform and serve as the baseline examinations for future reference.

Keyword

Anterior cruciate ligament; Reconstruction; Radiograph; CT; Knee; Postoperative

MeSH Terms

Anterior Cruciate Ligament/*diagnostic imaging
Anterior Cruciate Ligament Injuries/diagnostic imaging/*surgery
Anterior Cruciate Ligament Reconstruction/*methods
Humans
Postoperative Care
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Schematic drawing of ACL bundles in flexed knee. Anteromedial (AM) bundle includes fascicles attached to proximal part of femoral attachment site and to anteromedial aspect of tibial attachment. Posterolateral (PL) bundle consists of fascicles attached to femur distally and to tibia posterolaterally. If knee is extended, PL bundle is taut and has appearance of being flat and broad. On contrary, when knee is flexed, AM bundle becomes taut. ACL = anterior cruciate ligament, L = lateral, M = medial

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  Fig. 2 Illustrations of anteroposterior view of knee showing technique for single bundle (A) and double bundle reconstruction (B) of ACL. ACL = anterior cruciate ligament, AM = anteromedial bundle, L = lateral, M = medial, PL = posterolateral bundle

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  Fig. 3 Tunnel position after double-bundle ACL reconstruction reflects natural course of two ACL bundles. A. Anteroposterior radiograph showing greater proximal and anterior course of anteromedial (AM) graft (1-o'clock), as compared to posterolateral (PL) graft (2-o'clock) on lateral femoral condyle. B. On oblique radiograph, AM bundle tunnel shows more anterior course than PL bundle tunnel. ACL = anterior cruciate ligament

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  Fig. 4 Terms and directions used in anatomy and radiology (A) and terms and directions used in surgery (B). drawing of eye in (B) represents view in surgery.

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  Fig. 5 Normal femoral tunnel position. A. Use of Bernhard and Hertel grid to assess femoral tunnel placement. a = Blumensaat's line: tangent to roof of intercondylar notch, b = Parallel to Blumensaat's line and tangent to inferior border of condyle, c = Perpendicular to Blumensaat's line, at intersection of tangent line with deep border of lateral femoral condyle, d = Perpendicular to Blumensaat's line, at intersection of tangent line with shallow border of lateral femoral condyle. Dotted circle = ideal location, 27% deep-shallow and 34% high-low. B. Angle measurement of femoral tunnel to femur on coronal CT image using picture archiving and communication system software.

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  Fig. 6 Normal tibial tunnel position. A. Tibial tunnel (white arrow) is placed at site of tibial footprint; black arrow indicates tibial spine. B. Tibial tunnel (arrow) enters intercondylar notch, in between tibial spines on coronal CT. C. Schematic drawing of lateral view of knee shows intercondylar portion of graft is oriented taut and parallel to or steeper than Blumensaat's line (black line), and entire tunnel is positioned posterior to line extended along Blumensaat's line. Anterior-posterior position of tibial tunnel as ratio is also depicted. Most anterior vertical line indicates 0% and most posterior vertical line, 100% on Amis and Jakob line (black double arrows), respectively. Position of center of ACL tibial insertion (red double arrows) should lie between 27 and 60% along Amis and Jakob line. ACL = anterior cruciate ligament

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  Fig. 7 Angular measurement of tibial tunnel. A. Angle of tibial tunnel with transtibial technique. Angle should not exceed 72°. B. Example of too steep tibial tunnel. Tibial tunnel angle of ≥ 72° is associated with greater loss of flexion and anterior laxity. In this case, angle of tibial tunnel was 75°.

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  Fig. 8 Normal femoral and tibial tunnels on multiplanar reformat CT images. Oblique coronal multiplanar reformat images aligned along axes of femoral (A) and tibial (B) tunnels clearly demonstrate entire course and width (double arrows) of both tunnels with parallel walls.

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  Fig. 9 Schematic drawing of kinematics of graft on flexion (A) and extension (B). Red line demonstrates taut graft in too shallow and too high placed tunnels. If tunnel placement is too high (blue line), graft will be over stretched in extension and may reduce range of motion. Optimal graft placement is indicated with black lines.

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  Fig. 10 Example of tibial tunnel positioned too anteriorly. Sagittal CT image reveals tibial tunnel is drilled anterior to Blumensaat's line (white line). Greater anterior placement of tibial tunnel will cause impingement of graft during extension. Note fracture (arrows) in roof of tibial tunnel on sagittal (A) and axial (B) images.

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  Fig. 11 Migration of button style extra-cortical fixation device. Images obtained immediately (A) and 6 months after surgery (B) show mild sliding of EndoButton fixation device into femoral tunnel (arrows).

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  Fig. 12 Gap between fixation device and bone cortex. On axial and coronal post-operative CT scans, gap is seen (arrows) between cortex and fixation device, caused by tissue interposition

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  Fig. 13 Migration of bioabsorbable interference screws. Compared to that seen on radiograph obtained immediately after surgery (A), tibial fixation screw (arrow) can be seen protruding into anterior knee on radiograph obtained on 6-month follow-up (B). It is easily overlooked, as bioabsorbable screws are radiolucent.

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  Fig. 14 Tunnel widening. Early post-operative baseline image (A), and that 2 years after surgery (B) displaying widening and loss of parallelism (> 2 mm widening) of femoral tunnel (dotted lines).

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  Fig. 15 Post-operative CT scan shows intramuscular location of screw tip. Patient had popliteal area pain 3 months after surgery and fixator was removed.

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