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ORIGINAL RESEARCH
Anterior Cruciate Ligament
Reconstruction Grafts: MR

䡲 MUSCULOSKELETAL IMAGING
Imaging Features at Long-term
Follow-up—Correlation with
Functional and Clinical Evaluation1
Nadja Saupe, MD
Purpose: To assess the presence of increased intrasubstance signal
Lawrence M. White, MD
intensity within anterior cruciate ligament (ACL) grafts
Mary M. Chiavaras, MD
and to assess whether such signal intensity changes are
Jason Essue correlated to clinical assessments of graft instability and
Iris Weller, MD patient function 4 –12 years after ACL reconstruction.
Monica Kunz
Mark Hurtig, MD Materials and Ethical permission and written informed patient consent
Paul Marks, MD Methods: were obtained. The study was HIPAA compliant. Forty-
seven patients were included and underwent 1.5-T mag-
netic resonance (MR) imaging of the knee that was treated
surgically. Signal intensity characteristics of the ACL graft
were evaluated on sagittal intermediate-weighted and sag-
ittal and axial T2-weighted fast spin-echo MR images. The
amount of signal intensity change, femoral and tibial graft
tunnel position, and orientation of ACL graft in the coronal
plane were assessed. Objective index of graft stability or
laxity was performed with arthrometric testing, and sub-
jective function was assessed by using International Knee
Documentation Committee (IKDC) scoring.

Results: Increased intrasubstance graft signal intensity was found in

70 % (33 of 47) and in 64% (30 of 47) of patients on inter-
mediate-weighted MR images and T2-weighted MR images,
respectively. When present, intrasubstance graft signal in-
tensity changes involved less than 25% of the maximal cross-
sectional area of the graft in 70% (23 of 33) of cases on
intermediate-weighted acquisitions and in 70% (21 of 30) of
cases on T2-weighted acquisitions. No significant association
was seen between graft signal intensity changes on interme-
diate-weighted and T2-weighted images and IKDC score
(P ⫽ .667 and .698, respectively), arthrometric testing (P ⫽
.045–.99), and time since surgery (P ⫽ .592 and .610, re-
spectively).

1
From the Department of Medical Imaging, Mount Sinai Conclusion: Small amounts of increased intrasubstance graft signal
Hospital and University Health Network, University of To- intensity on intermediate- and T2-weighted images can be
ronto, Toronto, Ontario, Canada (N.S., L.M.W., M.M.C., seen after ACL reconstruction at long-term follow-up of 4
M.K.); Sunnybrook Health Sciences Centre, Toronto, On-
years or longer and do not necessarily correlate with find-
tario, Canada (J.E., I.W., P.M.); and Department of Clinical
ings of joint instability or functional limitations in patients
Studies, University of Guelph, Guelph, Ontario, Canada
(M.H.). Received September 19, 2007; revision requested after ACL repair.
December 11; revision received March 4, 2008; accepted
April 7; final version accepted May 21. Address corre- 娀 RSNA, 2008
spondence to N.S., Department of Radiology, Orthopedic
University Hospital Balgrist, Forchstrasse 340, CH-8008
Zurich, Switzerland (e-mail: nadja.saupe@balgrist.ch ).

