Liggieri, César Janovsky, Alexandre Pedro Nicolini, Moises Cohen

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

Article

Ultrasonography

for

evaluation

of

hamstring

tendon

diameter:

is

it

possible

to

predict

the

size

of

the

graft?

夽

Diego

da

Costa

Astur,

João

Victor

Novaretti

∗

_,

_Andre

_Cicone

_Liggieri,

César

Janovsky,

Alexandre

Pedro

Nicolini,

Moises

Cohen

DepartamentodeOrtopediaeTraumatologia,EscolaPaulistadeMedicina,UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil

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Articlehistory:

Received12December2016 Accepted23February2017 Availableonline8June2018

Keywords:

Anteriorcruciateligament Kneeinjuries

Ultrasonography

a

b

s

t

r

a

c

t

Objective:Performthepreoperativemeasurementofthehamstringtendonsusing ultra-soundimaging,validating andcorrelating themeasuredvalue withthat foundduring surgicalreconstructionoftheligament.

Methods:Across-sectionalstudywascarriedoutwith24patientswhounderwent ultra-sonographicmeasurementofthesemitendinosusandgracilismuscletendonsandwere subsequentlysubmittedtosurgicalreconstructionoftheACL,withipsilateral semitendi-nosusandgracilistendongrafting.

Results:Thepatients’agesrangedfrom16to43years,withameanof24.8years(SD=8.4 years),79.2%weremen,andthedistributionbysidewas41.7%rightkneesand58.3%left knees.Anon-significantcorrelationcoefficientwasfoundbetweentheareacalculatedby ultrasound(2×semitendinosusarea+2×gracilisarea)andtheintraoperativemeasurement (r=0.16;p=0.443).Noevidenceofadifferencebetweenintraoperativemeasurements<8mm and≥8mmwasfoundfortheareacalculatedbytheultrasound(p=0.746).Thedifference observedbetweenthegroupswas−0.01(95%CI:−0.09to0.07).

Conclusion:Preoperativeultrasoundimagingofthesemitendinosusandgracilistendons doesnotpresentastatisticallysignificantcorrelationwiththeintraoperativemeasurement ofthequadruplehamstringgraftforligamentreconstruction.

夽

StudyconductedatUniversidadeFederaldeSãoPaulo,EscolaPaulistadeMedicina,CentrodeOrtopediaeTraumatologiadoEsporte (CETE),SãoPaulo,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](J.V.Novaretti). https://doi.org/10.1016/j.rboe.2018.05.005

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Ultrassonografia

para

avaliac¸ão

do

diâmetro

dos

tendões

flexores

do

joelho:

é

possível

predizer

o

tamanho

do

enxerto?

Palavras-chave:

Ligamentocruzadoanterior Traumatismosdojoelho Ultrassonografia

r

e

s

u

m

o

Objetivo: Fazeramensurac¸ãopré-operatóriadostendõesflexoresdojoelhocomousodo examedeultrassonografia,validarecorrelacionarovalormedidocomaqueleencontrado duranteareconstruc¸ãocirúrgicadoligamento.

Métodos: Estudotransversalcom24 pacientessubmetidosamensurac¸ão ultrassonográ-fica dos tendões dos músculos semitendíneoe grácil e posteriormente submetidos a reconstruc¸ãocirúrgicadoLCA,comenxertoipsilateraldostendõessemitendíneoegrácil doprópriopaciente.

Resultados: Aidadedospacientesvariouentre16e43anos,commédiade24,8(DP=8,4), 79,2%eramhomenseadistribuiçãoquantoaoladofoide41,7%joelhosdireitose58,3% joelhosesquerdos.Foiencontradocoeficientedecorrelaçãonãosignificanteentreaárea cal-culadaapartirdoultrassom(2×áreadosemitendíneo+2×áreadográcil)eamedidaobtida intraoperatoriamente(r=0,16,p=0,443).Nãofoiencontradaevidênciadediferençaentre medidasintraoperatórias<8mme≥8mmquantoàáreacalculadaapartirdoultrassom (p=0,746).Adiferençaobservadaentreosgruposfoide-0,01(IC95%:-0,09a0,07).

