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INTRODUCTION
1. Background
Rupture of the Anterior cruciate ligament (ACL) is a common injury
that causes instability of the knee joint, secondary damage to the
components of the knee joint and eventually leads to osteoarthritis
affecting daily activities, sports activities of patient.
The standard method of treatment of complete ACL rupture is Anterior
Cruciate Ligament Reconstruction. However, a recent meta-analysis
demonstrated that normal knee function is restored in only 37% of patients
undergoing ACL reconstruction. Similarly, knee laxity is prevalent, with
31.8% of patients exhibiting a positive Lachman test and 21.7% of
patients exhibiting a positive pivot shift. Up to 35% individuals cannot
return to the preinjury level of sports activity after ACL reconstruction.
The pooled graft rupture rate was 5.2%. These data indicate that there is
still a need to improve existing ACL regimens and techniques.
Currently, there are many studies looking for solutions to enhance the
effectiveness of ACL recontruction treatment towards maximizing surgery
recovery and transplantation optimization. Many studies of double-bundle
ACL reconstruction have the results of restoring knee stability better than
single-bundle, especially improving the rotation stability. Double-bundle
ACL reconstruction resulted in significantly fewer graft failures than
single-bundle ACL reconstruction.
So far, autograft is still the best material used in ACL reconstruction.
The double-bundle ACL reconstruction procedure uses gracilis and
semitendinosus tendon autograft, each graft takes on one bundle, the grafts
need to meet the requirements of length and diameter. If you want to
actively choose this method, you need to evaluate it right before the
surgery to see if the graft have enough length and diameter or short and
small does not meet the requirements.
In fact, size of the gracilis tendon graft and semitendinosus tendon graft
are varies with each patient. Predicting the size of gracilis and
semitendinosus tendon graft before the surgery helps the surgeon to plan
before surgery, proactively advise patients about methods and cost of
surgery. Since then, the treatment is also more accurate and effective.
In the world, there have been studies to find out the size of gracilis and
semitendinosus tendon graft based on the relationship with height, weight,
thigh bone length, thigh circumference...However, the level of
compatibility is moderate and low, some reports also show that the patient
is too thin or too fat, the female is difficult to predict the size of the tendon
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based on anthropometry. Recently, many studies have shown that the CT
and MRI image give more accurate and objective results on tendon
dimensions study.
Since the 1990s, in Vietnam, there have been many reports and studies
on ACL reconstruction arthroscopic using autografts of gracilis and
semitendinosus tendon. However, currently we have not seen any studies
examining the size of gracilis and semitendinosus tendon in imaging and
its apply in double-bundle ACL reconstruction.
The thesis: "Research the size of gracilis and semitendinosus tendon
by diagnostic imaging techniques and the results of Double Bundle
Anterior Cruciate Ligament Reconstruction" with two aims:
1. Investigating the size of gracilis and semitendinosus tendon by
diagnostic imaging techniques.
2. Evaluating the results of Double Bundle Anterior Cruciate
Ligament Reconstruction.
2. The necessity of the thesis
Anterior cruciate ligament rupture is one of the most common injuries
causing knee instability affecting labor, activities, physical activity and
eventually leading to knee degeneration.
Current ACL results: Many patients do not recover their normal knee
function and often complain of persistent knee instability after surgery.
Many patients do not exercise or exercise as before injury, the rate of
ligament tearing after regeneration is high. The above facts show that the
neccessity to offer solutions to improve the treatment regimens for ACL
lesions.
3. The scientific contributions of the thesis
Currently, the study of the size of gracilis and semitendinosus tendon
based on the relationship with height, weight, thigh bone length, thigh
circumference... is still inconsistent. The use of modern techniques such as
CT and MRI scans to calculate and predict the size of gracilis and
semitendinosus tendon is a new, current and practical direction.
Double-bundle ACL reconstruction uses gracilis and semitendinosus
tendon autograft, each graft takes on 1 bundle. Before the surgery, we
examined CT and MRI image to predict size of gracilis and
semitendinosus tendon. This examination is intended to contribute to
prognosis of the potential for a graft to be suitable for surgery and to make
treatment more accurate and effective.
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4. The structure of the thesis
The thesis has 136 pages, including: Background (02 pages), Chapter 1 –
Overview (34 pages), Chapter 2- Objectives and Methodology (30 pages),
Chapter 3 - Research Results (31 pages), Chapter 4 – Discussion (36
pages), Conclusion (02 pages), Recommendation (01 page). The thesis
results are presented in 31 tables and 23 graphs. The reference includes 118
documents in which 16 are in Vietnamese and 102 in English.
Chapter 1: OVERVIEW
1.1. Anatomy and biomechanics of ACL
1.1.1. General anatomy of the ACL
The anterior cruciate ligament originates at the medial wall of the
lateral femoral condyle and inserts into the middle of the intercondylar
area. There are two components of the ACL the anteromedial bundle
(AM) and posterolateral bundle (PL). AM bundle attached to medial
aspect of the intercondylar eminence of the tibia. AM fibres have the most
proximal femoral attachment. PL is attached just lateral to midline of the
intercondylar eminence. Fibres are most inferior on femur, most posterior
on tibia.
1.1.2. Anatomy of ACL femoral insertion
The femoral origin is oval and is located in the posterior aspect of the
lateral femoral condyle 2-3mm.
While knee flexion, AM is higher and posterior than the PM. The
Resident’s ridge is the front limit of the ACL attachment point and the
Bifurcate rigde runs perpendicular to the outer ridge and divides the
boundary of 2 bundles.
1.1.3. Anatomy of ACL tibial insertion
The ACL fibres radiate fan-shaped when attached to the tibial. The
grip area is a low-lying, triangular area with the top at the back, the bottom
edge at the front, 10-14mm from the tibial plateau, at the front and outside
of the medial intercondylar tubercle. In the correlation of two bundles, the
AM attachment is located in front of the PM.
1.1.4. Function and biological properties of ACL
- The major mechanical function of the ACL is to prevent anterior
movement of the tibia of the femur.
- The ACL also contributes stability to other movements at the joint
including the angulation and rotation at the knee joint.
1.2. Anatomy of gracilis and semitendinosus tendon
1.2.1. Anatomy of gracilis and semitendinosus tendon
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The semitendinosus and gracilis are located in the medial side of thigh.
they are thin and flattened, broad above, narrow and tapering below.
At the medial of the knee before reaching the end of the grip, The
semitendinosus and gracilis located between the first layer (sartorius) and
the second layer (medial liagment), the gracilis is on the front and upper
than the semitendinosus.