姝 RSNA, 2008

Radiology: Volume 249: Number 2—November 2008 581

MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts
A
nterior cruciate ligament (ACL)
tears are the most common com-
plete ligamentous injury in the
knee (1). Treatment or reconstruction
techniques of ACL-deficient knee joints
have improved substantially during the
past decades (2,3), with current recon-
structions typically performed arthro-
scopically and with utilization of bone-
patellar tendon-bone or hamstring au-
tografts or allograft constructs. The
increased number of ACL reconstruc-
tions being performed (4) has led to an
increased demand for postoperative
knee evaluation when symptoms persist
or recur after ACL reconstructive pro-
cedures. Postoperative complications,
such as recurrent instability, impinge-
ment, arthrofibrosis, cystic graft degen-
eration, or tunnel widening, have been
extensively evaluated by using magnetic
resonance (MR) imaging (5–13).
The MR imaging characteristic of
ACL grafts has been previously described
to begin as uniformly low signal intensity
in appearance, similar to the signal char-
acteristics of the native graft harvest tis-
sue (patellar tendon or hamstring ten-
don). Increased intrasubstance graft sig-
nal changes subsequently have been
described to develop within the 1st year
Advances in Knowledge
䡲 Small amounts of increased intra-
substance graft signal can be seen
after anterior cruciate ligament
(ACL) reconstruction at long-term
follow-up (⬎4 years) on interme-
diate-weighted and T2-weighted
MR images in approximately two-
thirds of patients (70% and 64%,
respectively).
䡲 Increased intrasubstance graft
signal intensity seen on intermedi-
ate-weighted and T2-weighted
images does not correlate with
clinical findings of instability or
subjective functional limitations in
patients more than 4 years after
ACL repair.
䡲 No correlation was seen between
graft intrasubstance signal inten-
sity changes, graft femoral tunnel
position, or slope of an ACL graft
on coronal images.
582
after surgery and are proposed to repre-
sent changes related to synovial prolifer-
ation, vascularization, and “neoligamenti-
zation” of graft constructs. Complete res-
olution of such graft signal changes are
described by 18 –24 months after surgery
(1,14). Visualization of intrasubstance
ACL graft signal changes at long-term fol-
low-up MR imaging examination, particu-
larly at T2-weighted imaging, has been
ascribed as a pathologic finding indicative
of possible graft impingement, degenera-
tion, or partial tearing (6,9,15,16). The
aim of our study was to assess the pres-
ence of increased intrasubstance signal
intensity within ACL grafts and to assess
whether such signal intensity changes are
correlated to clinical assessments of graft
instability and patient function 4 –12
years after ACL reconstruction.
Materials and Methods
Ethical permission and written informed
patient consent were obtained for this
study. The study was Health Insurance
Portability and Accountability Act compli-
ant. A cohort of 410 consecutive patients,
who had undergone primary arthroscopic
ACL reconstruction between 1995 and
2001, was identified from clinical records.
All reconstructions were performed by
one subspecialty trained arthroscopic or-
thopedic surgeon (P.M., with 15 years of
experience in arthroscopic ACL recon-
struction). On the basis of review of clin-
ical notes, 205 of these patients met the
following study inclusion criteria: less
than 24 months between injury and ACL
reconstruction, no history of prior knee
surgery, no history of contralateral knee
joint surgery or ligamentous injury, and
no history of systemic disease. Of the 205
eligible patients, 57 patients were suc-
cessfully contacted, and written informed
consent was received to participate in the
Implication for Patient Care
䡲 Small amounts of increased intra-
substance signal intensity within
an ACL graft is a common finding
at long-term MR imaging follow-
up and is not directly related to
graft dysfunction (instability) or
patient function.
Saupe et al
current investigation. Of the remaining
148 patients who were not included in the
study, 57 patients were not willing to par-
ticipate, and 33 patients had moved away
from the Toronto area; we were unable to
contact 58 patients. All patients were pro-
spectively studied within an interval of 12
months (January 2006 to January 2007).
Ten of the 57 patients were excluded
from subsequent study data analysis. One
patient had a torn graft at clinical and MR
imaging examination. One patient who
had extensive metal-related MR imaging
artifacts was excluded because of inability
to assess the signal characteristics of the
ACL graft. Three patients did not success-
fully complete clinical examination, and
five patients did not successfully complete
MR imaging.
Finally, 47 patients were included in
the study group. Mean age at MR imag-
ing and clinical assessment was 34.3
years (age range, 22–53 years). There
were 26 men (mean age, 35.1 years; age
range, 25–53 years) and 21 women
(mean age, 33.2 years; age range,
22– 47 years). Mean age at surgery was
27.6 years (age range, 16 – 42 years).
Time since surgery ranged from 52 to
144 months, with a mean of 80 months.
No significant difference was found be-
tween mean age of men and women
(P ⫽ .867) in the study group. Twenty-
one left and 26 right knees were exam-
ined at MR imaging, and clinical assess-
ments were performed. In 46 patients,
bone-patellar tendon-bone grafts had
been previously used for ACL recon-
Published online before print
10.1148/radiol.2492071651
Radiology 2008; 249:581–590
Abbreviations:
ACL ⫽ anterior cruciate ligament
IKDC ⫽ International Knee Documentation Committee