Conclusão: A mensuraçãopré-operatória por métodode imagemultrassonográfico dos tendõesdosmúsculossemitendíneoegrácilnãoapresentacorrelaçãoestatisticamente significante coma mensuração intraoperatória doenxerto quádruplo de flexores para reconstruçãoligamentar.

Introduction

Anterior cruciate ligament (ACL) reconstruction is one of the most performed surgeries worldwide, with more than 120,000 procedures per year in the United States.1 _In order to restore the ACL function on knee stability, graft reconstruction is currently considered the gold standard. This graft may be autologous or from a tissue bank (allograft).2,3

Thechoiceofgraft dependson the patient, the typeof implant used, and the availability of a tissuebank.3,4 _The following grafts are most commonly used: tendons of the knee flexor muscles (hamstring), semitendinosusand gra-cilis,patellartendon,andquadricipitaltendon.InBrazil,knee flexorgraftingistheoptionusedby82.3%oftheknee special-istswhoparticipatedinresearchatanationalconference.5_In additiontoadequate technique,graft sizeisalsoextremely importantforthesuccessoftheprocedure.4

Whenusingquadricipitalorpatellargrafts,itispossible todeterminegraftsize.4 _However,_when_the_graft_option _is thehamstrings(kneeflexortendons),theliteraturedoesnot describeawell-recognizedandaccuratemethodforpredicting graftsizepreoperatively.Previousstudieshaveuseddifferent methodsofpreoperativemeasurementtoadequatelypredict flexorgraftsize,suchasanthropometricdata5–9_and_imaging studies.10–15

Thelimitationinpreoperativemeasurementinrelationto flexorgraftsisimportant,astherearereportsintheliterature thatgraftssmallerthan8mmindiameterincreasethechance ofACLreconstructionfailure.4,16–19

Thepresentstudy isaimedatperforming the preopera-tivemeasurementofthekneeflexortendonswithultrasound imaging, andto validateandcorrelate themeasured value withthatfoundduringthesurgicalreconstructionofthe lig-ament.

Material

and

methods

This isa cross-sectionalstudy submitted and approvedby the Research Ethics Committeeofthe institutionin which thestudywasconducted.Theinclusioncriteriawerepatients with clinical and radiological diagnosis ofACL injury who underwentsurgicalreconstructionofthisligamentusingan autograftfromthesemitendinosusandgracilistendonsofthe ipsilateral limb,who agreedtoparticipateinthestudy and signedtheInformedConsentForm.Thenon-inclusioncriteria werepatientsinwhomflexorgraftswereusedforaprevious surgicalprocedureandpatientswithrheumatologicdiseases. The exclusion criteria were patients who for any reason, despitehavingbeenscheduledtoreceivea semitendinosus-gracilisgraft,receivedgraftsotherthantheflexorgraftduring surgery,andpatientswhochosenottoparticipateinthestudy.

Ultrasoundevaluation

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Fig.1–(A)Ultrasonographicmeasurementofthesemitendinosusmuscletendoninatransverseplane;(B)ultrasonographic

measurementofthesemitendinosusmuscletendoninananteroposteriorplane.

7–11MHztransducer.Thepatientwaspositionedinthe ven-tralrecumbentposition,andthetendonsweremeasuredat thearticularline;threevalueswereobtained:anteroposterior (AP)diameterandtransversediameterinmillimeters(mm), andcross-sectionalareainsquaremillimeters(mm2_;_Fig.₁_A andB).

Surgicalprocedureandintraoperativemeasurement

The patients then underwent ACL reconstruction, using a semitendinosus and gracilis flexor tendon graft, always removedbythe sameorthopedistusingthefollowing tech-nique:3mmlongitudinalincisionintheanteromedialregion of the leg, beginning 2mm distal and medial to the tib-ialtuberosity.Thenthesemitendinosusandgracilistendons weredissectedand removedwithatendonstripper(Smith &Nephew,London,England).Thegraftwascleanedand pre-paredonaspecifictableforthispurpose(Smith&Nephew, London,England).Thetendonshad theirendssuturedand werefoldedinhalftogethertoformaquadruplegraft,as rou-tinelyusedinligamentreconstructions.Thegraftwasthen measuredwithagraftmeasurementblock(Smith&Nephew, London, England), which has orifices for measurement in 0.5mmincrements.Themeasurementswerealwaysmadein thecentralregionofthegrafttoavoiddifferencesin diame-terattheextremitiescausedbysuturesorirregularitiesofthe tendonsduetotheirextraction,andtothesizeoftheblock inwhichthegraftpresentedamaximumfillingofthe mea-surementhole,withoutdeformationofthegraftandwithfree passage(Fig.2).

