Changes in Cross-sectional Area and Signal Intensity of Healing Anterior Cruciate Ligaments and Grafts in the First 2 Years After Surgery

Am J Sports Med. 2019 Jul;47(8):1831-1843. doi: 10.1177/0363546519850572. Epub 2019 Jun 5.


Background: The quality of a repaired anterior cruciate ligament (ACL) or reconstructed graft is typically quantified in clinical studies by evaluating knee, lower extremity, or patient performance. However, magnetic resonance imaging of the healing ACL or graft may provide a more direct measure of tissue quality (ie, signal intensity) and quantity (ie, cross-sectional area).

Hypotheses: (1) Average cross-sectional area or signal intensity of a healing ACL after bridge-enhanced ACL repair (BEAR) or a hamstring autograft (ACL reconstruction) will change postoperatively from 3 to 24 months. (2) The average cross-sectional area and signal intensity of the healing ligament or graft will correlate with anatomic features of the knee associated with ACL injury.

Study design: Cohort study; Level of evidence, 2.

Methods: Patients with a complete midsubstance ACL tear who were treated with either BEAR (n = 10) or ACL reconstruction (n = 10) underwent magnetic resonance imaging at 3, 6, 12, and 24 months after surgery. Images were analyzed to determine the average cross-sectional area and signal intensity of the ACL or graft at each time point. ACL orientation, stump length, and bony anatomy were also assessed.

Results: Mean cross-sectional area of the grafts was 48% to 98% larger than the contralateral intact ACLs at all time points (P < .01). The BEAR ACLs were 23% to 28% greater in cross-sectional area than the contralateral intact ACLs at 3 and 6 months (P < .02) but similar at 12 and 24 months. The BEAR ACLs were similar in sagittal orientation to the contralateral ACLs, while the grafts were 6.5° more vertical (P = .005). For the BEAR ACLs, a bigger notch correlated with a bigger cross-sectional area, while a shorter ACL femoral stump, steeper lateral tibial slope, and shallower medial tibial depth were associated with higher signal intensity (R2 > .40, P < .05). Performance of notchplasty resulted in an increased ACL cross-sectional area after the BEAR procedure (P = .007). No anatomic features were correlated with ACL graft size or signal intensity.

Conclusion: Hamstring autografts were larger in cross-sectional area and more vertically oriented than the native ACLs at 24 months after surgery. BEAR ACLs had a cross-sectional area, signal intensity, and sagittal orientation similar to the contralateral ACLs at 24 months. The early signal intensity and cross-sectional area of the repaired ACL may be affected by specific anatomic features, including lateral tibial slope and notch width-observations that deserve further study in a larger cohort of patients.

Registration: NCT02292004 ( identifier).

Keywords: ACL; BEAR; MRI; bridge-enhanced ACL repair; reconstruction; repair; signal intensity; size.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries / surgery*
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Autografts / surgery
  • Cohort Studies
  • Female
  • Hamstring Muscles / surgery
  • Humans
  • Knee Joint / surgery
  • Magnetic Resonance Imaging
  • Male
  • Postoperative Period
  • Transplantation, Autologous
  • Young Adult

Associated data