Author contributions:
Guarantors of integrity of entire study, N.S., L.M.W.; study
concepts/study design or data acquisition or data analy-
sis/interpretation, all authors; manuscript drafting or
manuscript revision for important intellectual content, all
authors; manuscript final version approval, all authors;
literature research, N.S., M.M.C., I.W.; clinical studies,
M.M.C., J.E., M.K., M.H., P.M.; statistical analysis, N.S.,
L.M.W., I.W.; and manuscript editing, N.S., L.M.W.
Authors stated no financial relationship to disclose.
Radiology: Volume 249: Number 2—November 2008
MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts
struction, and, in one patient, a ham-
string tendon graft had been previously
used for ACL reconstruction. For femo-
ral and tibial graft fixation, bioabsorb-
able or metallic screws and cross pins
were utilized. MR imaging and clinical
assessment were performed on the
same day.
MR Imaging Protocol
MR imaging was performed with a 1.5-T
imager (Signa Excite-II; GE Healthcare,
Milwaukee, Wis) by using a dedicated
eight-channel extremity send-receive
knee coil, with patients in a supine posi-
tion and with a fully extended knee. The
imaging parameters utilized for all pa-
tients are summarized in Table 1.
MR Imaging Analysis
All MR images were analyzed in consen-
sus by two fellowship-trained musculo-
skeletal radiologists with 12 years
(L.M.W.) and 2 years (N.S.) of profes-
sional experience. Readers were blinded
to findings of arthrometric (objective
quantitative index of graft stability or lax-
ity) (17) and subjective (International
Knee Documentation Committee [IKDC]
scoring) measurement at MR imaging
evaluation.
The following MR imaging findings
were evaluated:
1. Increased signal intensity of the
intraarticular portion of the ACL graft
was analyzed on intermediate-weighted
and T2-weighted images as present (in-
crease of signal intensity within the sub-
Table 1
MR Imaging Parameters for Long-term Follow-up of ACL Reconstruction Grafts
T2-weighted Fast Spin-Echo
Parameter Fat Saturation
Plane Axial
Repetition time (msec) 3500
Echo time (msec) 69
Field of view (mm) 140 ⫻ 140
Matrix size 256 ⫻ 256
Flip angle (degrees) 90
Thickness (mm) 4 4
No. of signals acquired 1.5
Echo train length 8 8
* SPGR ⫽ spoiled gradient-recalled acquisition in the steady state.
Radiology: Volume 249: Number 2—November 2008
stance of the graft) or absent (no in-
creased signal intensity change). If in-
creased intrasubstance signal intensity
was present, the location of signal inten-
sity was defined as within the proximal
and/or distal half of the tendon graft.
2. When present, the amount of in-
creased intrasubstance graft signal inten-
sity was assessed and subclassified as
comprising less than 25%, 25%–50%, or
more than 50% of the maximum cross-
sectional area of the graft on intermediate
and T2-weighted acquisitions.
3. Increased intrasubstance graft sig-
nal intensity, when present, was further
characterized as being either striated (lin-
ear) in morphologic appearance, oriented
along the long axis of the graft, or as focal
or globular in morphologic appearance on
intermediate-weighted and T2-weighted
images.
4. The position of the ACL graft tibial
tunnel was assessed relative to the Blumen-
saat line (slope of the intercondylar roof) on
sagittal intermediate-weighted and T2-
weighted images (Fig 1). If the anterior
margin of the articular orifice of the tibial
tunnel was located posterior to the Blumen-
saat line, the distance was recorded as a
negative value (in millimeters), and if it was
located anterior to the Blumensaat line, the
distance was recorded as a positive value
(in millimeters) (1).
5. The position of the ACL graft fem-
oral tunnel was assessed relative to the
intersection of the posterior femoral cor-
tex and the distal femoral physeal scar
corresponding to the superior-posterior
Sequence
Intermediate-weighted Three-Dimensional
Fast Spin-Echo SPGR*
Coronal Coronal
5117 44
40 4 15
140 ⫻ 140 160 ⫻ 160
256 ⫻ 512 512 ⫻ 512
90 25
1.5
1 1
1 6
Saupe et al
margin of the intercondylar roof on sagit-
tal images (Fig 2). Positioning of the pos-
terior margin of the articular orifice of the
femoral tunnel at the intersection point
was recorded as 0. If the posterior margin
of the tunnel orifice was located below
this intersection, the measured distance
between these points was recorded as a
positive value (in millimeters) (6).
6. The slope of the graft in the
coronal plane was assessed as the an-
gle formed between a line drawn along
the long axis of the ACL graft and the
plane of the tibial articular surface
(18) (Fig 3).
Clinical Assessment
Knee stability.—As an objective quantita-
tive index of graft stability or laxity, test-
ing with an arthrometer (KT 1000; Med-
Metric, San Diego, Calif) in all patients
was performed (17). Testing was per-
formed by a single examiner (J.E., with 1
year of experience and training in arthro-
metric measurement) who was blinded to
MR imaging findings, IKDC results, and
clinical history. Both the knee that was
treated with surgery and the contralateral
knee were examined in each patient by
using a single-calibrated arthrometric de-
vice (KT 1000) with a force of 15, 20, and
30 lb. Measurements were obtained
three times for each force in each knee.
The mean difference (in millimeters)
of measured anteroposterior transla-
tional displacement between the two
knees (treated vs contralateral knee)
was then calculated for each patient at
Intermediate-weighted T2-weighted Fast Spin-Echo
Fast Spin Echo Fat Saturation
Sagittal Sagittal
2000 4100
75
140 ⫻ 140 140 ⫻ 140
288 ⫻ 256 256 ⫻ 256
90 90
4 4
2 1.5
8
583
MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts Saupe et al

