The Egyptian Journal of Radiology and Nuclear Medicine (2016) 47, 521–529

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology and Nuclear Medicine

www.elsevier.com/locate/ejrnm
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ORIGINAL ARTICLE

MRI evaluation of the knee post double bundle

ACL reconstruction: Association of graft findings
and comparison with arthroscopy
Mohammed Farghally Amin a,*, Hoda Abd El Kareem b, Ahmed Fathy Sadek c,
Ahmed Nady Saleh c

a
Department of Radiology, Minia University, Egypt
b
Department of Radiology, South Valley University, Egypt
c
Department of Orthopaedic Surgery and Traumatology, Minia University, Egypt

Received 16 June 2015; accepted 1 February 2016

Available online 26 February 2016

KEYWORDS Abstract Purpose: To determine the association of graft complications after anterior cruciate
MRI; ligament reconstruction using double bundle graft by magnetic resonance imaging using
ACL; arthroscopy/surgery as a gold standard.
Graft; Patient and methods: A total of 126 patients (130 knees) with complete ACL tears were recruited
Reconstruction for this prospective study, and all patients subsequently underwent an MRI examination to evaluate
graft integrity and signal intensity.
Results: Out of 130 knees with ACL reconstruction, partial tears of the AM bundle were seen in
25 knees (19.2%) and complete tear of the AM bundle was seen in 26 (20%). Partial tears of the
PL bundle were seen in 35 knees (26.9%), and complete tears of the PL bundle in 31 knees
(23.8%). These patients’ signs of instability were noted in 2 patients with partial tear of PL bundle
and in 9 patients with complete tear of PL bundle.
Conclusion: Increased signal intensity within the anteromedial or posterolateral bundles of a dou-
ble bundle ACL reconstruction is frequently associated with a partial tear. Impingement of the
anteromedial graft is frequently associated with partial tear and increased signal intensity which
is proved by arthroscopy/surgery. A low incidence of other complications is seen.
Ó 2016 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

1. Introduction

* Corresponding author at: ElMinya High Road, ElMinya, Egypt. The anterior cruciate ligament (ACL) is the most commonly
Tel.: +20 102870909; fax: +20 862342505. injured ligament in the knee, resulting in a significant morbid-
E-mail address: [email protected] (M.F. Amin). ity most pronounced in the resulting sagittal plan instability.
Peer review under responsibility of The Egyptian Society of Radiology Anatomically ACL is divided into two distinct bundles namely
and Nuclear Medicine.
http://dx.doi.org/10.1016/j.ejrnm.2016.02.001
0378-603X Ó 2016 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
522 M.F. Amin et al.

