MRI EVALUATION OF BIOLOGICALLY ENHANCED ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Keywords:
anterior cruciate ligament reconstruction, platelet-rich plasma, anterior cruciate ligament residual remnant preservation, graft healing processAbstract
Introduction: Platelet-rich plasma (PRP) and anterior cruciate ligament (ACL) residual remnant preservation are used today as biologic therapies aimed at stimulating graft healing process after ACL reconstruction, but their synergism has not been established yet. The aim of our study was to investigate the combined influence of PRP and ACL remnant preservation on graft healing after ACL reconstruction and evaluate the results with MRI.
Material and methods: The study included 52 patients (45 men and 7 women, mean age 28) divided into 2 groups: group I (control group) - 28 patients in whom after the removal of ACL residual bundle, a standard single bundle ACL reconstruction was made, and group II (examined group) - 24 patients in whom remnant preserving ACL reconstruction with addition of PRP was performed. The results were assessed 6 months after surgery by MRI evaluation of the graft healing process.
Results: Patients in the examined group had more frequently a light hyperintense signal of the intra-articular part of the graft (75% vs. 35.7%, p=0.0046) and absence of synovial fluid at tunnel-graft interface (45.8% vs. 21.4%, p=0.06), average 0.98 cm2 less surface of bone edema around the graft (p=0.009) than those from the control group.
Conclusion: Combined use of PRP and ACL remnant preservation has a positive influence on graft healing after ACL reconstruction leading to faster ligamentization and osteoligamentous integration of the graft.
References
Cameron M, Buchgraber A, Passler H, Vogt M, Thonar E, Fu F, et al. The natural history of the anterior cruciate ligament-deficient knee. Changes in synovial fluid cytokine and keratan sulfate concentrations. Am J Sports Med 1997; 25(6): 751-754. doi: 10.1177/036354659702500605.
Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 2011; 45(7): 596-606. doi: 10.1136/bjsm.2010.076364.
da Silveira Franciozi CE, Ingham SJ, Gracitelli GC, Luzo MV, Fu FH, Abdalla RJ. Updates in biological therapies for knee injuries: anterior cruciate ligament. Curr Rev Musculoskelet Med 2014; 7(3): 228-238. doi: 10.1007/s12178-014-9228-9.
Junkin DM Jr, Johnson DL. ACL tibial remnant, to save or not? Orthopedics 2008; 31(2): 154-159. doi: 10.3928/01477447-20080201-13.
Tie K, Chen L, Hu D, Wang H. The difference in clinical outcome of single-bundle anterior cruciate ligament reconstructions with and without remnant preservation: A meta-analysis. Knee 2016; 23(4): 566-574. doi: 10.1016/j.knee.2015.07.010.
Graziani F, Ivanovski S, Cei S, Ducci F, Tonetti M, Gabriele M. The in vitro effect of different PRP concentrations on osteoblasts and fibroblasts. Clin Oral Implants Res 2006; 17(2): 212-219. doi: 10.1111/j.1600-0501.2005.01203.x.
Murray MM, Spindler KP, Devin C, Snyder BS, Muller J, Takahashi M, et al. Use of a collagen-platelet rich plasma scaffold to stimulate healing of a central defect in the canine ACL. J Orthop Res 2006; 24(4): 820-830. doi: 10.1002/jor.20073.
Le ADK, Enweze L, DeBaun MR, Dragoo JL. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Curr Rev Musculoskelet Med 2018; 11(4): 624-634. doi: 10.1007/s12178-018-9527-7.
Fallouh L, Nakagawa K, Sasho T, Arai M, Kitahara S, Wada Y, Moriya H, Takahashi K. Effects of autologous platelet-rich plasma on cell viability and collagen synthesis in injured human anterior cruciate ligament. J Bone Joint Surg Am 2010; 92(18): 2909-2916. doi: 10.2106/JBJS.I.01158.
Nin JR, Gasque GM, Azcárate AV, Beola JD, Gonzalez MH. Has platelet-rich plasma any role in anterior cruciate ligament allograft healing? Arthroscopy 2009; 25(11): 1206-1213. doi: 10.1016/j.arthro.2009.06.002.
Silva A, Sampaio R. Anatomic ACL reconstruction: does the platelet-rich plasma accelerate tendon healing? Knee Surg Sports Traumatol Arthrosc 2009; 17(6): 676-682. doi: 10.1007/s00167-009-0762-8.
Andriolo L, Di Matteo B, Kon E, Filardo G, Venieri G, Marcacci M. PRP Augmentation for ACL Reconstruction. Biomed Res Int 2015; 2015: 371746. doi: 10.1155/2015/371746.
Mifune Y, Ota S, Takayama K, Hoshino Y, Matsumoto T, Kuroda R, et al. Therapeutic advantage in selective ligament augmentation for partial tears of the anterior cruciate ligament: results in an animal model. Am J Sports Med 2013; 41(2): 365-373. doi: 10.1177/0363546512471614.