each force (15, 20, and 30 lb). The
mean difference in anteroposterior
translational displacement between a
patient’s treated (ACL reconstructed)
and untreated (normal) knee was cat-
egorized as normal if the mean antero-
posterior displacement difference was
less than 3 mm and as abnormal if the
mean anteroposterior displacement
difference was 3 mm or greater (17).
IKDC score.—Subjective patient as-
sessment of function was performed by
using IKDC evaluation forms. The IKDC
subjective knee form consists of 18
questions in the domain of symptoms,
functioning during activities of daily liv-
ing and sports, current function of the
knee, and participation in work and
sports. The highest possible result is
100 (19). As recommended by previous
investigators, IKDC patient data were
subcategorized into patient groups ac-
cording to age as follows: 16 –24 years,
25–34 years, 35–50 years, and 51– 65
years (19).
Statistical Analysis
The graft signal intensity changes on in-
termediate- and T2-weighted images
and arthrometric assessments were
classified as binary variables. Differ-
ences in arthrometric measurement of
more than 3 mm were considered ab-
normal, and differences in arthrometric
measurement of less than 3 mm were
considered normal. Therefore, for com-
parison of patients in the normal versus
abnormal group in view of continuous
variables, the Wilcoxon rank sum test
was used. For comparison in respect to
categoric variables, the Fisher exact test
was used. For both tests, Bonferroni cor-
rection was performed, and P values less
than .008 were considered to indicate sig-
nificant differences. For the subclassified
amount of increased intrasubstance graft
signal intensity on T2- and intermediate-
weighted images in comparison to patient
sex and to changes of more than 3 mm
between treated and untreated knees at
arthrometric testing at different forces,
analysis of variance was used.
For assessment of potential differ-
ences between the arthrometric mea-
surements in untreated and treated
knees, a Student two-tailed t test was
utilized. A P value of less than .05 was
considered to indicate a significant dif-
ference. For assessment of IKDC re-
sults in comparison to patient sex, a
one-level analysis of variance was used.
For assessment of IKDC results at dif-
ferent ages, analysis of covariance was
used to keep age as a continuous vari-
able because of the sparse number of
patients in each age group. For all statis-
tical calculations, SPSS software (ver-
sion 11.0, SPSS, Chicago, Ill) was used.
Results
MR Imaging Findings
Intermediate-weighted imaging.—In-
creased intrasubstance ACL graft signal
was found in 33 (70%) of 47 patients at
intermediate-weighted imaging. When
present, increased signal intensity was lo-
cated in the proximal half of the graft in
24 (73%) of 33 patients, in the distal
halves of the graft in 28 (85%) of 33 pa-
tients, and in both the proximal and distal
halves of ACL graft in 19 (58%) of 33
patients.
In those patients with increased
graft signal intensity changes on inter-
mediate-weighted images, 23 (70%) of