anteromedial (AM) and posterolateral (PL). This anatomic 2. Patients and methods
distinction reflects their anatomic insertions on the tibia. The
AM bundle (which is more sagittal oriented) originates more Following approval by our center human ethical committee, a
proximally and anteriorly on the lateral femoral condyle than total of 126 patients (130 knees) who were diagnosed (based on
the PL bundle, and inserts anteromedially at the tibial foot clinical and radiological backgrounds) as having complete
print, whereas the PL bundle inserts into the tibia posterolat- ACL tears and either pain or limited extension were recruited
erally (1–3). When the knee is extended, the PL bundle for this prospective study between June 2010 and May 2014.
becomes 15% longer and the AM bundle becomes 30% short- The mean age of patients involved in this study was 35 years
ened while on knee flexion the reverse takes place. The PL bun- (range: 22–48). All patients underwent double bundle ACL
dle is also tightened during internal and external rotation of reconstruction, using a combination of B-PT-B and semitendi-
the tibia (4–6). This complex anatomic arrangement of the nosus grafts in 76 patients, and a combination of semitendi-
bundles allows the ACL to withstand axial stresses and tensile nosus and gracilis tendons in 50 patients.
forces on the knee, as one component of the ACL is taut and
therefore functional in any position of the knee (6). 2.1. Clinical diagnosis
During the past 3 decades, surgical reconstruction of ACL
has become an accepted treatment for symptomatic ACL defi-
ciency (7,8). The goal of surgery is to prevent joint instability All patients recruited for this study were clinically assessed for
with subsequent possible joint degeneration. general signs of infection, locking, giving way, history of
A variety of donor sites are available, including Bone- trauma or recreational activities. Examination was routinely
Patellar-Tendon-Bone graft (BPTB), combined semitendi- performed including inspection, palpation, ROM and special
nosus and gracilis hamstring tendons, and quadriceps tendon. tests with special emphasis on anterior drawer, lachman, pivot
In addition, the use of allograft (whether chemically treated, shift, and Mac Murray tests. In addition prearthroscopic eval-
irradiated or fresh frozen) or synthetic tapes represents other uation of anterior and side to side translation was performed.
available options. On the other hand, different methods of fix- All of these patients underwent double bundle ACL recon-
ation of the graft have been applied including interference struction surgery either open (33) or arthroscopic (97) else-
screws, suspensory devices (Endobutton), and cross pins (8) where and were evaluated by diagnostic arthroscopy by two
(Fig. 1). well experienced Knee surgeons (A.F.S. and A.N.S.). The clin-
ACL reconstruction is currently one of the most common ical diagnosis of post-reconstruction complications and the
surgical procedures in sports medicine and has yielded promis- treatment results were compared with MRI findings.
ing clinical results for patients with ACL injuries. However, a
substantial number of postoperative complications may occur 3. Diagnostic arthroscopy
after ACL reconstruction, including range of motion (ROM)
deficit, quadriceps weakness, and donor-site morbidity, partic- The procedure was performed via standard regime including
ularly after harvesting BPTB graft (9). the following.
Donor-site morbidity can manifest clinically as anterior After spinal anesthesia, the patient lay supine. A pneumatic
knee pain, donor-site tenderness, pain on kneeling, or sensory tourniquet was applied to the mid thigh and after standard
loss over the anterior knee. Of these, anterior knee pain is a scrubbing and draping; it was elevated to 150 mmHG above
frequent and important complication, with the potential to systolic blood pressure. A standard anterolateral portal was
impede rehabilitation and return to sports activity (10). established 1 cm proximal to the joint line and 1 cm lateral
Magnetic resonance (MR) imaging is the preferred to the patellar tendon. A standard screening of the knee joint
advanced imaging modality for the evaluation of symptomatic was performed beginning at the suprapatellar pouch, the patel-
ACL graft reconstructions (1), and can help aid preoperative lofemoral joint, the lateral gutter, and the medial gutter during
planning (10,11). full extension of the knee. On 90 degree flexion the medial joint
The aim of this study was to determine the association of compartment including the medial capsule, the coronary liga-
graft complications after ACL reconstruction using double ment, and the medial meniscus was inspected. Then the scope
bundle graft by MRI compared to arthroscopy results. was pulled outward slowly to inspect the tibial insertion of the

Fig. 1 A diagram shows: single bundle ACL reconstruction (SB ACLR) (a), double bundle ACL reconstruction (DB ACLR).
MRI evaluation of the knee post double bundle ACL reconstruction 523

