ÖN ÇAPRAZ BAĞ REKONSTRÜKSİYONU YAPILAN HASTALARDA TÜNEL GENİŞLİĞİNİN ÖLÇÜMÜNDE MANYETİK REZONANS GÖRÜNTÜLEME VE BİLGİSAYARLI TOMOGRAFİ’NİN KARŞILAŞTIRMALI GÜVENİLİRLİK ANALİZİ

Öz

Giriş:

Ön çapraz bağ (ÖÇB) cerrahisi sonrası tünel genişlemesi radyolojik olarak farklı tetkikler ile ölçülebilmektedir. Hasta takiplerinde tünel genişlemesinin değerlendirilmesinde bilgisayarlı tomografi (BT) ve manyetik rezonans görüntüleme (MRG) tetkikleri kullanılmaktadır. Çalışmamızın amacı; artroskopik ÖÇB tamiri uygulanan hastalarda femoral ve tibial tünel genişliği ölçümünde görüntüleme tetkikleri arasındaki güvenilirliği analiz etmektir. 

Gereç ve yöntemler:

Kliniğimizde hamstring otogrefti kullanılarak asansör sistemi ile izoanatomik artroskopik ÖÇB rekonstrüksiyonu yapılan ve takiplerinde lineer tünel genişlemesi olan 24 hasta çalışmaya dahil edildi. Hastaların BT ve MRG’de aksiyel, koronal ve sagittal planda tünel genişlikleri, 5 gözlemci tarafından ölçüldü. Kesitler üzerinde her gözlemci tarafından femoral ve tibial tüneller için giriş, orta, çıkış genişliği PACS (Picture Archiving and Communication System) sistemi üzerindeki cetvel uygulaması ile ölçüldü. Ölçümler birer hafta arayla tekrarlandı ve bağımsız bir cerrah tarafından kayıt edildi. 

Bulgular:

Çalışmamızda femur ölçümlerinin tüm kesitlerinde toplam 90 ölçümden MRG’de 14, BT’de 11 anlamlı fark görüldü (p<0.05). Tibia ölçümlerinin tüm kesitlerinde toplam 90 ölçümden MRG’de 19, BT’de 11 anlamlı fark görüldü (p<0.05). Femur koronal kesitlerinde gözlemci-içi güvenilirlik MRG’de 0.69, BT’de 0,85 olarak bulundu, sagittal kesit için MRG’de 0.41 ve BT’de 0.77 ve aksiyel kesit için ise MRG’de 0.45 BT’de 0.78 olarak bulundu. Tibia kesitlerinde koronal ölçümlerde gözlemci-içi güvenilirliğimizi MRG’de 0.66, BT’de 0.81, sagittal kesitlerde MRG’de 0.38, BT’de 0.69, aksiyel kesitlerde MRG’de 0.45, BT’de 0.79 olarak bulundu. Femur kesitlerinde gözlemcilerin ölçümü giriş, orta veya çıkıştan yapmaları arasında anlamlı fark bulunmamıştır. Tibiada femur ölçümlerine göre hatalı ölçüm sayısı daha yüksek ve güvenilirlik daha düşük bulundu. 

Sonuçlar:

Sonuç olarak lineer genişlemesi olan hastalarda tünelin girişinden, ortasından veya çıkışından ölçümünün fark yaratmayacağını; ölçümlerde koronal kesitlerin kullanılmasının ve mümkünse görüntülemede BT’nin tercih edilmesinin daha doğru sonuçlar vereceğini düşünmekteyiz. Ancak ilerleyen yıllarda daha yüksek çözünürlüklü MRG ile yapılacak karşılaştırmalı çalışmalarda benzer veya daha fazla güvenilirlik saptanması durumunda tünel genişlemesi ölçümünde BT’nin radyoaktif etkileri de düşünüldüğünde MRG daha tercih edilir hale gelebilir. 

Anahtar Kelimeler

• Ön çapraz bağ yırtığı,Bilgisayarlı tomografi,Manyetik rezonans görüntüleme,Tünel genişliği,Düz grafi

RELIABILITY ANALYSIS OF MAGNETIC RESONANCE IMAGING AND COMPUTERIZED TOMOGRAPHY IN THE MEASUREMENT OF TUNNEL WIDTH AFTER ANTERIOR CRUCIATE LIGAMENT REPAIR.

