ALPER KAYA, Demet KARADAĞ, BERK GÜÇLÜ, Funda UÇAR, T. Teoman BENLİ

Evaluation of the two bundles of the anterior cruciate ligament with 1.5 tesla magnetic resonance imaging

Amaç: Ön çapraz bağ (ÖÇB) anatomisi ile ilgili çalışmalar normal ÖÇB’nin anteromedial (AM) ve posterolateral (PL) olmak üzere işlevsel iki demetten oluştuğunu göstermiştir. Çalışmamızda normal ÖÇB’nin her iki demeti, klinikte rutin olarak kullanılan 1.5 tesla manyetik rezonans görüntüleme (MRG) ile değerlendirildi. Çalışma planı: Çalışmaya, ÖÇB yetersizliği olmayan ve çeşitli nedenlerle diz MRG tetkiki yapılan 150 hasta (96 kadın, 54 erkek; ort. yaş 33.4±11.6; dağılım 18-59) alındı. Hastaların standart diz MRG’leri (77 sağ, 73 sol) ÖÇB’nin ayırt edilebilir demetleri açısından bir ortopedi uzmanı ve radyoloji uzmanı tarafından bağımsız olarak değerlendirildi. Tüm sagital ve koronal kesitlerde ÖÇB’nin ve demetlerinin tibia platosuyla yaptığı açılar ölçüldü. Ayrıca, birincil sorunları nedeniyle artroskopik cerrahi tedavi uygulanan 64 hastanın (%42.7) artroskopi bulguları MRG bulgularıyla karşılaştırıldı. Sonuçlar: Tüm MRG’lerde ÖÇB’nin sağlam olduğu görüldü. Doksan üç hastada (%62) ÖÇB aksiyel, koronal ve sagital planlarda tek demet olarak izlenirken, 57 hastada (%38) iki demet olarak izlendi. Çift demet olarak izlenen planlar, 14 hastada (%9.3) her üç plan, 41 hastada (%27.3) aksiyel ve koronal planlar, bir hastada (%0.7) koronal ve sagital planlar, bir hastada (%0.7) ise sadece koronal plan idi. Tek demet olarak değerlendirilen MRG’lerde, ÖÇB ile tibia platosu arasındaki açı sagital planda ortalama 55.3°, koronal planda ise 70.3° ölçüldü. Çift demet olarak değerlendirilen MRG’lerde ise, AM demetin tibia platosuyla yaptığı açı koronal planda ortalama 70.1°, sagital planda 55.1° bulundu; bu değerler PL demet için sırasıyla ortalama 81° ve 53.5° idi. Sagital, koronal ve aksiyel MR görüntülerinde ÖÇB’nin çift demet olarak izlenebilirliği cinsiyet ve tarafla ilişkili bulunmadı (p>0.05). İzlenebilir demet sayısı açısından her bir plan için gözlemciler arasında anlamlı fark bulunmadı (p>0.05). Artroskopi yapılan tüm hastalarda ÖÇB’nin bütünlüğünün tam ve işlevsel olduğu, tamamında her iki demetin de bulunduğu görüldü. Bu hastaların sadece %42.2’sinde MRG ile bir veya birden fazla planda ÖÇB çift demet olarak izlenmişti. Çıkarımlar: Klinikte rutin olarak kullanılan 1.5 tesla standart MRG ile ÖÇB çok yüksek oranda görüntülenebilirken, ÖÇB’nin

Anahtar Kelimeler:

Ön çapraz bağ, Manyetik rezonans görüntüleme, Artroskopi, Diz eklemi, İşlevsel lateralizasyon, Tibia

Ön çapraz bağ iki demetinin 1.5 tesla manyetik rezonans görüntüleme ile değerlendirilmesi