ACL graft, the femoral insertion, the intercondylar notch, and sagittal images) and uncovered posterior horn of lateral menis-
the degree of synovialization of the graft. The operated limb cus (a line drawn parallel to the posterior cortex of the lateral
was then put on figure-of-four position to facilitate inspection tibia intersects the posterior horn of lateral meniscus on sagit-
of the lateral compartment including the lateral joint capsule, tal images). A graft was considered disrupted when no intact
the lateral meniscus, and the popliteus tendon. Any possible fibers were seen and fluid signal was interposed between the
complication that was suspected either clinically or radiologi- torn ends (10–14). The graft was considered partially torn
cally was assessed and managed. Then the knee was irrigated when there was focal graft thinning compared to any detected
and the wound was sutured. A crepe bandage was applied segment of normal graft diameter (14).
and then the tourniquet was deflated. Images were also assessed for other complications including
cystic degeneration of the graft, roof impingement, and
3.1. MRI protocol arthrofibrosis. Cystic degeneration of the graft was defined
as a fluid collection within the graft (13), either within the
A postoperative follow-up MRI scan was obtained on all femoral tunnel, the intra-articular portion, or tibial tunnel.
patients at a mean of 34 months (range: 24–40) (39 patients Roof impingement of the graft was defined as contact of the
were presented with knee pain and 36 patients were presented impinged graft with the antero-inferior margin of the inter-
with limited mobility), and MRI was done using a 1.5 T Gyro- condylar roof and associated posterior bowing and SI alter-
scan Intera (Philips Medical Systems, Netherlands) and an ation of the graft (13,14). The presence or absence of
extremity coil. The knee was imaged at rest in the coil, with osteophytes in the femoral intercondylar notch was recorded.
approximately 8° of flexion. Arthrofibrosis was defined as the presence of scar tissue in
Sagittal proton density–weighted fast spin-echo (FSE) with the knee joint (13). Localized anterior arthrofibrosis, or a
fat saturation, coronal gradient-echo, and axial T2-weighted cyclops lesion, was defined as a nodular fibrous lesion in the
spin-echo (SE) sequences were acquired with the following anterior intercondylar notch (12). The integrity of the medial
parameters: TR/TE 3500–4467/65–70 ms; echo train length and lateral menisci, posterior cruciate ligament, lateral collat-
(ETL) 8; number of signals acquired NEX 3; receiver band- eral ligament (LCL), medial collateral ligament (MCL),
width ±31.25 kHz; acquisition time 5 min 10 s. Coronal STIR quadriceps and patellar tendons was also evaluated and graded
(TR/TE 3600–4100/84–88 ms; ETL 10; number of signals as normal, degenerated or thickened, partially torn, or torn.
acquired 2; acquisition time, 5 min 29 s; receiver bandwidth The severity of anterior knee pain (AKP) was classified into
±31.25 kHz) and intermediate-weighted (proton density) 3 stages: (I) pain after activity only; (II) pain during and after
FSE (2000–2300/14–18 ms; ETL 6; number of signals acquired activity, but still able to perform at a satisfactory level; and
2; acquisition time, 5 min 20 s; receiver bandwidth (III) pain during and after activity which is more prolonged
±41.67 kHz) sequences were performed. All sequences were and severe to the degree that hinders the patient from perform-
acquired using a 4-mm slice thickness, 256–512  192–256 ing at a satisfactory level.
matrix size, and 14 cm field of view.
3.3. Statistical analysis
3.2. MRI analysis
The data analysis was carried out using SPSS 14.0 statistical
All MR images were analyzed in consensus by two muscu- software. The statistical significance of association between
loskeletal radiologists (MA and HA) with both having 15 years MRI findings was calculated using the Fisher Exact Probabil-
of professional experience, and readers were blinded to clinical ity Test.
data. Evaluation concentrated on signal intensity within graft
fibers, graft orientation and graft continuity. More specifically, 4. Results
for each MR image plane, images were assessed for the follow-
ing primary signs: diffuse increased ACL graft signal intensity Thirty patients were symptomatic and out of 126, 21 were with
(SI), and the SI of the intra-articular portion of both grafts was anterior knee pain and 11 with limited extension of the knee.
analyzed as described by Howell (12). The intra-articular por- The imaging findings are listed in Table 1.
tion of the grafts was divided into proximal, middle, and distal
thirds, and location of focal increased graft signal if present 4.1. Graft SI
(proximal, middle, or distal) was analyzed. The SI was ana-
lyzed on PD-weighted and T2-weighted images and graded Graft SI in the AM bundle was normal in 97 of the 130 knees
on a scale with (I) being a normal SI similar to posterior cru- and increased in 33 knees (24.4%), grade II in 19 knees and
ciate ligament (PCL), (II) >50% of the graft having a normal grade III in 14 knees. SI in the PL bundle was normal in 40
SI, and (III) <50% of the graft having a normal SI. The grade knees and increased in 90 knees, grade II in 47 knees, and
IV by Howell (100% of the graft having an increased SI) was grade III in 43 knees (Fig. 1).
incorporated with grade III. When increased PD-weighted SI
and T2-weighted SI were also analyzed (10).
Graft orientation on sagittal images (either taut between 4.2. Graft disruption
femur and tibia, horizontal or lax), complete or partial ACL
graft discontinuity (anteromedial or posterolateral). Secondary Regarding prearthroscopic clinical evaluation, positive ante-
signs of ACL graft tear included the presence of anterior tibial rior drawer test was seen in 129 cases (30 cases grade I, 80 cases
translation (posterior cortex of mid lateral tibia translated grade II and 19 cases grade III). Out of 130 knees with ACL
>5 mm anterior to the posterior cortex of the femur on reconstruction, partial tears of the AM bundle were seen in
524 M.F. Amin et al.