Figure 1

Figure 1: Sagittal intermediate-weighted MR images (repetition time msec/echo time msec, 2000/15) in a (a) 38-year-old woman, (b) 48-year-old man, and (c) 51-
year-old woman show the position of the tibial tunnel (arrowheads) relative to a distal extension of Blumensaat line (dashed line, a–c). In a, the anterior margin of the
tunnel is located anterior to Blumensaat line; in b, it is directly posterior; and in c, it is even more posterior.

584 Radiology: Volume 249: Number 2—November 2008

MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts Saupe et al

Figure 2
33 patients had signal intensity changes
comprising less than 25% of the maxi-
mum cross-sectional area of the graft.
In six (18%) of 33 patients, signal inten-
sity changes involved 25%–50% of the
cross-sectional area of the tendon graft,
and in four (12%) of 33 patients, signal
intensity changes involved more than
50% of the maximal cross-sectional
area of the tendon graft.
T2-weighted imaging.—Increased
signal intensity was seen within the sub-
stance of the ACL graft in 30 (64%) of 47
patients on T2-weighted images. Such in-
creased signal intensity was located in the
proximal half of the graft in 23 (77%) of
30 patients, in the distal half of the graft in
24 (80%) of 30 patients, and in both the
proximal and distal halves of the ACL
graft in 17 (57%) of 30 patients.
Figure 2: Sagittal intermediate-weighted MR images (2000/15) in a (a) 35-year-old woman and (b) 41-
Of the patients with increased intrasu- year-old man show the position of the femoral tunnel. In a, the position of the posterior margin of the femoral
bstance graft signal intensity changes on ACL graft tunnel (arrowheads) is shown at the intersection of posterior femoral cortex (arrows) and posterior
T2-weighted images, 21 (70%) of 30 pa- aspect of the distal femoral physeal scar. In b, the posterior margin of the femoral tunnel (arrowheads) is posi-
tients showed increased signal intensity tioned 4 mm below this intersection (arrows).
comprising less than 25% of the maximum
cross-sectional area of the graft (Fig 4). In
seven (23%) of 30 patients, signal intensity
changes involved 25%–50% of the cross-
sectional area of the tendon graft (Fig 5),
and in two (7%) of 30 patients, signal inten-
sity changes involved more than 50% of the
cross-sectional area of the tendon graft Figure 3
(Fig 6).
Striated signal appearance.—When
present, intrasubstance graft signal inten-
sity was characterized as striated on in-
termediate-weighted images in 29 (88%)
of 33 patients and on T2-weighted images
in 27 (90%) of 30 patients.
Focal or globular signal appear-
ance.—Observed intrasubstance ACL
graft signal intensity was characterized as
focal or globular in appearance on inter-
mediate-weighted images in 13 (39%) of
33 patients and on T2-weighted images in
13 (43%) of 30 patients.
Both striated and focal or globular
signal intensity were found on interme-
diate-weighted images in nine (27%) of
33 patients and on T2-weighted images
in 10 (33%) of 30 patients.
Tibial tunnel position.—Mean mea-
surement of tibial tunnel position was Figure 3: Coronal intermediate-weighted MR images (5117/40) in a (a) 33-year-old man and (b) 39-year-
old man show the slope of the graft as the angle between the long axis of the ACL graft (dashed line, a and b)
⫺3.6 mm ⫾ 2.8 (standard deviation)
and the plane of the tibial articular surface. In a, a smaller ACL angle was found than in b (65° in a, 81° in b).
behind the Blumensaat line (range, ⫺8
Arrowheads in a and b demarcate the medial and lateral margins of the graft.
to 6 mm) (Fig 1). Tibial tunnel position

Radiology: Volume 249: Number 2—November 2008 585

MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts Saupe et al

was sited posterior to an extension of
the Blumensaat line in 45 (96%) of 47
patients (range, ⫺8 to 0 mm).
Femoral tunnel position.—Mean po-
sition of the graft femoral tunnel was lo-
cated 1.2 mm ⫾ 1.17 below the intersec-
tion of the posterior femoral cortex and
the distal femoral physeal scar (range,
Figure 4
Figure 4: (a) Axial T2-weighted (3500/69) and (b) sagittal intermediate-weighted (2000/15) MR images in
a 28-year-old man show a small amount of striated increased signal intensity within the ACL graft (arrow-
heads), which comprised less than 25% of the maximum cross-sectional area of graft.
Figure 5
0 – 6 mm) (Fig 2). The posterior margin of
the articular orifice of the femoral tunnel
was located immediately at the intersec-
tion of the posterior femoral cortex and
the posterior physeal scar in 30 (64%) of
47 patients.
Slope of the graft.—The measured
mean angle formed between the long axis
of the ACL graft and the plane of the tibial
articular surface in the coronal plane was
71.4° ⫾ 5.3 (range, 62°– 85°) (Fig 3).
Clinical Assessment
Knee stability.—Three (6%) of 47 pa-
tients had an abnormal result in the
mean anteroposterior displacement dif-
ference (treated vs untreated knee) by
using a force of 15 lb, nine (19%) of 47
patients had an abnormal result by us-
ing a force of 20 lb, and 13 (28%) of 47
patients had an abnormal result by us-
ing a force of 30 lb.
Results of anteroposterior displace-
ment of treated and untreated knees in
all patients are shown in Table 2. There
were no significant differences in mean
arthrometric measurements between
treated and untreated knees at 15 and
20 lb (P ⫽ .14 and .06, respectively). A
significant difference in anteroposterior
displacement arthrometric measure-
ments between treated and untreated
knees was found at 30 lb (P ⫽ .009).
Results of analysis of variance showed a
highly significant effect of untreated ver-
sus treated (P ⫽ .001) and measure-
ments at increasing forces (P ⫽ .001).
IKDC score.—Results of the IKDC
form are presented in Table 3. Patients
were divided into different age groups
as suggested by Anderson et al (19).
Results of analysis of covariance showed
no significant effect of age (P ⫽ .351).

