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How to optimize the use of MRI in anatomic ACL reconstruction

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      Magnetic resonance imaging (MRI) is the most current diagnostic imaging procedure for suspected ACL injuries. It is an accurate, highly sensitive and specific tool for the diagnosis of ACL tears, graft tears and associated injuries. However, it can also be used for various other aspects of anatomic ACL reconstruction.


      Special sequences as the oblique sagittal plane should be obtained from a parallel line to the lateral epicondyle, ensuring a proper visualization of both bundles of the ACL. Another special set of images, the oblique-coronal sequence, allows for the ACL long-axis evaluation. The coronal-oblique sequence increases the sensitivity and specificity of diagnosing isolated AM or PL bundle injuries and also helps to visualize the proximal insertion of the bundles for haemorrhage and rupture.


      Quantitative measurements can be taken from a proper MRI protocol, so as to determine the rupture pattern; measure insertion site size, inclination angle and autograft size; and evaluate for post-operative complications. These parameters help surgeons to objectively decide for a better graft and technique for an individualized approach and to evaluate the anatomic placement of the graft.


      MRI can be used in different ways, serving as a very valuable tool in anatomic ACL reconstruction. Special protocols can provide accurate visualization of the double-bundle anatomy. Objective parameters to aid in pre-operative decisions and graft’s anatomic placement evaluation can be also extracted from the MR images.

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      Most cited references 31

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      The phenomenon of "ligamentization": anterior cruciate ligament reconstruction with autogenous patellar tendon.

       R Roux,  D Amiel,  F Harwood (1985)
      Reconstruction of the anterior cruciate ligament (ACL) with patellar tendon (PT) is a common procedure for the symptomatic ACL-deficient knee. Questions regarding graft incorporation, viability, and nutrition of the transplanted tissue are of concern. This relates to the graft's response to its new intrasynovial milieu and new physical forces. These factors were studied in a rabbit model of ACL reconstruction using PT and were evaluated with histological and biochemical parameters with respect to time. A histological and biochemical metamorphosis of the grafted PT occurred in this study. Autografts demonstrated a gradual assumption of the microscopic properties of normal ACL; by 30 weeks postoperatively, cell morphology was ligamentous in appearance. Normally, type III collagen is not observed in PT, however, a gradual increase in its concentration was seen in the grafts; by 30 weeks its concentration (10%) was the same as in normal ACL. Similarly, glycosaminoglycans content increased from its normally low level in PT to that found in native ACL. Collagen-reducible crosslink analysis demonstrated that grafted tissue changed from the normal PT pattern of low dihydroxylysinonorleucine (DHLNL) and high histidinohydroxymerodesmosine (HHMD) to the pattern seen in normal ACL (high DHLNL and low HHMD) by 30 weeks. These data suggest that when PT is placed in the anatomic and environmental milieu of the ACL, a "ligamentization" of the grafted tissue results; also the autograft initially depends on synovial fluid nutrition, as revascularization occurs after 6 weeks.
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        Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis.

        Meta-analysis. To define the accuracy of clinical tests for assessing anterior cruciate ligament (ACL) ruptures. The cruciate ligaments, and especially the ACL, are among the most commonly injured structures of the knee. Given the increasing injury prevalence, there is undoubtedly a growing need for clinical decision making of health care providers. We reviewed the literature to analyze the diagnostic accuracy of the clinical examination for assessing ACL ruptures. MEDLINE (1966 to April 2005), EMBASE (1989 to April 2005), and CINAHL (1982 to April 2005) searches were performed. Also reference lists of the included studies were reviewed. Studies selected for data extraction were those that addressed the accuracy of at least 1 physical diagnostic test for ACL rupture and compared the performance of the clinical examination of the knee with a reference standard, such as arthroscopy, arthrotomy, or MRI. Searching was limited to English, German, and Dutch languages. Twenty-eight studies that assessed the accuracy of clinical tests for diagnosing ACL ruptures met the inclusion criteria. Study results were, however, heterogeneous. The Lachman test is the most valid test to determine ACL tears, showing a pooled sensitivity of 85% (95% confidence interval [CI], 83-87) and a pooled specificity of 94% (95% CI, 92-95). The pivot shift test is very specific, namely 98% (95% CI, 96-99), but has a poor sensitivity of 24% (95% CI, 21-27). The anterior drawer test shows good sensitivity and specificity in chronic conditions, respectively 92% (95% CI, 88-95) and 91% (95% CI, 87-94), but not in acute conditions. In case of suspected ACL injury it is recommended to perform the Lachman test. Because the pivot shift test is very specific both in acute as well as in chronic conditions, it is recommended to perform the pivot shift test as well.
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          Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart.

          Anatomy is the foundation of orthopaedic surgery, and the advancing knowledge of the anterior cruciate ligament (ACL) anatomy has led to the development of improved modern reconstruction techniques that approach the anatomy of the native ACL. Current literature on the anatomy of the ACL and its reconstruction techniques, as well as our surgical experience, was used to develop a flowchart that can aid the surgeon in performing anatomic ACL reconstruction. We define anatomic ACL reconstruction as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. A guideline was written to accompany this flowchart with more detailed information on anatomic ACL reconstruction and its pitfalls, all accompanied by relevant literature and helpful figures. Although there is still much to learn about anatomic ACL reconstruction methods, we believe this is a helpful document for surgeons. We continue to modify the flowchart as more information about the anatomy of the ACL, and how to more closely reproduce it, becomes available. (c) 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

            Author and article information

            [ ]Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA 15213 USA
            [ ]Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, USA
            +1-412-6053265 , +1-412-6870802 , ,
            Knee Surg Sports Traumatol Arthrosc
            Knee Surg Sports Traumatol Arthrosc
            Knee Surgery, Sports Traumatology, Arthroscopy
            Springer-Verlag (Berlin/Heidelberg )
            15 August 2012
            15 August 2012
            July 2013
            : 21
            : 7
            : 1495-1501
            © The Author(s) 2012
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            © Springer-Verlag Berlin Heidelberg 2013


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