Table 1 MRI findings of ACL graft. Table 2 Results of MRI and arthroscopy/surgery.
Finding Graft Diagnosis MRI Arthroscopy
AM PL Partial tear AM 25 22
Partial tear PL 35 31
Graft SI Normal 97 40
Complete tear AM 26 23
Grade II 19 47
Complete tear PL 31 29
Grade III 14 43
Both grafts complete tear 12 14
Graft Tear Partial 25 35
Impingement 15 15
Complete 26 31
Generalized arthrofibrosis 10 8
Both graft 12
Cyclops 8 11
Impingement 15
Displaced interference screws 5 –
Arthrofibrosis Focal (cyclops) 8
Ganglion cyst 6 –
generalized 10
Displaced interference 5
screws
Ganglion cyst 6
Infection 1 Table 3 The diagnostic value of MRI of the knee in
Widening of the tunnel 2 evaluation of partial AM bundle tear.
Sensitivity 95.66
Specificity 97.22
NPV 99.09
25 knees (19.2%) and complete tear was seen in 26 knees PPV 88
(20%). Partial tears of the PL bundle were seen in 35 knees
(26.9%), and complete tears in 31 knees (23.8%).
Both AM and PL bundles were completely torn in 12 knees
(9.2%) (Fig. 2). These 12 patients had anterior knee pain and Table 4 The diagnostic value of MRI of the knee in
limited knee extension; all of these patients have positive sec- evaluation of partial PL bundle tear.
ondary signs of incompetent ACL. They denied any history
of trauma. Sensitivity 93.99
Specificity 95.83
Regarding diagnostic arthroscopy results, partial tears of
NPV 95.87
the AM bundle were seen in 22 knees (16.9%) and complete PPV 88.57
tear of the AM bundle was seen in 23 knees (17.6%). Partial
tears of the PL bundle were seen in 31 knees (23.8%), and
complete tears of the PL bundle in 29 knees (22.3%). Both
AM and PL bundles were completely torn in 14 knees (10.7%). Graft impingement was seen in 15 knees (11.5%). No
Sensitivity, specificity, NPV and PPV are shown in Tables impingement of the PL bundle was noted (Fig. 3) (Table 1).
2–7. Generalized arthrofibrosis was seen in 10 knees (7.6%) and 8

Fig. 2 (a and b) Sagittal PD with fat saturation MR images in a 40-year-old male shows a large amount of increased striated and
globular signal intensity within the ACL graft (white arrow in (a and b)) involving more than 50% of the cross-sectional area of the graft.
MRI evaluation of the knee post double bundle ACL reconstruction 525

Table 5 The diagnostic value of MRI of the knee in

evaluation of complete AM bundle tear.
Sensitivity 95.83
Specificity 97.12
NPV 99.02
PPV 88.46

Table 6 The diagnostic value of MRI of the knee in

evaluation of complete PL bundle tear.
Sensitivity 90.62
Specificity 98
NPV 97.03
PPV 93.55

