Revascularization Process of the Bone–Patellar Tendon–Bone Autograft Evaluated by Contrast-Enhanced Magnetic Resonance Imaging 6 and 12 Months After Anterior Cruciate Ligament Reconstruction

Abstract

Background: Contrast-enhanced magnetic resonance imaging (MRI) studies conducted on animal models have shown that the observed signal intensity changes are related to the degree of graft vascularity and its biomechanical properties.

Purpose: To evaluate by contrast-enhanced MRI the revascularization process at 3 distinct sites discerned in relation to the surrounding microenvironment along the course of bone–patellar tendon–bone (BPTB) autograft in uncomplicated human anterior cruciate ligament (ACL)–reconstructed knees.

Study Design: Case series; Level of evidence, 4.

Methods: Thirty-two male patients were assessed with a 3-dimensional fast field echo/short tau inversion recovery (FFE/STIR) MRI sequence at the third postoperative day and at time intervals of 6 and 12 months after surgery. Signal-to-noise quotient (SNQ) was calculated for 3 specific graft sites (intra-articular site, intraosseous tibial tunnel site, and intraosseous juxta screw site) before and after gadolinium administration. Comparisons of the enhancement index (EI: SNQ_after/SNQ_before gadolinium) were performed independently for each graft site and time interval.

Results: Three days postoperatively, insufficient vascularization was noticed at the 3 sites. Six and 12 months after surgery, the enhancement index was significantly increased in all 3 sites (P < .001). The intra-articular site, 6 months postoperatively, achieved satisfactory contrast medium uptake (enhancement index >1), with significantly higher enhancement index values compared with the other 2 sites (P < .001). Twelve months after surgery, only the intraosseously enclosed sites displayed an increase of the enhancement index, although nonsignificant (P = .09 and P = .07, respectively).

Conclusion: Revascularization of the graft occurs gradually along its length, with the intra-articular site being the first and the faster part to complete this phase, while both the intraosseous sites are still in progress throughout the first postoperative year. Revascularization is an important link at the intrinsic healing chain of the ACL graft. The surrounding microenvironment does seem to play a significant role in this process, and the differences in its composition along the graft course are reflected at the revascularization progress of the corresponding sites.