Öz

Background:

Tunnel widening after Anterior cruciate ligament (ACL) surgery can be measured by several radiological methods. Computed tomography (CT) and magnetic resonance imaging (MRI) are used the assessment of tunnel widening in patient follow-up. The aim of our study is to analyse the reliability of tunnel width measuring between two different radiographic methods.

 

Material and Methods:

24 patients who were performed isoanatomic Arthroscopic Anterior Cruciate Ligament Reconstruction by using hamstring autograft with elevator system in our clinic and had linear tunnel widening in their follow-up were included in the study. Five observers measured the tunnel width on sagittal, coronal and axial images of CT and MRI of the patients. Entrance, middle and out wide for the femoral and tibial tunnels were measured by each observer on these sections with a ruler application on the PACS system (Picture Archiving and Communication System). The measurements were repeated with one week interval and the measurements were documented by an independent surgeon.

 

Results:

14 significant differences in MRI measurements and 11 significant differences in CT measurements were seen in a total of 90 femoral measurements in all sections (p<0.05). 19 significant differences in MRI measurements and 11 significant differences in CT measurements were seen in a total of 90 tibial measurements in all sections (p<0.05). Intraobserver reliability of femoral coronal, sagittal and axial sections was found 0.69 in MRI and 0.85 in CT, 0.41 in MRI and 0.77 in CT, 0.45 in MRI and 0.78 in CT, respectively. Intraobserver reliability of tibial coronal, sagittal and axial sections was found 0.66 in MRI and 0.81 in CT, 0.38 in MRI and 0.69 in CT, 0.45 in MRI and 0.79 in CT, respectively. There was no significant difference between making the measurement of observer in the entrance, middle or out at femoral sections. The tibial measurements were found to be higher number of incorrect measurements and lower reliability than femoral measurements.

 

Conclusions:

As a result, there is no difference whether making the measurement of tunnel from entrance, middle or out in patients with liner widening, the using of coronal section in measurements and if possible CT scan preference would give more accurate results. However, in later years the comparative studies with higher-resolution MRI to measure the widening of the tunnel in case of similar or greater reliability with computed tomography, MRI will be more preferable when also we take into account of radioactive effects of CT.

Anahtar Kelimeler

• Anterior cruciate ligament tear,computed tomography,magnetic resonance imaging,tunnel width,conventional graphy

Kaynakça

1. Referans1- Ellison, A. E., Berg, E. E. Embryology, anatomy, and function of the anterior cruciate ligament. The Orthopedic clinics of North America, 1985;16(1),3.
2. Referans2- Duthon, V. B., Barea, C., Abrassart, S., Fasel, J. H., Fritschy, D., Ménétrey, J. Anatomy of the anterior cruciate ligament. Knee Surgery, Sports Traumatology, Arthroscopy, 2006; 14(3), 204-213.
3. Referans3- Kondo, E., Merican, A. M., Yasuda, K., Amis, A. A. Biomechanical analysis of knee laxity with isolated anteromedial or posterolateral bundle–deficient anterior cruciate ligament. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2014; 30(3), 335-343.
4. Referans4- Fink, C., Zapp, M., Benedetto, K. P., Hackl, W., Hoser, C., Rieger, M. Tibial tunnel enlargement following anterior cruciate ligament reconstruction with patellar tendon autograft. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2001;17(2), 138-143.
5. Referans5- Struewer, J., Efe, T., Frangen, T. M., Schwarting, T., Buecking, B., Ruchholtz, S., Ziring, E. Prevalence and influence of tibial tunnel widening after isolated anterior cruciate ligament reconstruction using patella-bone-tendon-bone-graft: long-term follow-up. Orthopedic reviews, 2012; 4(2), 21.
6. Referans6- Weber, A. E., Delos, D., Oltean, H. N., Vadasdi, K., Cavanaugh, J., Potter, H. G., Rodeo, S. A. Tibial and femoral tunnel changes after ACL reconstruction: a prospective 2-year longitudinal MRI study. The American journal of sports medicine, 2015; 43(5), 1147-1156.
7. Referans7- Webster, K. E., Feller, J. A., Elliott, J., Hutchison, A., Payne, R. A comparison of bone tunnel measurements made using computed tomography and digital plain radiography after anterior cruciate ligament reconstruction. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2004; 20(9), 946-950.
8. Referans8- Shrout, P. E., Fleiss, J. L. Intraclass correlations: uses in assessing rater reliability. Psychological bulletin, 1979; 86(2), 420.