Table 7 The diagnostic value of MRI of the knee in

evaluation of complete tear of both bundles.
Sensitivity 82.35 Fig. 4 Sagittal PD MR image in a 32-year-old male shows graft
Specificity 100 impingement against the roof of the intercondylar region
NPV 97.46 (Blumensaat’s line) with increased signal intensity within the graft
PPV 100 Grade III.

tunnels was seen in 2 knees, one of them 12 month post-

(6.2%) of them only proved by arthroscopy, while localized surgery and the other 10 months post-surgery related to cystic
cyclops lesion was seen in 8 knees (Fig. 5); 11 lesions were or mucoid degeneration of graft.
proved by arthroscopy (see Fig. 4 and Table 8). Lateral collateral ligament sprains were seen in 2 knees
Ganglion cyst related to the graft in the tibia was seen in 6 (grade 2). Increased signal intensity was seen within the patel-
knees, closely related to the tibial tunnel (Fig. 6). Displaced lar tendon in 3 knees, all of whom had graft harvest from the
interference screws were seen in 5 knees (Fig. 7). Imaging fea- patellar tendon. Marginal and intercondylar osteophytes were
tures compatible with septic arthritis were seen in one knee of a seen in 4 patients. The posterior cruciate ligament and
known diabetic patient. Widening of the femoral and tibial quadriceps tendon were normal in all patients.

Fig. 3 (a) Sagittal PD and (b) Coronal STIR MR images in a 37-year-old female show disruption of both grafts, white arrow in a shows
remnant of AM graft.
526 M.F. Amin et al.

Table 8 Incidence of different rupture patterns of anterome-

dial (AM) and posterolateral (PL) grafts.
AM graft PL graft Total
Normal Partial Tear Complete tear
Normal 81 10 13 104
Partial tear 3 93 2 14
Complete tear 3 3 6 12
Total 87 22 21 130

4.3. Associations between MRI graft findings

The SI in intact ACL grafts and partially ruptured AM or PL

bundles was evaluated in each knee (Tables 2 and 3). The SI
was increased in 12 of the 22 patients (54%) with a partial rup-
ture of the AM bundle and in 28 out of 85 patients (42%) with
an intact AM bundle (p = 0.013). SI in the PL bundle was
increased in 28 of 31 patients with a partial rupture (90%)
and 22 of 70 patients with an intact graft (31%) (p = 0.001).
Of the 15 patients with graft impingement, a partial tear of
the AM graft was seen in 7 patients (p = 0.0165), and
increased SI was seen in the AM bundle in 5 patients and
PL bundle in 2 patients.

5. Discussion Fig. 6 Sagittal PD MR image in a 34-year-old male shows a

ganglion cyst related to the graft in the tibia with internal
The number of double bundle (anatomic) graft ACL recon- septation.
structions has increased in recent years because such procedure
results in better rotational stability than traditional single
bundle graft ACL reconstruction with fewer graft failures MRI evaluation of traditional SB ACL graft reconstruction
(15–18). This was shown in a recent review of 14 randomized and complications is well established in the literature
controlled trials by Järvelä and Suomalainen (19,20). (10,13,22–25), but there are only a moderate number of publi-
Controversially, an earlier meta-analysis of four randomized cations of DB MRI imaging. According to Casagranda et al.
controlled trials showed no difference in reported clinical the complications of SB and DB ACL reconstructions are sim-
outcome measures (21). ilar (25).

Fig. 5 (a) Sagittal PD and (b) Sag PD with fat sat MR images in a 39-year-old male show a cyclops lesion (white arrow) with intact ACL
graft.
MRI evaluation of the knee post double bundle ACL reconstruction 527

Fig. 7 (a) Coronal STIR and (b) Sagittal PD MR images in a 25-year-old male with ACL graft tear and loose femoral screw associated
with Hardware malposition.