1.2.2. Related nerve branch
The saphenous nerve is a sensory nerve that supplies the intra-articular
part of the knee and skin on the medial aspect of the knee, lower leg and
ankle. It divides into its two terminal branches:
The infra-patellar branch curves anteriorly to supply the anterior-
medial aspect of the knee whereas the sartorial branch pierces the sartorial
fascia to become subcutaneous.
The sartorial branch continues distally alongside the great saphenous
vein, giving sensation to the medial aspect of the lower leg.
1.3. Overview of treatments for ACL injuries
1.3.1. Non-surgical treatment
- In the acute phase, when the patient still has symptoms of pain, swelling,
hemorrhage, limiting movement: Joint aspiration, wearing a brace on knee
for 3 weeks, apply cool compress, elevate the injuries leg...
- Stability stage: For patients to practice rehabilitation exercises, including
stretching exercises, exercises to strengthen muscles and enhance blood
flow, exercises to adapt and to sense the body...
1.3.2. Surgical treatment
Surgical methods of treatment of ACL injuries are diverse and
technically diverse from non-joint surgery to internal surgery such as
suturing a ligament, regenerating with different materials... At first is open
surgery but increasingly arthroscopic surgery has become more and more
dominant and gradually open surgery is only historical.
ACL reconstruction arthroscopic is performed with many different
techniques. The differences between the techniques include: how to create
the bone tunnel (inside-out, outside-in, all-inside), using the graft sources
(autograft, allograft, xenograft, artificial), technique of fixing the graft to
the bone tunnel (screw inserting the tunnel, the button hanging ...), the
ACL reconsstruction technique according to the anatomical structure (one
bundle, two bundles).
1.3.3. Development process of ACL reconstruction
1.3.3.1. In the world
Studies on knee anatomy, trauma injury and treatment were developed
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very early in the 19th century. In the 20th century, ACL reconstruction
made great progress with the techniques of Jones, K.G. (1970), Lipscomb,
A.B.(1982)...Until the 1990s, single-bundle ACL reconstruction with
tunneling technology at the "Isometricity" position. This is the classic and
most popular technique with many studies by Amis, A.A. (1995),
Pinczewski, L.A. (2002)...
The 21st century has changed from ACL reconstruction from the
principle of "isometricity" to the anatomy principle. The forefront of this
research trend are double-bundle ACL reconstruction studies by Mott,
H.W. (1983), Zaricznyj, B (1987), Rosenberg and Graf, B (1994), Yasuda
K. (2006), Freddie H. Fu (2008)...
1.3.3.2. In Vietnam
In Vietnam, ACL reconstruction has been performed and published in
Vietnamese literature since 1982. The studies on one-bundle ACL
reconstruction have been reported by Duong Duc Binh (1982), Doan Le.
Dan (1996), Nguyen Tien Binh (2000), Truong Tri Huu (2008), Dang
Hoang Anh (2009), Tran Trung Dung (2011)...
The research on double-bundle ACL reconstruction has also been
developed recently and obtained many positive results with the reports of
the authors Tang Ha Nam Anh, Vu Hai Nam (2012), Vu Nhat Dinh
(2013), Le Manh Son (2015), Tran Hoang Tung (2018)...
1.4. Studies investigating the size of the gracilis and semitendinosus
tendon graft
1.4.1. Characteristics of the gracilis and semitendinosus tendon graft
Research of Pichler W., (2008), the shortest semitendinosus tendon is
200mm, 18.5% of the semitendinosus tendon is less than 240mm, 11% is
shorter than 200mm, does not qualify for the minimum length to one-
bundle ACL reconstruction with 2-strand graft. ACL reconstruction by
Hamstring tendon autograft, Offerhaus C. (2018) report only 82.7% of
patients had a tendon graft that diameter reached request.
Research on double-bundle ACL recontruction using gracilis and
semitendinosus tendon autograft, each graft takes on one bundle.
Schwartzberg, RS (2014) found that if using the 2-strand graft only 57%
of patients had enough hamstring tendon graft tissue; using 3-strand graft,
88% of patients had enough tissue, using the 4-strand graft, only less than
30% of patients with graft meet the requirements.
1.4.2. Effect of graft size on surgical results
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There are many studies reporting different results, but most of the
authors agree that the length and diameter of the graft are very important,
directly affecting the results of ACL reconstruction.
1.4.3. Studies predicting graft size before surgery
* Research based on anthropometric indicators
Based on the correlation with the anthropometric index, many authors
have to predict the size of the gracilis and semitendinosus tendon based on
the index of height, weight, BMI, femur length, relative length of the
lower limb, thigh circumference... Reports have shown that the size of the
gracilis and semitendinosus tendon tend to correlate the average with some
anthropometric indicators.
* Research based on imaging diagnostics
In 2006, Yasumoto M. studied the measurement of the semitendinosus
tendon length on a CT scan. The results showed a high correlation (0.634,
P = 0.002) between the length semitendinosus tendon in 3-D CT scanner
and the actual length of the tendon graft.
In 2008, Bickel B.A. used Axial MRI layers before surgery to
determine the cross section of the gracilis and semitendinosus tendon. The
author found a high correlation between the cross sectional area on MRI
and the size of the graft in surgery. Other authors Wernecke G. (2011),
Grawe BM (2016) have reported similar results respectively, the MRI
imaging is positively and positively correlated with the actual diameter of
the graft in surgery with the coefficient correlation r = 0.62-0.92, p <0.05 .
Chapter 2: PATIENTS AND METHODOLOGY
2.1. Patients
Consisting of 85 patients diagnosed with complete ACL rupture who
were assigned to ACL reconstruction with gracilis and semitendinosus
tendon at Hospital 198 - Ministry of Public Security during June 2017 to
July 2018.
2.1.1. Patient selection criteria
- Patients aged 18-50, diagnosed with a complete rupture of ACL with
or without meniscal injuries, and need high-intensity exercise and physical
activity, indicated for ACL reconstruction.
- The patient underwent double-bundle ACL reconstructed if the
gracilis and semitendinosus tendon grafts size meet the requirements (3-
strand semitendinosus tendon graft at least 80mm in length, minimum
diameter 6.0mm. Minimum length of 4-strand gracilis tendon graft is
60mm, minimum diameter is 5.0mm). If grafts does not meet the
requirements, the patient will receive single-bundle ACL reconstruction.
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2.1.2. Patients exclusion criteria
- Patients with Hamstring tendon injury or abnormalities before surgery
(Clinical evaluation and imaging).
- ACL rupture is accompanied by damage to other ligaments such as
posterior cruciate ligament, lateral and medial collateral liagment.
- Patients with ACL injuries with severe articular cartilage damage or
with a previous knee fracture.