9. Referans9- Crespo, B., Aga, C., Wilson, K. J., Pomeroy, S. M., LaPrade, R. F., Engebretsen, L., Wijdicks, C. A. Measurements of bone tunnel size in anterior cruciate ligament reconstruction: 2D versus 3D computed tomography model. Journal of experimental orthopaedics, 2014; 1(1), 2.
10. Referans10- Kawaguchi, Y., Kondo, E., Kitamura, N., Kai, S., Inoue, M., Yasuda, K. Comparisons of femoral tunnel enlargement in 169 patients between single-bundle and anatomic double-bundle anterior cruciate ligament reconstructions with hamstring tendon grafts. Knee Surgery, Sports Traumatology, Arthroscopy, 2011; 19(8), 1249-1257.
11. Referans11- Iorio, R., Di Sanzo, V., Vadalà, A., Conteduca, J., Mazza, D., Redler, A., et al. ACL reconstruction with hamstrings: how different technique and fixation devices influence bone tunnel enlargement. Eur Rev Med Pharmacol Sci 2013; 17:2956-2961.
12. Referans12- Iriuchishima, T., Shirakura, K., Yorifuji, H., Aizawa, S., Fu, F. H. Size comparison of ACL footprint and reconstructed auto graft. Knee surgery, sports traumatology, arthroscopy, 2013; 21(4), 797-803.
13. Referans13- Hwang MD, Jason WP, Metz S, Metz J. Tibial insertions of the anteromedial and posterolateral bundles of the anterıor cruciate ligament: Morphometry, arthroscopic landmarks and orientation model for bone tunnel placement. Arthroscopy. 2008; 24:154-161.
14. Referans14- Zaffagini S, Martelli S, Acquaroli F. Computer investigation of ACL orientation during passive range of motion. Comput Biol Med. 2004; 34(2):153-163.
15. Referans15- Olsen, O. E., Myklebust, G., Engebretsen, L., Bahr, R. Injury mechanisms for anterior cruciate ligament injuries in team handball a systematic video analysis. The American journal of sports medicine, 2004; 32(4); 1002-1012.
16. Referans16- Zantop T, Brucker PU, Vidal A, Zelle BA, Fu FH. Intraarticular rupture pattern of the ACL. Clin Orthop Relat Res 2007; 454:48-53.
17. Referans17- Gabriel, M. T., Wong, E. K., Woo, S. L. Y., Yagi, M., Debski, R. E. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. Journal of Orthopaedic Research, 2004; 22(1), 85-89.
18. Referans18- L’Insalata, J. C., Klatt, B., Fu, F. H., Harner, C. D. Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surgery, Sports Traumatology, Arthroscopy, 1997; 5(4), 234-238.
19. Referans19- Clatworky MG, Annear P, Bulow JU, Barlett RJ. Tunnel widening in anterıor cruciate ligament reconstruction; a prospective evaluation of hamstring and patellar tendon grafts. Knee Surgery Sports Traumatol Arthroscopy 1999; 7(3);138-145.
20. Referans20- Robbrecht, C., Claes, S., Cromheecke, M., Mahieu, P., Kakavelakis, K., Victor, J., Verdonk, P. Reliability of a semi-automated 3D-CT measuring method for tunnel diameters after anterior cruciate ligament reconstruction: a comparison between soft-tissue single-bundle allograft vs. autograft. The Knee, 2014; 21(5), 926-931.
21. Referans21- Wilson TC, Kantaras A, Atay A, Johnson DL. Tunnel enlargement after anterıor cruciate ligament surgery. Am J Sports Medicine 2004; 32:543-549.
22. Referans22- Marchant MHJrr, Willimon SC, Vinson E, Pietrobon R, Grrett We, Higgins LD. Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterıor cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010; 18:1059-1064.
23. Referans23- Parkar AP, Adriaensen ME, Strand T, Inderhaug E, Harlem T, Solheim E. How to read post-operative radiographs and CT scans after single-bundle anteriorcruciate ligament reconstruction. Skeletal Radiol. 2013;42(11):1489-1500.