Muneta T, Koga H. Anterior cruciate ligament remnant and its values for preservation. Asia Pac J Sports Med Arthrosc Rehabil Technol 2016; 7: 1-9. doi: 10.1016/j.asmart.2016.09.002.
Gohil S, Annear PO, Breidahl W. Anterior cruciate ligament reconstruction using autologous double hamstrings: a comparison of standard versus minimal debridement techniques using MRI to assess revascularisation. A randomised prospective study with a one-year follow-up. J Bone Joint Surg Br 2007; 89(9): 1165-1171. doi: 10.1302/0301-620X.89B9.19339.
Kazusa H, Nakamae A, Ochi M. Augmentation technique for anterior cruciate ligament injury. Clin Sports Med 2013; 32(1): 127-140. doi: 10.1016/j.csm.2012.08.012.
Lai CCH, Ardern CL, Feller JA, Webster KE. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med 2018; 52(2): 128-138. doi: 10.1136/bjsports-2016-096836.
Yoshida R, Cheng M, Murray MM. Increasing platelet concentration in platelet-rich plasma inhibits anterior cruciate ligament cell function in three-dimensional culture. J Orthop Res 2014; 32(2): 291-295. doi: 10.1002/jor.22493.
Yoshida R, Murray MM. Peripheral blood mononuclear cells enhance the anabolic effects of platelet-rich plasma on anterior cruciate ligament fibroblasts. J Orthop Res 2013; 31(1): 29-34. doi: 10.1002/jor.22183.
Cheng M, Johnson VM, Murray MM. Effects of age and platelet-rich plasma on ACL cell viability and collagen gene expression. J Orthop Res 2012; 30(1): 79-85. doi: 10.1002/jor.21496.
Mastrangelo AN, Magarian EM, Palmer MP, Vavken P, Murray MM. The effect of skeletal maturity on the regenerative function of intrinsic ACL cells. J Orthop Res 2010; 28(5): 644-651. doi: 10.1002/jor.21018.
Scherping SC Jr, Schmidt CC, Georgescu HI, Kwoh CK, Evans CH, Woo SL. Effect of growth factors on the proliferation of ligament fibroblasts from skeletally mature rabbits. Connect Tissue Res 1997; 36(1): 1-8. doi: 10.3109/03008209709160209.
Joshi SM, Mastrangelo AN, Magarian EM, Fleming BC, Murray MM. Collagen-platelet composite enhances biomechanical and histologic healing of the porcine anterior cruciate ligament. Am J Sports Med 2009; 37(12): 2401-2410. doi: 10.1177/0363546509339915.
Weiler A, Förster C, Hunt P, Falk R, Jung T, Unterhauser FN, et al. The influence of locally applied platelet-derived growth factor-BB on free tendon graft remodeling after anterior cruciate ligament reconstruction. Am J Sports Med 2004; 32(4): 881-891. doi: 10.1177/0363546503261711.
Orrego M, Larrain C, Rosales J, Valenzuela L, Matas J, Durruty J, et al. Effects of platelet concentrate and a bone plug on the healing of hamstring tendons in a bone tunnel. Arthroscopy 2008; 24(12): 1373-1380. doi: 10.1016/j.arthro.2008.07.016.
Figueroa D, Melean P, Calvo R, Vaisman A, Zilleruelo N, Figueroa F, et al. Magnetic resonance imaging evaluation of the integration and maturation of semitendinosus-gracilis graft in anterior cruciate ligament reconstruction using autologous platelet concentrate. Arthroscopy 2010; 26(10): 1318-1325. doi: 10.1016/j.arthro.2010.02.010.
Mirzatolooei F, Alamdari MT, Khalkhali HR. The impact of platelet-rich plasma on the prevention of tunnel widening in anterior cruciate ligament reconstruction using quadrupled autologous hamstring tendon: a randomised clinical trial. Bone Joint J 2013; 95-B(1): 65-69. doi: 10.1302/0301-620X.95B1.30487.
Vadalà A, Iorio R, De Carli A, Ferretti M, Paravani D, Caperna L, et al. Platelet-rich plasma: does it help reduce tunnel widening after ACL reconstruction? Knee Surg Sports Traumatol Arthrosc 2013; 21(4): 824-829. doi: 10.1007/s00167-012-1980-z.
Vogrin M, Rupreht M, Dinevski D, Hašpl M, Kuhta M, Jevsek M, et al. Effects of a platelet gel on early graft revascularization after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind, clinical trial. Eur Surg Res 2010; 45(2): 77-85. doi: 10.1159/000318597.
Rupreht M, Vogrin M, Hussein M. MRI evaluation of tibial tunnel wall cortical bone formation after platelet-rich plasma applied during anterior cruciate ligament reconstruction. Radiol Oncol 2013; 47(2): 119-124. doi: 10.2478/raon-2013-0009.
Rupreht M, Jevtič V, Serša I, Vogrin M, Jevšek M. Evaluation of the tibial tunnel after intraoperatively administered platelet-rich plasma gel during anterior cruciate ligament reconstruction using diffusion weighted and dynamic contrast-enhanced MRI. J Magn Reson Imaging. 2013; 37(4): 928-935. doi: 10.1002/jmri.23886.