- Patients with open physes, severe bone bruising or medical conditions
contraindicated surgery.
- Patient did not agree to participate in the study.
2.2. Research method
The longitudinal observational methodology
RESEARCH CHART
85 patients with ACL rupture have surgical indications ACL
reconstruction with the gracilis and semitendinosus tendon
autograft
Collect information on anthropometric
Measure the length and CSA of the gracilis and semitendinosus
tendons on CT and MRI image Aim 1
Graft harvest
Evaluation of length and diameter of tendon after harvest
Requirements:
- Gracilis graft (4-strand) ≥ 60mm long, ≥ 5mm diameter
- Semitendinosus graft (3-strand) ≥ 80mm, diameter ≥ 6mm
42 patients were performed double-bundle
ACL reconstruction
Evaluate the results postoperatively
Aim 2
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2.3. Research content
2.3.1. Research equipment and devices
- 16 slice CT scanner and 1.5T MRI and Syngovia-Vascular modeling
and measurement software
- Medical scales, vernier calipers, protractors, protruding gauges
- Scalpels, surgical scissors, surgical clamps, tendon removal tools ...
2.3.2. Diagnosis and assessment of patients before surgery
Diagnosis and assessment of patients before surgery based on clinical
examination methods such as Lachman, anterior drawer test and Pivot-
shift...Assessment anterior–posterior translation by KT1000. Evaluation of
ACL rupture on MRI.
2.3.3. Study the size of the gracilis and semitendinosus tendons
* Record some characteristics of the research team before surgery:
Age, gender. Measure the parameters on the patient: height, weight, BMI,
thigh length, thigh circumference according to the guidance of the
National Institute of Nutrition.
* Investigate the length of gracilis and semitendinosus tendons on 16
slice CT scanner before surgery: Investigate the length of gracilis and
semitendinosus tendons on the CT by the method of Yasumoto, M. (2006).
Measure the length of the gracilis and semitendinosus tendons based on
the determination of density of tendons on 3 axial planes, coronal, coronal,
sagittal associated with 3D images.
.
Figure 2.6. 3D-CT image rendering and tendon length measurement before surgery
* Investigation CSA of gracilis and semitendinosus tendons on 1.5
Tesla MRI machine before surgery: Investigate the section of gracilis and
semitendinosus tendons on the Axial layers under the method of Bickel
B.A.(2008) 3cm above the medial knee joint.
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Figure 2.7. Measure the CSA of gracilis and semitendinosus tendons on MRI
* Graft harvesting, measure the actual length and diameter
- Measure the length of the the section of gracilis and semitendinosus
tendons: Use scissors to trim the auxiliary strips and the thin tail of the
tendon, keeping the tendon thick enough to be used as grafts.
- Measure the length and diameter of the graft: We use 4-strand gracilis
and 3-strand semitendinosus. Particularly the technique of 3-strand
semitendinosus requires the veins to be reversed through the Endobutton
ring at least 20mm.
Figure 2.8. Measure the length and diameter of the graft
* Subgroup patients and study the relationship
- Group A: Gracilis tendon graft (4-strand) with a length ≥ 60mm,
diameter ≥ 5.0mm; Semitendinosus (3-strand) has a length of ≥ 80mm, a
diameter ≥ 6.0mm. Patients with eligible graft dimensions will receive
double-bundle ACL reconstruction and evaluate results for goal 2.
- Group B: Gracilis and semitendinosus tendon graft are not enough
size according to the above standard. This group of patients underwent
conventional ACL reconstruction surgery and the results of treatment will
not be assessed in goal 2 of the study.
2.3.4. Clinical research: 42 patients of group A (with the size of the
gracilis and semitendinosus tendon graft eligible) were undergoing
double-bundle ACL reconstruction.
* Surgical method: We used double-bundle ACL reconstruction
technique of Christel P. (2008) combined with the all-inside technique of
Lubowitz J.H. (2011).
* Rehabilitation of knee joints after surgery: Patients are rehabilitated
according to the Guidelines of Wright R.W. (2015) and Malempati C.
(2015).
* Method of evaluating results
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- Evaluate clinical results:
+ General condition and at the incision
+ Pain level after surgery: VAS scale
+ Knee joint movement amplitude based on protractor.
+ Anterior drawer test, Lachman test, Pivot-shift.
+ Measure the anterior slip of the tibial plateau with KT1000.
- Evaluation of subclinical results:
+ X-ray of knee after surgery: Assessing the position of the tendon
hanging button. Evaluate the location of the femur tunnel along the
Blumensaat’s line, evaluate the location of the femoral tunnel along the
Amis Jacob’s line.
+ Postoperative MRI scan: Assessing over 10 patients who had
standard MRI knee at 1 year postoperative.
- Assessing complications and complications of surgery: complications
in surgery, the rate of complications, ACL revision frequency...
- Evaluation criteria
+ Evaluation of knee joint function on the Lyshlom scale.
+ Evaluating the level of sports activities on Cincinnati scale.
+ Evaluating functional of knee joints based on IKDC category.
2.3.5. Data processing methods
The collected information was coded, processed and analyzed on SPSS
16.0 and STATA 14.0 software. Apply statistical algorithms, analyze and
understand the implications.
2.4. Research ethics
The study was approved by the Medical Ethics Council of Hanoi
Medical University and the Medical Ethics Council of the 198 Ministry of
Public Security Hospital.
Chapter 3: RESEARCH RESULTS
3.1. Research results on the size of gracilis and semitendinosus
tendons
3.1.1. General characteristics
* Age and gender: The patients in the study group were all men with
average age of 27.3 ± 5.1 years, the lowest was 19 years old, the highest
was 42 years old.
* Height: The patients had an average height of 171.4 ± 4.2cm, the
lowest was 164cm, the highest was 181cm.
* Weight: Patients with an average weight of 69.9 ± 7.0kg, the lowest
was 50kg, the highest was 88kg.
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* BMI: The patients had an average BMI of 23.8 ± 2.14, the lowest
was 18.59; the highest was 29.4.
* Leg length: Patients with average foot length of 86.4 ± 3.4cm, the
lowest was 78cm, the highest was 95cm
* Thigh length: Patients with average thigh length 49.4 ± 2.07cm, the
lowest was 44cm, the highest was 55cm.
* Thigh circumference on the surgical side: The patients in the study
group had the average thigh circumference on the surgical side: 45.5 ±
3.5cm, the lowest was 37cm, the highest was 52.7cm.
* Thigh circumference on the non-surgical side: The patients had
average thigh circumference of 46.3 ± 3.5cm, the lowest was 38cm, the
highest was 54cm.
