The Graft Bending Angle Can Affect Early Graft Healing After Anterior Cruciate Ligament Reconstruction: In Vivo Analysis With 2 Years' Follow-up

Am J Sports Med. 2017 Jul;45(8):1829-1836. doi: 10.1177/0363546517698676. Epub 2017 Apr 12.


Background: A high graft bending angle (GBA) after anterior cruciate ligament (ACL) reconstruction has been suggested to cause stress on the graft. Nevertheless, evidence about its effect on graft healing in vivo is limited.

Hypothesis: The signal intensity on magnetic resonance imaging (MRI) would be higher in the proximal region of the ACL graft, and higher signals would be correlated to a higher GBA.

Study design: Descriptive laboratory study.

Methods: Anatomic single-bundle ACL reconstruction was performed on 24 patients (mean age, 20 ± 4 years) using the transportal technique. A quadriceps tendon autograft with a bone plug was harvested. To evaluate graft healing, the signal/noise quotient (SNQ) was measured in 3 regions of interest (ROIs) of the proximal, midsubstance, and distal ACL graft using high-resolution MRI (0.45 × 0.45 × 0.70 mm), with decreased signals suggesting improved healing. Dynamic knee motion was examined during treadmill walking and running to assess the in vivo GBA. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors at each motion frame, based on tibiofemoral kinematics determined from dynamic stereo X-ray analysis. Graft healing and GBAs were assessed at 6 and 24 months postoperatively. Repeated-measures analysis of variance was used to compare the SNQ in the 3 ROIs at 2 time points. Pearson correlations were used to analyze the relationship between the SNQ and mean GBA during 0% to 15% of the gait cycle.

Results: The SNQ of the ACL graft in the proximal region was significantly higher than in the midsubstance ( P = .022) and distal regions ( P < .001) at 6 months. The SNQ in the proximal region was highly correlated with the GBA during standing ( R = 0.64, P < .001), walking ( R = 0.65, P = .002), and running ( R = 0.54, P = .015) but not in the other regions. At 24 months, signals in the proximal and midsubstance regions decreased significantly compared with 6 months ( P < .001 and P = .008, respectively), with no difference across the graft area.

Conclusion: The signal intensity was highest in the proximal region and lowest in the distal region of the reconstructed graft at 6 months postoperatively. A steep GBA was significantly correlated with high signal intensities of the proximal graft in this early period. A steep GBA may negatively affect proximal graft healing after ACL reconstruction.

Keywords: MRI; anterior cruciate ligament; graft bending angle; graft healing; signal/noise quotient.

MeSH terms

  • Adolescent
  • Anterior Cruciate Ligament / diagnostic imaging*
  • Anterior Cruciate Ligament / surgery
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Biomechanical Phenomena
  • Female
  • Follow-Up Studies
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Tendons / diagnostic imaging
  • Transplantation, Autologous / methods*
  • Wound Healing*
  • Young Adult