Objectives: Studies on the anatomy of the anterior cruciate ligament (ACL) have shown that the normal ACL consists of two functional bundles named as anteromedial (AM) and posterolateral (PL) bundles. In this study, we evaluated the AM and PL bundles of the ACL using 1.5 tesla magnetic resonance imaging (MRI), which is routinely used in clinical practice. Methods: The study included 150 patients (96 females, 54 males; mean age 33.4±11.6 years; range 18 to 59 years) who did not have any signs of ACL insufficiency and whose knees were examined by MRI for other reasons. Standard magnetic resonance images (77 right, 73 left) were evaluated independently by an orthopedist and a radiologist in terms of distinguishable ACL bundles. The angle between the ACL (and each bundle) and the tibial plateau was measured on sagittal and coronal sections. Arthroscopic surgery was performed in 64 patients (42.7%) for primary diagnoses and arthroscopic and MRI findings were compared. Results: Magnetic resonance imaging showed an intact ACL in all the patients. The ACL was assessed as a single bundle in the axial, coronal, and sagittal planes in 93 patients (62%). A doublebundle appearance was noted in 57 patients (38%), involving all three planes in 14 patients (9.3%), axial and coronal planes in 41 patients (27.3%), coronal and sagittal planes in one patient (0.7%), and only coronal plane in one patient (0.7%). On MRI sections showing a single bundle ACL, the mean angle between the ACL and the tibial plateau was found as 55.3° in the sagittal plane, and 70.3° in the coronal plane. On sections with a double-bundle appearance, the mean angles between the AM bundle and the tibial plateau were 70.1° and 55.1° in the coronal and sagittal planes, respectively. The corresponding angles for the PL bundle were 81° and 53.5°. The incidence of double bundle ACL appearance in coronal, sagittal, and axial MRI sections was not influenced by sex and side (p>0.05). The number of bundles identified in each plane did not show a significant difference between the two observers (p>0.05). During arthroscopic surgery, both bundles were identified with normal integrity and function of the ACL in all the patients. Of these, MRI could depict a double-bundle appearance in one or more planes in only 42.2% of the patients. Conclusion: Even though standard 1.5 tesla MRI, routinely used in clinical practice, has a very high success rate in demonstrating the ACL, it can visualize the two-bundle structure only in about one-third of the patients. in anterior cruciate ligament anatomy. Knee Surg Sports Traumatol Arthrosc 2006;14:1151-8. 30. Reicher MA, Rauschning W, Gold RH, Bassett LW, Lufkin RB, Glen W Jr. High-resolution magnetic resonance imaging of the knee joint: normal anatomy. AJR Am J Roentgenol 1985;145:895-902. 31. Mesgarzadeh M, Schneck CD, Bonakdarpour A. Magnetic resonance imaging of the knee and correlation with normal anatomy. Radiographics 1988;8:707-33. 32. Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y. Reconstruction of the anterior cruciate ligament. Singleversus double-bundle multistranded hamstring tendons. J Bone Joint Surg [Br] 2004;86:515-20. 33. Buoncristiani AM, Tjoumakaris FP, Starman JS, Ferretti M, Fu FH. Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 2006;22:1000-6. 34. Tashman S, Collon D, Anderson K, Kolowich P, Anderst W. Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med 2004;32:975-83. 35. Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama H, et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 2004;20:1015-25. 36. Manaster BJ, Crim J, Rosenberg ZS, editors. Knee. In: Diagnostic and surgical imaging anatomy: knee, ankle, foot. Utah: Amirsys Inc.; 2007. p. 96-113. 37. Gentili A, Seeger LL, Yao L, Do HM. Anterior cruciate ligament tear: indirect signs at MR imaging. Radiology 1994;193:835-40. 38. Steckel H, Vadala G, Davis D, Musahl V, Fu FH. 3-T MR imaging of partial ACL tears: a cadaver study. Knee Surg Sports Traumatol Arthrosc 2007;15:1066-71. 39. Kwon JW, Yoon YC, Kim YN, Ahn JH, Choe BK. Which oblique plane is more helpful in diagnosing an anterior cruciate ligament tear? Clin Radiol 2009;64:291-7. 40. Poellinger A, Scheffler S, Hamm B, Asbach P. Magnetic resonance imaging of double-bundle anterior cruciate ligament reconstruction. Skeletal Radiol 2009;38:309-15.

Keywords:

Anterior Cruciate Ligament, Magnetic Resonance Imaging, Arthroscopy, Knee Joint, Functional Laterality, Tibia,

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