3.1.2. The size of the gracilis and semitendinosus tendons on CT,
MRI imaging
Measured on 3DCT, the gracilis tendon had an average length of 238.6
± 22.8mm, the shortest was 152.5mm, the longest was 283.4mm. The
semitendinosus tendon had an average length of 273.5 ± 22.7mm, the
shortest was 214.2mm, the longest was 316.9mm.
Measured on MRI, the gracilis tendon had an average section of 8.34 ±
1.64mm2, the smallest was 5.3mm2, the largest was 14.2mm2. The
semitendinosus tendon had an average section of 15.64 ± 2.93mm, the
smallest is 8.4mm2, the largest is 26.1mm2.
3.1.3. Characteristics of gracilis and semitendinosus tendons in
surgery
The patients in the study group had an average gracilis tendon length of
238.4 ± 17.4mm, the shortest was 180mm, the longest was 280mm. The
semitendinosus tendon length was 279.7 ± 20.6mm, the shortest was
230mm, the longest was 330mm.
The patients in the study group had an average 4-strand gracilis tendon
graft diameter was 5.05 ± 0.73mm, the smallest was 4.0mm, the largest
was 6.5mm. The average diameter of 3-strand semitendinosus tendon graft
was 6.69 ± 0.49mm, the smallest was 5.5mm, the largest was 7.5mm.
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3.1.4. Analyze the correlation of the size of the Gracilis tendon graft
Table 3.2. Correlation in Gracilis tendon graft size (n = 85)
Correlation r, p GT Length GT Diameter
Parameter r p r p
Age 0,0815 0,4584 -0,0279 0,8001
Height 0,4111 <0,001 0,3451 0,0012
Weight 0,3781 <0,001 0,3838 0,0003
BMI 0,1935 0,0761 0,2372 0,0289
Leg length 0,5311 <0,001 0,3051 0,0045
Thigh length 0,4729 <0,001 0,3140 0,0034
Thigh circumference
0,1051 0,3356 0,1139 0,2995
(ipsilateral)
Thigh circumference
0,0147 0,8931 0,0799 0,4673
(contralateral)
GT Length (3DCT) 0,8537 <0,001 0,5041 <0,001
GT CSA (MRI) 0,4153 <0,001 0,7442 <0,001
3.1.5. Analyze the correlation of the size of the semitendinosus tendon
Table 3.3. Correlation of the size of the semitendinosus tendon (ST) (n=85)
Correlation r, p ST Length ST Diameter
Parameter r p r p
Age -0,1258 0,2512 -0,0594 0,5891
Height 0,5063 <0,001 0,3524 <0,001
Weight 0,2769 0,0100 0,4510 <0,001
BMI 0,0246 0,8235 0,3095 0,0039
Leg length 0,6229 <0,001 0,3414 0,0014
Thigh length 0,5530 <0,001 0,3349 0,0017
Thigh circumference
-0,0389 0,7236 0,0286 0,7950
(ipsilateral)
Thigh circumference
-0,1119 0,3081 -0,0291 0,7913
(contralateral)
ST Length (3DCT) 0,8743 <0,001 0,4599 <0,001
ST CSA (MRI) 0,2598 0,0164 0,7887 <0,001
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3.1.6. Predictive size of grascilis tendon graft in double-bundle ACL
reconstruction.
Table 3.4. Predictive results of Gracilis tendon length (n = 85)
Positive Probability of
Cut off predicti Sensitivity Specificity accurate
ve value diagnosis
Height 171,0cm 0,7838 0,5088 0,7143 0,5765
Leg length 85,9cm 0,8000 0,7018 0,6429 0,6824
Thigh length 49,0cm 0,8182 0,7895 0,6429 0,7412
GT Length 232,3mm 0,9231 0,8421 0,8571 0,8471
(3DCT)
Table 3.5. Predictive results of Gracilis tendon graft diameter (n = 85)
Positive Probability of
Sensitivit
Cut off predictive Specificity accurate
y
value diagnosis
Height 171cm 0,6757 0.5208 0.5208 0,5882
Weight 70,0 kg 0,6667 0,6250 0,6250 0,6118
BMI 23,7 0,6047 0,5417 0,5417 0,5412
GT CSA 0,8043
8,3mm2 0,7708 0,7708 0,7647
(MRI)
3.1.7. Predictive size of Semitendinosus tendon graft in double-
bundle ACL reconstruction.
Table 3.6. Predictive results of Semitendinosus tendon length (n = 85)
Positive Probability
Cut off predictive Sensitivity Specificity of accurate
value diagnosis
Height 171cm 0,9123 0,4521 0,6667 0,6941
Leg length 49,0cm 0,9273 0,6986 0,6667 0,6941
Thigh length 85,5cm 0,9245 0,6712 0,6667 0,6706
ST Length 256,9mm 0,9846 0,8767 0,9167 0,8824
(3DCT)
Table 3.7. Predictive results of Semitendinosus tendon graft diameter (n = 85)
Positive Probability of
Sensitivit
Cut off predictiv Specificity accurate
y
e value diagnosis
Height 171cm 0,9729 0.4390 0,6667 0,4470
Weight 70,0 kg 0,9778 0,5366 0,6667 0,5412
BMI 23,7 0,9756 0,4878 0,6667 0,4941
ST CSA (MRI) 14,7mm2 0,9831 0,7073 0,6667 0,7059
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3.2. Clinical application of the results
3.2.1. Condition after surgery
* Symptoms of pain after surgery
Pain is the most common complaint of patients on the first day, then
decreases and almost gone after 02 weeks with an average of 0.4 points.
* General condition and at the incision
The patients after surgery are stable body condition, all healed at the
first stage.
* Knee joint movement amplitude
All patients after surgery have amplitude normal stretching (0
degrees). Before the patients were discharged, the knee flexion was ≥ 90
degree. The amplitude of the knee folds increases during rehab.