Statisticalanalysis

Numericalvariablesweredescribed asmeansandstandard deviations(SD)andasminimumandmaximumvalues,and categoricalvariables,asabsoluteandrelativefrequencies.

Thecorrelationbetweentheintraoperativemeasurements and the area calculated by the ultrasound (2×area ofthe semitendinosus+2×gracilisarea)wasassessedbyPearson’s correlationcoefficient(r).

Fig.2–Intraoperativemeasurementofquadrupleflexor

graftsizewiththeappropriateguide.

Student’st-testwasappliedtocomparetheintraoperative measurementgroups(<8mmand≥8mm)withthemeanarea measurementscalculatedbyultrasound.

TheanalyseswereperformedusingSPSS® software ver-sion 18,anda significancelevelof0.05 wasadopted inall cases.

Results

Thisstudy included24patientswithclinicaland radiologi-caldiagnosis(magneticresonanceimaging)ofACLinjurywho underwentsurgicalACLreconstruction,withipsilateral auto-graftofthesemitendinosusandgracilistendons.

Thepatients’agesrangedfrom16to43years,withamean of24.8(SD=8.4);79.2%weremalesandthesidedistribution was41.7%rightand58.3%leftknees.

Table1presentsthedescriptiveanalysesofthepatients’ dataandtheultrasoundandintraoperativemeasurements.

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Table1–Patientcharacteristics,andultrasonographic andintraoperativemeasurements(n =24).

TransverseST

Mean(SD) 0.50(0.07)

Minimum–maximum 0.40–0.66

APST

Mean(SD) 0.27(0.05)

STarea

Mean(SD) 0.11(0.03)

Transversegracilis

Mean(SD) 0.40(0.07)

APgracilis

Mean(SD) 0.19(0.04)

Gracilisarea

Mean(SD) 0.06(0.02)

Intraoperativemeasurement

Mean(SD) 0.76(0.09)

Intraoperativemeasurement

<8mm 14(58.3)

≥8mm 10(41.7)

2×semitendinosusarea+2×gracilisarea

Mean(SD) 0.34(0.09)

Minimum–maximum 0.18–0.54 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00

0.00 0.05 0.10 0.15 0.20 0.25

2 x semitendinosus area+2 x gracilis area

Measurement obtained intraoperatively

0.30 0.35 0.40 0.45 0.50

Fig.3–Correlationbetweentheareacalculatedby

ultrasound(2×semitendinosusarea+2×gracilisarea)and themeasurementobtainedintraoperativelyinasampleof 24patients.

(2×semitendinosus area+2×gracilis area) and the mea-surementobtainedintraoperatively(Fig.3;r=0.16;p=0.443).

Furthermore,whencategorizingtheintraoperative mea-surementsintotwogroups,<8mmand≥8mm,nostatistically significant difference was observed in the area calculated byultrasound (Table 2; p=0.746). The differences observed betweenthegroupswas−0.01(95%CI:−0.09to0.07).

Table2–Measurementoftheareacalculatedby ultrasound(2×semitendinosus+2×gracilisarea)vs.

intraoperativemeasurement.

Areacalculatedby ultrasound (2×semitendinosus

area+2×gracilis

area)

Intraoperative measurementof kneeflexor tendons

<8mm(n=14) ≥8mm(n=10)

Mean(SD) 0.33(0.11) 0.34(0.06) Minimum–maximum 0.18–0.54 0.24–0.44 Student’st-test p=0.746

Discussion

The most important finding of the present study was

thatthepreoperativeultrasonographicmeasurementofthe

semitendinosus and gracilis tendons does not present a

statistically significant correlation with the intraoperative measurementofthequadrupleflexorgraftforligament recon-struction.

