Simplified MRI sequences for postoperative control of hamstring anterior cruciate ligament reconstruction

Usually, standard radiographs are used for postoperative quality follow-up after ACL reconstruction. However, with the use of hamstring grafts and bioabsorbable implants, accurate assessment of the tunnel and implant position is impossible. The graft and its relation to anatomical landmarks cannot be evaluated directly. MRI is an alternative to radiography, permitting direct graft visualization and 3-dimensional assessment of the tunnel position, but it is expensive and time consuming for routine use. The aim of this study was to develop a simplified MRI protocol and to evaluate it for routine postoperative quality follow-up after ACL reconstruction.

Various scanning protocols were tested in a series of 105 patients and evaluated for image sharpness, clarity of the structures, susceptibility to artefacts, applicability regarding precise analysis of graft and tunnel position, and time consumption. One simplified specific scan protocol was then defined and applied in a series of 60 consecutive patients after hamstring ACL replacement. The position of the femoral and tibial tunnels was measured in the sagittal, coronal and axial sections and classified according to Harner (femoral) and Stäubli (tibial). Impingement of the graft in the intercondylar roof was analysed according to Howell. The position of the bioabsorbable interference screws was assessed.

Scan protocol: T2-weighted gradient-echo sequences (GRE) with TR 246 ms, TE 11 ms, flip angle 25°, 2 mm sections and a 256×256 matrix yielded the best image quality of tendon grafts and bone tunnels with tolerable time consumption (average scanning time per patient 1 min 40 s). Altogether 8–16 sections were obtained for every patient. Tunnel placement: 46/60 (77%) of the femoral tunnels were in zone 4, 13/60 (21%) at the border of zones 3 to 4, 1/60 (2%) in zone 3 in the sagittal plane (Harner). The femoral tunnels in the axial plane were at 10:30 o’clock in 32/60 (53%), at 11:00 o’clock at 24/60 (40%) and at 10:00 o’clock in 4/60 (4%) patients. The mean distance of the anterior border of the tibial tunnel from the anterior cortex was 39% (± 4.9%) related to the total sagittal diameter of the tibia. There was no graft impingement. The position of the interference screws was anterior to the grafts in all cases.

Simplified MRI sequences can be used for postoperative quality follow-up after ACL replacement and are an alternative to standard radiographs giving more specific and precise information regarding tunnel position and screw placement. Analyzing the bone tunnels in a series of 60 patients demonstrated that correct assessment of tunnel placement after arthroscopic ACL reconstruction is feasible using this simplified MRI technique.