3.2.2. Evaluate knee joint function after surgery
* Stability Assessment by KT1000 arthrometer
Table 3.18. Assessment anterior–posterior translation by KT1000 (n=42)
Preoperative 6 months 9 months 12 months
KT1000
n % n % n % n %
≤ 2 mm 0 0 22 52,4 25 59,5 30 71,4
3-5 mm 20 47,7 16 38,1 14 33,4 10 23,8
6-10 mm 19 45,2 4 9,5 3 7,1 2 4,8
>10 mm 3 7,1 0 0 0 0 0 0
Average±S
6,4±2,5 mm 2,6±2,3 mm 2,3±2,2 mm 1,6±1,9 mm
D
* Stability Assessment by Pivot-Shift test
Table 3.19. Assessment by Pivot-Shift test (n=42)
Preoperative 6 months 9 months 12 months
Mức độ
n % n % n % n %
Độ 0 0 0 27 64,3 31 73,8 35 83,3
Độ I 0 0 13 30,9 9 21.4 6 14,3
Độ II 25 59,5 2 4,8 2 4,8 1 2,4
Độ III 17 40,5 0 0 0 0 0 0
* Functional Evaluation by Lysholm score
Table 3.20. Evaluation by Lysholm score (n=42)
Preoperative 6 months 9 months 12 months
Lysholm n % n % n % n %
Excellent 0 0 18 42,9 24 57,1 26 61,9
Good 0 0 20 47,6 16 38,1 14 33,3
Fair 10 23,8 4 9,5 2 4,8 2 4,8
Poor 32 76,2 0 0 0 0 0 0
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Average±SD 54,7±9,1 89,5±5,4 92,3±5,8 93,6±5,7
* Functional Evaluation by IKDC category
Table 3.21. Evaluation by IKDC category (n=42)
Preoperative 6 months 9 months 12 months
IKDC
n % n % n % n %
A 0 0 22 52,4 25 59,6 27 64,3
B 0 0 16 38,1 14 33,3 12 28,6
C 8 19,1 4 9,5 3 7,1 3 7,1
D 34 80,9 0 0 0 0 0 0
A+ B 0 90,5% 92,9% 92,9%
* Sports activity according to the Cincinnati scale score
Table 3.22. Sports activity according to the Cincinnati scale score (n=42)
Sports Preoperative 6 months 9 months 12 months
activity n % n % n % n %
Level I 0 0 12 28,6 20 47,6 26 61,9
Level II 0 0 19 45,2 16 38,1 10 23,8
Level III 24 57,1 8 19,1 6 14,3 6 14,3
Level IV 18 42,9 3 7,1 0 0 0 0
Average
47,2±3,8 74,5±15 82,0±10 84,5±10,6
±SD
3.2.3. Accidents and complications
- Surgery complications: not recorded any patients having
complications in surgery such as vascular lesions, nerves, broken bone
tunnel or defect after transplantation fixed.
- Symptoms:
+ Inflammation of fistula with tendon removal: 02 patients (4.8%)
+ Knee joint effusion after surgery: 01 patient (2.4%)
- The graft was ruptured: No patient was re-repture after 12 months of
follow-up.
3.2.4. Several factors affect the outcome of the 2-bundle surgical
group treatment
* Several factors affect Lyslom scores and IKDC classification
Age factors, diameter of the AM and PL bundles, the time from injury
to surgery and meniscus injury were not statistically significant to the
Lyslom score and IKDC classification 12 months after surgery
* Several factors affect the level of sports activity
Age factors, diameter of AM and PL bundles were not significantly
related to the results of rehabilitation of sports activity level 12 months
after surgery.
The results of restoration of sports activities in the group of patients
with no meniscus injury had better recovery results than the group of
patients with damaged meniscus. Results of rehabilitation of sports
16
activities in patients who arrive late after 12 weeks are worse than those in
patients who arrive early before 12 weeks.
Chapter 4: DISCUSSION
4.1. Study the size of the gracilis and semitendinosus tendons
4.1.1. Characteristics of the gracilis and semitendinosus tendons in
the study
Gracilis tendon graft with an average length of 238.4 ± 17.4mm; made
4- strand with an average length of 59.6 ± 0.6mm (45.0-70.0mm); Average
diameter of 5.05 ± 0.73mm (4.0-6.5mm).
Semitendinosus tendon has an average length of 279.7 ± 20.6mm;
made 3-strand with an average length of 86.6 ± 0.6mm (70.0-103.3mm);
Average diameter 6.69 ± 0.49mm (5.5-7.5mm).
Nguyen Quoc Dung (2017): The 2-strand semitendinosus tendon graft
with an average length of 13.58cm (11-16cm), an average diameter of
5.89mm (5.0-6.5mm); The 2-strand gracilis tendon graft has an average
length of 11.96cm (10.5-14cm) and an average diameter of 4.33mm (3.5-
5.5mm). Xie G. (2012): gracilis tendon graft with an average length of
251.5 ± 20.8mm; made 4-strand with an average diameter of 5.9 ± 0.6mm.
Semitendinosus tendon has an average length of 279.9 ± 20.8mm; made 4-
strand with an average diameter of 7.4 ± 0.7mm
4.1.2. The relationship between the size of the gracilis,
semitendinosus tendons and the anthropometric indicators
* Age and gender (n = 85)
We found no correlation between age and size of gracilis and
semitendinosus tendons graft. This is also consistent with studies of other
authors in the world, the size of the gracilis and semitendinosus tendons is
not correlated with the age of the patient.
* Height, weight (n = 85)
The height of patients was positively correlated, the same direction
with the length of gracilis and semitendinosus tendons at average level
with correlation coefficient r = 0.41-0.51. The patient's weight is
positively correlated with the tendon diameter of gracilis and
semitendinosus tendons at an average level with a correlation coefficient r
= 0.38-0.45
Similar to our study, author Reboonlap N. et al (2012), Xie G. (2012),
Schwartzberg R.S. (2014), Le Manh Son (2015) also reported the height
and weight correlated with the average level with the size of the gracilis
and semitendinosus tendons.
17
* Body mass index (BMI) (n = 85)
The correlation study results showed that BMI had a positive
correlation, low to moderate level with gracilis tendon diameter (r = 0.24;
p <0.03) and semitendinosus tendon diameter (r = 0.31; p <0.004).
Similar to our study, author Xie G. (2012), Schwartzberg R.S. (2014)
also found a correlation of the gracilis tendon diameter with BMI.
Some other authors like Pepeira R.N. (2016), Celiktas M. (2013) did
not find a correlation between BMI and diameter of gracilis and
semitendinosus tendons. However, these are studies using double-stranded
ligament grafts for the one-bundle ACL reconstruction technique.
* Leg length, thigh length (n = 85).
The correlation coefficient of leg length with the length of gracilis and
semitendinosus tendons is r = 0.53-0.62, respectively. The correlation
coefficient of thigh length with gracilis and semitendinosus tendon length
is r = 0.47-0.55.
Similarly to our study, Reboonlap N. (2012), Schwartzberg, R S.
(2008) reported that the length of legs and thigh length of patients were
positively correlated with the length of the gracilis and semitendinosus
tendons.
* Thigh circumference on the surgical side and the non-surgical side
As well as the studies of many other authors in the world, we found
that the size of the gracilis and semitendinosus tendons was not
significantly correlated with thigh circumference of the patient.