Statistical Results
The relationship between intrasubstance
signal intensity changes of ACL grafts on
intermediate-weighted and T2-weighted
images and continuous variables is
shown in Table 4. The relationship be-
tween intrasubstance signal intensity
changes of ACL grafts on intermediate-
weighted and T2-weighted images and
binary variables is shown in Table 5.
Results of analysis of variance for the
subclassified amount of increased intra-
substance graft signal intensity on T2-
weighted and intermediate-weighted
images showed no effect for patient sex
or for changes of more than 3 mm be-
Figure 5: (a) Axial T2-weighted (3500/69) and (b) sagittal intermediate-weighted (2000/15) MR images in tween treated and untreated knees at
a 46-year-old man show a globular region of increased signal intensity change within the ACL graft (arrow-
arthrometric testing at different forces.
heads). On the basis of assessment of this and contiguous axial and sagittal images, the amount of increased
There was also no interaction found for
signal intensity was graded as involving 25%–50% of the maximum cross-sectional area of graft.
these parameters. The only significant

586 Radiology: Volume 249: Number 2—November 2008

MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts Saupe et al

Figure 6
effect was found in the subclassified
amount of increased intrasubstance
graft signal intensity on intermediate-
weighted images for anterior position-
ing of the tibial tunnel (P ⫽ .03).

Discussion
During the first 3 months after ACL re-
construction, graft constructs are typi-
cally uniformly low in signal intensity on
T1- and T2-weighted images. Thereaf-
ter, a progressive vascularization of
periligamentous soft tissues with subse-
quent synovialization and remodeling
results in graft ligamentization (20).
During this postoperative phase (12–18
months), the graft may normally show a
Figure 6: (a) Axial T2-weighted (3500/69) and (b) sagittal intermediate-weighted (2000/15) MR images in
degree of intrasubstance increased sig- a 35-year-old man show a large amount of increased striated and globular signal intensity within the ACL graft
nal intensity on T1- and T2-weighted (arrowheads) involving more than 50% of the cross-sectional area of the graft.
images that is reflective of synovial and
neovascular proliferation around and
within the graft, which is referred to as Table 2
“neoligamentization” of graft tissue (9).
However, by 2 years after ACL recon- Results of Arthrometric Measurement according to Force in 47 Patients
struction, the literature suggests that a Force (lb) Treated Knee (mm) Untreated Knee (mm) Difference (mm) P Value*
normal graft tendon should resume a
15 2.8 ⫾ 1.1 2.5 ⫾ 1.3 0.3 ⫾ 1.3 .14
uniform normal low-signal-intensity MR
20 4.8 ⫾ 1.8 4.1 ⫾ 1.7 0.7 ⫾ 1.8 .06
imaging appearance (1,14).
30 7.4 ⫾ 2.3 6.2 ⫾ 2.2 1.2 ⫾ 2.4 .009
Prior studies (6,21) have revealed
findings of increased intrasubstance Note.—Data are means ⫾ standard deviations.
graft signal as a sign of graft impinge- * A two-tailed Student t test for each force was used. A P value of less than .05 was considered to indicate a significant difference.
ment. Furthermore, partial tears of an
ACL graft may appear as areas of in-
creased signal intensity within the graft tients more than 4 years after ACL recon- Table 3
tissue with some residual intact fibers struction. IKDC Score according to Age Group
on T2-weighted images (7). Recht et al Several factors have been identified
Mean
(22) reported that T2-weighted acquisi- as the cause of increased graft signal Age Group Age (y) IKDC Score*
tions may also show regions of in- intensity on short– echo time images
16–24 years
creased signal intensity within an intact that may lead to a false interpretation of
0 male patients NA NA
graft, if such signal was not isointense a discontinuous or torn graft. By using
2 female patients 22.0 64.4 ⫾ 8.1
relative to fluid and not traversing the shorter echo times at clinical MR imag- 25–34 years
full thickness of the graft construct. ing, focal increased signal intensity can 13 men 29.5 86.8 ⫾ 11.1
These findings of Recht and co-workers be seen on intermediate- and T1- 11 women 30.0 89.3 ⫾ 7.6
are in agreement with the results of our weighted MR acquisitions in tendons 35–50 years
study, in which we observed increased and ligaments because of variations in 12 men 39.7 79.3 ⫾ 15.5
intrasubstance graft signal intensity on in- the density of the fiber bundles and the 8 women 40.4 79.0 ⫾ 10.7
termediate- and T2-weighted MR images mobility of intrasubstance protons (23). 51–65 years
in the majority of patients imaged more Focal increased ACL graft signal inten- 1 man 53.0 95.4
0 women NA NA
than 4 years after ACL graft reconstruc- sity on intermediate-weighted acquisi-
All age groups
tion. In our study, the observed increased tions has also been hypothesized to be
26 men 35.1 83.6 ⫾ 13.6
intrasubstance graft signal intensity related to subtle alterations in the colla- 21 women 33.2 83.0 ⫾ 11.6
changes did not correlate with findings of gen structure of the graft caused by in- 47 patients 34.3 83.4 ⫾ 12.6
measured anterior tibial translational in- strumentation or mechanical stress (9).
stability (arthrometric measure) or func- As a result, some investigators (9) have Note.—*Data are means ⫾ standard deviation. NA ⫽
not applicable.
tional limitations (IKDC scoring) in pa- favored the use of T2-weighted se-