Radice F, Yánez R, Gutiérrez V, Rosales J, Pinedo M, Coda S. Comparison of magnetic resonance imaging findings in anterior cruciate ligament grafts with and without autologous platelet-derived growth factors. Arthroscopy 2010; 26(1): 50-57. doi: 10.1016/j.arthro.2009.06.030.
Seijas R, Ares O, Catala J, Alvarez-Diaz P, Cusco X, Cugat R. Magnetic resonance imaging evaluation of patellar tendon graft remodelling after anterior cruciate ligament reconstruction with or without platelet-rich plasma. J Orthop Surg (Hong Kong) 2013; 21(1): 10-14. doi: 10.1177/230949901302100105.
Sánchez M, Anitua E, Azofra J, Prado R, Muruzabal F, Andia I. Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology. Arthroscopy 2010; 26(4): 470-480. doi: 10.1016/j.arthro.2009.08.019.
Papalia R, Franceschi F, Vasta S, Di Martino A, Maffulli N, Denaro V. Sparing the anterior cruciate ligament remnant: is it worth the hassle? Br Med Bull 2012; 104: 91-111. doi: 10.1093/bmb/ldr053.
Wu B, Zhao Z, Li S, Sun L. Preservation of remnant attachment improves graft healing in a rabbit model of anterior cruciate ligament reconstruction. Arthroscopy 2013; 29(8): 1362-71. doi: 10.1016/j.arthro.2013.05.010.
Li Z, Liu Y, Shi B, Wu X, Zhu J, Wang Z, Li Z. [An experimental study on anterior cruciate ligament reconstruction with remnants and remaining bundle preservation]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009; 23(3): 282-286. PMID: 19366134.
Ohsawa T, Kimura M, Kobayashi Y, Hagiwara K, Yorifuji H, Takagishi K. Arthroscopic evaluation of preserved ligament remnant after selective anteromedial or posterolateral bundle anterior cruciate ligament reconstruction. Arthroscopy 2012; 28(6): 807-817. doi: 10.1016/j.arthro.2011.11.033.
Ahn JH, Wang JH, Lee YS, Kim JG, Kang JH, Koh KH. Anterior cruciate ligament reconstruction using remnant preservation and a femoral tensioning technique: clinical and magnetic resonance imaging results. Arthroscopy 2011; 27(8): 1079-1089. doi: 10.1016/j.arthro.2011.03.002.
Guo L, Yang L, Duan XJ, Xu Q, Chen JR, Chen GX, et al. Second-look arthroscopy study after anterior cruciate ligament reconstruction: effect of residual anterior cruciate ligament tissue upon accelerating revascularization of allologous bone-patellar tendon-bone grafting. Zhonghua Yi Xue Za Zhi 2009; 89(29): 2030-2033. PMID: 20017323.
Noh JH, Kyung HS, Roh YH, Kang TS. Remnant-preserving and re-tensioning technique to cover the graft in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25(4): 1205-1210. doi: 10.1007/s00167-015-3854-7.
Demirağ B, Ermutlu C, Aydemir F, Durak K. A comparison of clinical outcome of augmentation and standard reconstruction techniques for partial anterior cruciate ligament tears. Eklem Hastalik Cerrahisi 2012; 23(3): 140-144. PMID: 23145756.
Zhang Q, Zhang S, Cao X, Liu L, Liu Y, Li R. The effect of remnant preservation on tibial tunnel enlargement in ACL reconstruction with hamstring autograft: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2014; 22(1): 166-173. doi: 10.1007/s00167-012-2341-7.
Ahn JH, Lee SH, Choi SH, Lim TK. Magnetic resonance imaging evaluation of anterior cruciate ligament reconstruction using quadrupled hamstring tendon autografts: comparison of remnant bundle preservation and standard technique. Am J Sports Med 2010; 38(9): 1768-1777. doi: 10.1177/0363546510368132.
Wilson TC, Kantaras A, Atay A, Johnson DL. Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med 2004; 32(2): 543-549. doi: 10.1177/0363546504263151.
Janssen RP, Scheffler SU. Intra-articular remodelling of hamstring tendon grafts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22(9): 2102-2108. doi: 10.1007/s00167-013-2634-5.
Gnannt R, Chhabra A, Theodoropoulos JS, Hodler J, Andreisek G. MR imaging of the postoperative knee. J Magn Reson Imaging 2011; 34(5): 1007-1021. doi: 10.1002/jmri.22672.
Ekdahl M, Wang JH, Ronga M, Fu FH. Graft healing in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2008; 16(10): 935-947. doi: 10.1007/s00167-008-0584-0.
Deehan DJ, Cawston TE. The biology of integration of the anterior cruciate ligament. J Bone Joint Surg Br 2005; 87(7): 889-895. doi: 10.1302/0301-620X.87B7.16038.