4.1.3. Study the size of the gracilis and semitendinosus tendons on
imaging diagnostics
* Length of gracilis and semitendinosus tendons on CT
Measured on 3-D CT, the semitendinosus tendon had an average length
of 273.5 ± 22.7mm, the shortest was 214.2mm, the longest was 316.9mm;
Gracilis tendon had an average length of 238.6 ± 22.8mm, the shortest was
152.5mm, the longest was 283.4mm.
The results of the correlation study, the length of gracilis and
semitendinosus tendons on the 3D-CT and in surgery have a close
correlation with each other. The correlation coefficients are respectively
with gracilis and semitendinosus tendons r = 0.85-0.87, which is
statistically significant with p = 0.001.
Yasumoto M. (2006) measured on a 3-D CT semitendinosus tendon
with an average length of 248.0 ± 17.1mm (from 220.3-285.4mm). Actual
measurement in surgery, gracilis tendon has a length of 257.2 ± 16.5mm
18
(from 230.0-290.0mm). The results of the correlation study, the length of
the semitendinosus tendon on 3D-CT and in surgery have a close
correlation with each other. The correlation coefficient r = 0.63,
statistically significant with p = 0.002
* The CSA of the gracilis and semitendinosus tendons on the MRI
Measured on MRI, the CSA of gracilis tendon had an average area of
8.34 ± 1.46mm2, the smallest was 5.3mm2, the largest was 14.2mm2, the
CSA of semitendinosus tendon had an average area of 15.64 ± 2.93mm2 ,
the smallest was 8.4mm2, the largest was 26.1mm2.
The CSA of gracilis and semitendinosus tendons on MRI and the
diameter of the graft of the gracilis and semitendinosus tendons during
surgery have a strong correlation with each other. Correlation coefficients
were respectively with gracilis and semitendinosus tendons r = 0.74-0.79;
is statistically significant with p = 0,000.
Galanis, N (2016) measured the section of gracilis tendon on MRI with
an average of 10.18 ± 2.16; The semitendinosus tendon had an average
CSA of 13.22 ± 2.46 The CSA of tendons on the MRI correlates positively
and in the same direction with the actual diameter of the graft in surgery.
The correlation coefficients were respectively with gracilis and
semitendinosus tendons r = 0.563-0,807, with statistical significance with
p <0.05.
Vardiabasis N. et al (2019) measured the diameter of tendons on MRI
located at 3cm above the knee joint. Diameter of gracilis tendon on MRI
was 3.50 ± 0.47mm; The semitendinosus tendon diameter measured on
MRI was 4.53 ± 0.63mm. The tendons diameter on MRI correlated
positively and in the same direction with the actual diameter of the graft in
surgery with r = 0.62-0.71, which is statistically significant with p
<0.0001.
4.1.4. Application of tendon size research results based on imaging
diagnostics
* Results of the research the size of the gracilis and semitendinosus
tendons on CT, MRI
In order to predict gracilis and semitendinosus tendons that are eligible
for length to performed double-bundle ACL reconstruction, we choose
gracilis tendon measured on CT with a length greater than or equal to
232.3mm, semitendinosus tendon measured on CT greater than or equal to
256.9mm (probability of accurate prediction of CT from 84.7% - 88.2%)
In order to predict the gracilis and semitendinosus tendons eligible for
diameter to double-bundle ACL reconstruction, we selected CSA of
19
gracilis tendon measured on MRI greater than or equal to 8,3mm 2, the
CSA of semitendinosus tendon measured on MRI greater than or equal to
14,7mm2 (probability of accurate prediction of MRI from 70.7% - 76.5%)
Wernecke et al. (2011) selected the minimum CSA of gracilis tendon at
least 10mm2 and the minimum CSA of semitendinosus tendon was 17mm2
to predict the possibility of gracilis and semitendinosus tendons graft
suitable for double-bundle ACL reconstruction. Due to the use of the 2-
stranded tendons, the author has selected the CSA of gracilis and
semitendinosus tendons on the MRI at higher level than ours.
* Factors affecting the predicted results
Objective factors: the quality of the scanner (CT, MRI) such as the
number of slices of the CT, the power output of the MRI machine, the
quality of the image processing software.
Subjective factors: technician, techniques; who built images and
measures results; surgeon skills, tendon harved technique, suture
technique, tendon stretching technique before measurement, technical
errors in measurement
4.2. Results of double-bundle ACL reconstruction
4.2.1. Reasons for choosing 4 tunnels technique for double-bundle
ACL reconstruction
Many large-scale system studies in the world show that double-bundle
ACL reconstruction results in better recovery of knee stability than single-
bundle ACL reconstruction, especially to improve rotation. The rate of re-
rupture ACL in the group of double-bundle surgery technicians is also
lower than that of the single-bundle reconstruction group.
Mascarenhas, R. (2015) conducted meta-analysis studies comparing the
results of single-bundle and double-bundle technique using 9 meta-
analysis studies. The results show that with the highest level of evidence,
double-bundle ACL reconstruction results in improved knee joint stable on
the KT machine and the Pivot Shift method is better than single-bundle
ACL reconstruction.
Svantesson E (2017) reported the results of 22,460 patients undergoing
ACL recontruction arthroscopic with gracilis and semitendinosus tendons.
Results showed that patients who had double-bundle surgery techniques
had a lower risk of re-rupture of ACL than patients who had single-bundle
surgery technique, the difference in the rate of re-rupture of ACL between
the 2 groups was statistically significant. p = 0.019.
4.2.2. Indications for double-bundle ACL reconstruction
20
We designate double-bundle ACL reconstruction in patients diagnosed
with complete rupture of ACL, from 18-50 years old, in need of regular
high intensity physical exercise and exercise.
Authors Muller, B. (2013) indicated double-bundle ACL reconstruction
for patients diagnosed with rupture of both AM and PL bundles. Le Manh
Son (2015) indicated double-bundle ACL reconstruction on young patients
with strong daily activity levels.
4.2.3. Double-bundle ACL reconstruction technique
We use Acufex device to support drilling 2 tunnels for AM and PL
bundles by the technique of Christel P. (2008). This device is designed to
guide the AM and PL tunnels to the right position, keeping the bone
bridge between the two tunnels about 2-3mm, the angle between the two
tunnels enough to make sure the two tunnels are not broken. Le Manh Son
(2015), Tran Hoang Tung (2018) when performing double -bundle ACL
reconstruction also use Acufex device to increase accuracy and reduce
surgical complications.
Our tunnel drilling and PL bundle fixing technique is based on the all-
inside ACL reconstruction technique described by Lubowitz J.H. (2011).
The all-inside ACL reconstruction technique is also applied by many
domestic authors such as Tang Ha Nam Anh (2013), Nguyen Manh Khanh
(2015), Tran Quoc Lam (2018), the results are very positive.