The evolution of anatomic (double bundle) ACL recon- prospective study (27). Recently, van Eck et al. described sur-
struction was basically intended to restore as anatomic recon- gically confirmed patterns of DB reconstruction re-rupture in a
struction as possible thus mimicking the native ACL in both cohort of 40 patients presented for revision surgery (27). The
anatomy and biomechanics (26). It was originally defined as most common pattern (35%) was a mid-substance rupture of
the functional restoration of the ACL to its native dimensions, the AMB graft with a mid-substance rupture of the PLB graft,
collagen orientation, and insertion sites (27,28). while in 19% of patients the PLB graft was intact. Also, in a
During the first 3 months after ACL reconstruction, graft recent study by Kiekara et al. they found that 3% of their
constructs are typically uniformly low in signal intensity on patients had both grafts disrupted. In this study, more PLB
T1- and T2-weighted images. Thereafter, a progressive vascu- graft disruptions were noted which were confirmed by arthro-
larization of periligamentous soft tissues with subsequent syn- scopy (26).
ovialization and remodeling results in graft ligamentization In MRI evaluation, the recognition of graft disruption was
(25,29). During this postoperative phase (12–18 months), the based on the discontinuity of graft fibers. This MRI finding
graft may normally show a degree of intrasubstance increased was the most reliable (sensitivity 72% and specificity 100%)
signal intensity on T1- and T2-weighted images that are reflec- in a study by Collins et al. (13) of surgically confirmed graft
tive of synovial and neovascular proliferation around and disruption. In their group, the comprehensive assessment of
within the graft, which is referred to as ‘‘neoligamentization” other previously described MRI primary findings of graft dis-
of graft tissue (24). However, by 2 years after ACL reconstruc- ruption such as graft thickness, graft SI, and graft orientation
tion, the literature suggests that a normal graft tendon should did not further increase sensitivity.
resume a uniform normal low-signal-intensity MR imaging Association between MRI findings was evaluated regarding
appearance (24). arthroscopy results. In this study, partial rupture was associ-
Prior studies (24) have revealed findings of increased intra- ated with the increased SI of the graft. Impingement of the
substance graft signal as a sign of graft impingement. Further- AMB graft was associated with a partial tear of the AMB graft
more, partial tears of an ACL graft may appear as areas of and with increased SI of the PLB graft.
increased signal intensity within the graft tissue with some resid- Many authors stated that Visualization of intrasubstance
ual intact fibers on T2-weighted images. On the other hand, ACL graft signal changes at long-term follow-up MR imaging
Recht and Kramer (10) reported that T2-weighted acquisitions examination, particularly at T2-weighted imaging, has been
may also show regions of increased signal intensity within an ascribed as a pathologic finding indicative of possible graft
intact graft, if such signal was not isointense relative to fluid impingement, degeneration, or partial tearing (10).
and not traversing the full thickness of the graft construct. In this study both grafts were disrupted in small percentage
In this study as MRI scan was obtained on all patients at a of patients. Clinically, disruption of both grafts is an impor-
mean of 26 months, it revealed increased signal intensity in tant finding because it can lead to revision ACL surgery if
PLB graft in the majority of patients and in AMB graft in con- the patient complains of symptoms of instability in the oper-
siderable number of patients (25.3%), and these results corre- ated knee. However, long-term follow-up will reveal if the par-
late with Saupe et al. and differ from what was stated tial tears of the grafts seen in MRI will lead to total disruption
previously in the literature. of the grafts and instability symptoms of the operated knees
In this study, as regards diagnostic arthroscopy results, with a need for a revision ACL surgery.
17.6% of patients had a complete tear of the AMB graft, Three of the 22 arthroscopically diagnosed partial-thickness
22.3% of patients had a complete tear of the PLB graft, and AM bundle tears were described as lax at arthroscopy with no
10.7% of patients had both grafts disrupted. Previously, van evidence of disruption of its fibers. It is possible that although
eck et al. reported DB graft failure with both grafts disrupted morphologically intact, these grafts were functional failures
in 8% of patients with surgical confirmation in a 2-year leading to the false-negative MR imaging interpretations.
528 M.F. Amin et al.

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