Radiology: Volume 249: Number 2—November 2008 587

MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts Saupe et al

quences to evaluate signal characteris- Hodler et al (15) in cadaveric ACLs. The reconstruction without the loss of sta-
tics and integrity of ACL grafts. In our clinical importance of degeneration of bility (25,26). Optimal positioning of
study, increased intrasubstance graft ACLs or graft constructs is probably the tibial tunnel is important to prevent
signal intensity changes were found on limited, but degeneration may result in graft impingement (27), which most
both short– echo time (intermediate- MR findings that simulate findings of commonly occurs when the graft tibial
weighted) and T2-weighted images in a possible ligament tears (15). In a study tunnel is positioned at a point anterior
similar proportion of cases (intermedi- by Narvekar (24), five patients with mu- to the Blumensaat line (6). To re-create
ate-weighted signal intensity in 70%, coid degeneration (increased T1- and the anatomic origin of the ACL during
T2-weighted signal intensity in 64%). T2-weighted signal intensity changes) of graft reconstruction, optimal position-
A potential cause of mild intrasu- the ACL had an intact ligament at knee ing of the femoral tunnel is along the
bstance signal changes within an ACL arthroscopy, without signs of ligamen- posterior margin of the femoral notch in
graft at long-term follow-up is degenera- tous instability at clinical examination. the sagittal plane (28,29). A 62.5% in-
tive changes (eg, eosinophilic or mucoid The goal of graft fixation is to pre- cidence of graft failure has been de-
degeneration). Such intrasubstance de- vent stretching or loosening of recon- scribed in cases where the femoral tun-
generative changes were found in ap- struction grafts, thereby permitting nel is placed too far anteriorly (28). In
proximately 60% of cases in a study by early motion and weight bearing after our study, the anterior margin of the
tibial tunnel was located posterior to the
Blumensaat line in 96% of cases, and
Table 4 the posterior margin of the femoral tun-
P Values of the Relationship between Signal Intensity Changes of ACL Graft and nel was positioned posteriorly, along
Assessed Continuous Variables the femoral notch immediately at the
intersection of the posterior femoral
Time Since IKDC Tunnel Position Slope of
cortex and the posterior physeal scar, in
Parameter Surgery Age Score Tibial Femoral Graft
64% of cases.
Overall signal intensity changes on Optimal anatomic orientation of an
intermediate-weighted ACL graft relative to the tibia in the
images (n ⫽ 33) .592 .600 .667 .542 .251 .492 coronal plane is similarly important in
Striated .547 .399 .887 .315 .425 .826 successful ACL reconstruction (30). To
Focal or globular .128 .391 .773 .773 .246 .194 avoid graft laxity and loss of extension, a
Overall signal intensity changes on coronal ACL angle less than 75° has
T2-weighted images (n ⫽ been described in the literature as opti-
30) .610 .773 .698 .421 .304 .179 mal (30). This result is in good correla-
Striated .576 .332 .722 .245 .723 .477
tion to our findings, with a mean slope
Focal or globular .128 .391 .773 .773 .246 .194
of ACL graft tendons in our study cohort
Note.—Number of patients was 47. Tibial and femoral tunnel position were measured in millimeters. Slope of the graft was measuring 71.4° ⫾ 5.3 in the coronal
measured in degrees. P values were calculated by using the Wilcoxon rank sum test with Bonferroni correction. P values less plane.
than .008 were considered to indicate statistically significant differences.
The clinical detection of pathologic
anterior translational laxity of the knee
is based on excessive forward transla-
tion of the tibia relative to the femur.
Table 5
Instrumented cadaveric studies (31,32)
P Values of the Relationship between Signal Intensity Changes of ACL Graft and have revealed that sectioning the ACL
Assessed Binary Variables alone results in increased anterior tibial
Parameter Sex 15-lb Force 20-lb Force 30-lb Force motion. Several factors have been iden-
tified that can affect displacement mea-
Overall signal intensity changes on surements, including joint flexion, joint
intermediate-weighted images (n ⫽ 33) .112 .208 .102 .037 rotation, freedom of rotation during the
Striated .130 .549 .274 .017 testing, displacement force, limb muscle
Focal or globular ⬎.99 .550 .520 .482 tone, and soft-tissue restraints. All
Overall signal intensity changes on
these factors must be kept constant
T2-weighted images (n ⫽ 30) .660 .544 .252 .176
while measuring anterior translational
Striated .051 .567 .465 .045
displacement by using devices such as
Focal or globular ⬎.99 .550 ⬎.99 ⬎.99
the arthrometer (33–35).
Note.—Number of patients was 47. P values were calculated by using the Fisher exact test with Bonferroni correction. P values A wide range of anterior displace-
less than .008 were considered to indicate statistically significant differences. Arthrometric results are mean measurement ment measurements can be found in the
differences of more than 3 mm between the treated and the contralateral knee by using forces of 15, 20, and 30 lb.
normal knee (17). As a result of this