4.2.4. Characteristics of double-bundle ACL reconstruction group.
* Graft size
4-strand gracilis tendon graft (minimum length 60mm, minimum
diameter 5.0mm) and 3-strand semitendinosus tendon graft (minimum
length 80mm, minimum diameter 6.0mm)
The size of our 4-strand gracilis tendon graft is similar to Sim J.A.
(2015), Nguyen Manh Khanh (2015). The size of our 3-strand
semitendinosus tendon graft is similar Sim J.A. (2015) and Krishna, L.
(2018).
* Operation duration
The mean operative time in our study was 85.95 ± 9.12 minutes, the
fastest was 65 minutes and the longest was 100 minutes. The operative
time in our study is longer than the authors who performed 1-bundle ACL
reconstruction such as Tran Trung Dung (2011), Tran Quoc Lam (2018),
equivalent to some other authors who also do 2-bundle ACL
reconstruction technique as Le Manh Son (2015).
* Location of the femur and tibia tunnels
The femoral tunnel of the AM bundle compared to the Blumensaat’s
line was 25.9 ± 1.8%, the position of the femoral tunnel of the PL bundle
compared to the Blumensaat’s line was 31.3 ± 1.9%. The position of the
INTRODUCTION
1. Background
Rupture of the Anterior cruciate ligament (ACL) is a common injury
that causes instability of the knee joint, secondary damage to the
components of the knee joint and eventually leads to osteoarthritis
affecting daily activities, sports activities of patient.
The standard method of treatment of complete ACL rupture is Anterior
Cruciate Ligament Reconstruction. However, a recent meta-analysis
demonstrated that normal knee function is restored in only 37% of patients
undergoing ACL reconstruction. Similarly, knee laxity is prevalent, with
31.8% of patients exhibiting a positive Lachman test and 21.7% of
patients exhibiting a positive pivot shift. Up to 35% individuals cannot
return to the preinjury level of sports activity after ACL reconstruction.
The pooled graft rupture rate was 5.2%. These data indicate that there is
still a need to improve existing ACL regimens and techniques.
Currently, there are many studies looking for solutions to enhance the
effectiveness of ACL recontruction treatment towards maximizing surgery
recovery and transplantation optimization. Many studies of double-bundle
ACL reconstruction have the results of restoring knee stability better than
single-bundle, especially improving the rotation stability. Double-bundle
ACL reconstruction resulted in significantly fewer graft failures than
single-bundle ACL reconstruction.
So far, autograft is still the best material used in ACL reconstruction.
The double-bundle ACL reconstruction procedure uses gracilis and
semitendinosus tendon autograft, each graft takes on one bundle, the grafts
need to meet the requirements of length and diameter. If you want to
actively choose this method, you need to evaluate it right before the
surgery to see if the graft have enough length and diameter or short and
small does not meet the requirements.
In fact, size of the gracilis tendon graft and semitendinosus tendon graft
are varies with each patient. Predicting the size of gracilis and
semitendinosus tendon graft before the surgery helps the surgeon to plan
before surgery, proactively advise patients about methods and cost of
surgery. Since then, the treatment is also more accurate and effective.
In the world, there have been studies to find out the size of gracilis and
semitendinosus tendon graft based on the relationship with height, weight,
thigh bone length, thigh circumference...However, the level of
compatibility is moderate and low, some reports also show that the patient
is too thin or too fat, the female is difficult to predict the size of the tendon
2
based on anthropometry. Recently, many studies have shown that the CT
and MRI image give more accurate and objective results on tendon
dimensions study.
Since the 1990s, in Vietnam, there have been many reports and studies
on ACL reconstruction arthroscopic using autografts of gracilis and
semitendinosus tendon. However, currently we have not seen any studies
examining the size of gracilis and semitendinosus tendon in imaging and
its apply in double-bundle ACL reconstruction.
The thesis: "Research the size of gracilis and semitendinosus tendon
by diagnostic imaging techniques and the results of Double Bundle
Anterior Cruciate Ligament Reconstruction" with two aims:
1. Investigating the size of gracilis and semitendinosus tendon by
diagnostic imaging techniques.
2. Evaluating the results of Double Bundle Anterior Cruciate
Ligament Reconstruction.
2. The necessity of the thesis
Anterior cruciate ligament rupture is one of the most common injuries
causing knee instability affecting labor, activities, physical activity and
eventually leading to knee degeneration.
Current ACL results: Many patients do not recover their normal knee
function and often complain of persistent knee instability after surgery.
Many patients do not exercise or exercise as before injury, the rate of
ligament tearing after regeneration is high. The above facts show that the
neccessity to offer solutions to improve the treatment regimens for ACL
lesions.
3. The scientific contributions of the thesis
Currently, the study of the size of gracilis and semitendinosus tendon
based on the relationship with height, weight, thigh bone length, thigh
circumference... is still inconsistent. The use of modern techniques such as
CT and MRI scans to calculate and predict the size of gracilis and
semitendinosus tendon is a new, current and practical direction.
Double-bundle ACL reconstruction uses gracilis and semitendinosus
tendon autograft, each graft takes on 1 bundle. Before the surgery, we
examined CT and MRI image to predict size of gracilis and
semitendinosus tendon. This examination is intended to contribute to
prognosis of the potential for a graft to be suitable for surgery and to make
treatment more accurate and effective.
3
4. The structure of the thesis
The thesis has 136 pages, including: Background (02 pages), Chapter 1 –
Overview (34 pages), Chapter 2- Objectives and Methodology (30 pages),
Chapter 3 - Research Results (31 pages), Chapter 4 – Discussion (36
pages), Conclusion (02 pages), Recommendation (01 page). The thesis
results are presented in 31 tables and 23 graphs. The reference includes 118
documents in which 16 are in Vietnamese and 102 in English.
Chapter 1: OVERVIEW
1.1. Anatomy and biomechanics of ACL
1.1.1. General anatomy of the ACL
The anterior cruciate ligament originates at the medial wall of the
lateral femoral condyle and inserts into the middle of the intercondylar
area. There are two components of the ACL the anteromedial bundle
(AM) and posterolateral bundle (PL). AM bundle attached to medial
aspect of the intercondylar eminence of the tibia. AM fibres have the most
proximal femoral attachment. PL is attached just lateral to midline of the
intercondylar eminence. Fibres are most inferior on femur, most posterior
on tibia.
1.1.2. Anatomy of ACL femoral insertion
The femoral origin is oval and is located in the posterior aspect of the
lateral femoral condyle 2-3mm.