Following thepublication ofstudiesshowingthe

impor-tance offlexorgraftsizeand its associationwithagreater riskofACLreconstructionfailure,specificallywhensmaller than8mm,4,16–19_several_studies_have_been_conducted_in_an attempttopreoperativelymeasurethesemitendinosusand gracilistendons,andtocorrelatethatmeasurementwiththe quadrupleflexorgraftsizethatwouldbeobtainedatthetime ofsurgery.

Anthropometricdatahavebeenstudiedindifferent popu-lations,but theobtainedresultsareinconsistent,hindering anappropriatecorrelationbetweenthesedataandthe intra-operativemeasurementofthequadrupleflexorgraft.6–9,20,21

Studies that used imaging tests for the preoperative measurement of the semitendinosus and gracilis tendons have presenteda bettercorrelationwith theintraoperative measurement. Inadditiontoseveralstudieswithmagnetic resonance imaging,10–14,22,23 _computed _tomography _with 3-D15_{reconstruction}_and,_more_recently,_{ultrasonography}_have beenused.14

In the study by Erquicia et al.,14 _both _magnetic reso-nanceimaging(MRI;withmagnificationsof2×and4×)and ultrasoundwereused.Thoseauthorsconcludedthatthe cal-culationofthecross-sectionalareawiththethreemethods wasadequatetoestimatethesizeofthequadruplegraft flex-orsinthesurgicalprocedure.Whiletheresultsobtainedwith ultrasoundwerecomparabletothoseofMRIwith2× magnifi-cation,4×MRIpresentedmuchhigheraccuracy.Finally,they asserted thatlowerlimitvalueswithacross-sectionalarea of25mm2_,₁₇_mm2_,_and₁₄_mm2_, _in_relation_to_the₂_× _MRI, 4×MRI,andultrasound,respectively,wouldbeadequateto predictaflexorgraftwithatleast8mm.

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smallestareaobtainedonultrasonographywas24mm2_._This differencemayduetothefactthattheultrasoundimagingis operator-dependentandthat,specificallyinthecaseof ten-donmeasurementbythisradiologicalmethod,inwhichthe tendonsundergospatialdeformationaccordingtothe pres-sureappliedwiththetransducerbythe examiner,it isnot possibletoquantifyand standardizeit.Thus,thistestwas notreproducibleinrelationtopreviousstudies.

Theauthorsaimed studyingtheuse ofultrasonography inthemeasurementofthesemitendinosusandgracilis ten-donspreoperativelyduetotheaccessibilityandthelowcost ofthisexam,aspectsofrelevantimportanceinBrazil, espe-ciallyinpublichealthservice.MRI,althoughroutinelydonein casesofligamentinjury,isnotusuallyperformedusingthe specifictechniquesproposedforsemitendinosusandgracilis tendonmeasurementsinpublishedstudies.Thus,for preoper-ativemeasurement,ultrasoundwouldbeamorepracticaland cheapermethodinBrazil.However,thehypothesisthat ultra-sonographywould beasuitableexam topredictquadruple flexorgraftsizewasnotconfirmed.

Oneofthelimitationsofthepresentstudyisthefactthat thesemitendinosusandgracilistendonswerenotmeasured intheintraoperativeperiodandwerenotassociatedwiththe data obtainedby ultrasound imaging. Perhaps inthis way somecorrelation could have been found, rather than sim-plycomparingwiththemeasurementofthegraftalreadyin quadruple format, despite the actionsimplemented inthe measurementtoavoiddiscrepancies.Anotherlimitationwas thenonuseofanother(morespecific)methodfor intraoper-ativemeasurement, sincethe measurementguidespresent inthematerialsroutinelyusedforreconstructionoftheACL showincrementsofonly0.5mm,whichinitselfweakensthe correlationwiththeultrasoundmeasurements,inwhichthe valuesareaccurateuptotheseconddecimalplace.Studies usinganintraoperativetoolwithhighermeasurement accu-racymaybetterassessthecorrelationbetweenultrasoundand intraoperativemeasurement.

Conclusion

Preoperativeultrasoundimagingofthesemitendinosusand gracilismuscletendonsdoesnotpresentastatistically signif-icantcorrelationwiththeintraoperativemeasurementofthe quadrupleflexorgraftforligamentreconstruction.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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