588 Radiology: Volume 249: Number 2—November 2008

MUSCULOSKELETAL IMAGING: MR Imaging of Reconstruction Grafts
variation, a useful measure of patho-
logic anterior translational laxity is to
compare the contralateral knee with the
injured knee, with an anterior displace-
ment difference greater than 3 mm in-
dicative of excess anterior joint laxity
(17). In our study, no significant associa-
tion was found between ACL graft MR
signal intensity changes and arthrometric
displacement differences greater than 3
mm between the treated and untreated
knee.
Similarly, findings of the subjective
IKDC knee form (19), a well-standard-
ized outcome instrument and a valuable
measure of symptoms, function, and
sport activity, showed no significant as-
sociation to signal intensity changes of
the ACL graft in our study cohort.
Limitations of our investigation in-
cluded the lack of histopathologic or sec-
ond-look arthroscopic correlation with
the MR imaging findings described. It is
possible that the signal changes ob-
served are related to pathologic condi-
tions of the graft tendon, which may not
be shown in clinically evident laxity or
patient function. However, the exact
cause of the signal changes observed
has not been proved or confirmed by
the study findings. Another limitation of
our study was the influence of potential
study-selection bias. Our study results
are based on findings in a cohort of pa-
tients presumably doing clinically well
after surgery, and not seeking medical
or clinical reassessment. Not all consec-
utive patients who underwent ACL re-
construction surgery were able to be
successfully enrolled in the study. It is
feasible that patients not doing well clin-
ically and those with potential complica-
tions may have been lost to contact and
follow-up. However, the cohort study is
likely reflective of a spectrum of postop-
erative findings in patients at long-term
follow-up after ACL surgery.
In summary, mild degrees of in-
creased intrasubstance graft signal in-
tensity can be seen after ACL recon-
struction at long-term follow-up (⬎4
years) on both intermediate- and T2-
weighted images in about two-thirds of
patients. Such intrasubstance graft sig-
nal intensity change does not correlate
with findings of anterior translational in-
Radiology: Volume 249: Number 2—November 2008
stability or functional limitations in pa-
tients after long-term follow-up of ACL
reconstruction in grafts that have good
tibial and femoral tunnel positions and
good ACL slope angle.
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