While knee flexion, AM is higher and posterior than the PM. The
Resident’s ridge is the front limit of the ACL attachment point and the
Bifurcate rigde runs perpendicular to the outer ridge and divides the
boundary of 2 bundles.
1.1.3. Anatomy of ACL tibial insertion
The ACL fibres radiate fan-shaped when attached to the tibial. The
grip area is a low-lying, triangular area with the top at the back, the bottom
edge at the front, 10-14mm from the tibial plateau, at the front and outside
of the medial intercondylar tubercle. In the correlation of two bundles, the
AM attachment is located in front of the PM.
1.1.4. Function and biological properties of ACL
- The major mechanical function of the ACL is to prevent anterior
movement of the tibia of the femur.
- The ACL also contributes stability to other movements at the joint
including the angulation and rotation at the knee joint.
1.2. Anatomy of gracilis and semitendinosus tendon
1.2.1. Anatomy of gracilis and semitendinosus tendon
4
The semitendinosus and gracilis are located in the medial side of thigh.
they are thin and flattened, broad above, narrow and tapering below.
At the medial of the knee before reaching the end of the grip, The
semitendinosus and gracilis located between the first layer (sartorius) and
the second layer (medial liagment), the gracilis is on the front and upper
than the semitendinosus.
1.2.2. Related nerve branch
The saphenous nerve is a sensory nerve that supplies the intra-articular
part of the knee and skin on the medial aspect of the knee, lower leg and
ankle. It divides into its two terminal branches:
The infra-patellar branch curves anteriorly to supply the anterior-
medial aspect of the knee whereas the sartorial branch pierces the sartorial
fascia to become subcutaneous.
The sartorial branch continues distally alongside the great saphenous
vein, giving sensation to the medial aspect of the lower leg.
1.3. Overview of treatments for ACL injuries
1.3.1. Non-surgical treatment
- In the acute phase, when the patient still has symptoms of pain, swelling,
hemorrhage, limiting movement: Joint aspiration, wearing a brace on knee
for 3 weeks, apply cool compress, elevate the injuries leg...
- Stability stage: For patients to practice rehabilitation exercises, including
stretching exercises, exercises to strengthen muscles and enhance blood
flow, exercises to adapt and to sense the body...
1.3.2. Surgical treatment
Surgical methods of treatment of ACL injuries are diverse and
technically diverse from non-joint surgery to internal surgery such as
suturing a ligament, regenerating with different materials... At first is open
surgery but increasingly arthroscopic surgery has become more and more
dominant and gradually open surgery is only historical.
ACL reconstruction arthroscopic is performed with many different
techniques. The differences between the techniques include: how to create
the bone tunnel (inside-out, outside-in, all-inside), using the graft sources
(autograft, allograft, xenograft, artificial), technique of fixing the graft to
the bone tunnel (screw inserting the tunnel, the button hanging ...), the
ACL reconsstruction technique according to the anatomical structure (one
bundle, two bundles).
1.3.3. Development process of ACL reconstruction
1.3.3.1. In the world
Studies on knee anatomy, trauma injury and treatment were developed
5
very early in the 19th century. In the 20th century, ACL reconstruction
made great progress with the techniques of Jones, K.G. (1970), Lipscomb,
A.B.(1982)...Until the 1990s, single-bundle ACL reconstruction with
tunneling technology at the "Isometricity" position. This is the classic and
most popular technique with many studies by Amis, A.A. (1995),
Pinczewski, L.A. (2002)...
The 21st century has changed from ACL reconstruction from the
principle of "isometricity" to the anatomy principle. The forefront of this
research trend are double-bundle ACL reconstruction studies by Mott,
H.W. (1983), Zaricznyj, B (1987), Rosenberg and Graf, B (1994), Yasuda
K. (2006), Freddie H. Fu (2008)...
1.3.3.2. In Vietnam
In Vietnam, ACL reconstruction has been performed and published in
Vietnamese literature since 1982. The studies on one-bundle ACL
reconstruction have been reported by Duong Duc Binh (1982), Doan Le.
Dan (1996), Nguyen Tien Binh (2000), Truong Tri Huu (2008), Dang
Hoang Anh (2009), Tran Trung Dung (2011)...
The research on double-bundle ACL reconstruction has also been
developed recently and obtained many positive results with the reports of
the authors Tang Ha Nam Anh, Vu Hai Nam (2012), Vu Nhat Dinh
(2013), Le Manh Son (2015), Tran Hoang Tung (2018)...
1.4. Studies investigating the size of the gracilis and semitendinosus
tendon graft
1.4.1. Characteristics of the gracilis and semitendinosus tendon graft
Research of Pichler W., (2008), the shortest semitendinosus tendon is
200mm, 18.5% of the semitendinosus tendon is less than 240mm, 11% is
shorter than 200mm, does not qualify for the minimum length to one-
bundle ACL reconstruction with 2-strand graft. ACL reconstruction by
Hamstring tendon autograft, Offerhaus C. (2018) report only 82.7% of
patients had a tendon graft that diameter reached request.
Research on double-bundle ACL recontruction using gracilis and
semitendinosus tendon autograft, each graft takes on one bundle.
Schwartzberg, RS (2014) found that if using the 2-strand graft only 57%
of patients had enough hamstring tendon graft tissue; using 3-strand graft,
88% of patients had enough tissue, using the 4-strand graft, only less than
30% of patients with graft meet the requirements.
1.4.2. Effect of graft size on surgical results
6
There are many studies reporting different results, but most of the
authors agree that the length and diameter of the graft are very important,
directly affecting the results of ACL reconstruction.
1.4.3. Studies predicting graft size before surgery
* Research based on anthropometric indicators
Based on the correlation with the anthropometric index, many authors
have to predict the size of the gracilis and semitendinosus tendon based on
the index of height, weight, BMI, femur length, relative length of the
lower limb, thigh circumference... Reports have shown that the size of the
gracilis and semitendinosus tendon tend to correlate the average with some
anthropometric indicators.
* Research based on imaging diagnostics
In 2006, Yasumoto M. studied the measurement of the semitendinosus
tendon length on a CT scan. The results showed a high correlation (0.634,
P = 0.002) between the length semitendinosus tendon in 3-D CT scanner
and the actual length of the tendon graft.
In 2008, Bickel B.A. used Axial MRI layers before surgery to
determine the cross section of the gracilis and semitendinosus tendon. The
author found a high correlation between the cross sectional area on MRI
and the size of the graft in surgery. Other authors Wernecke G. (2011),
Grawe BM (2016) have reported similar results respectively, the MRI
imaging is positively and positively correlated with the actual diameter of
the graft in surgery with the coefficient correlation r = 0.62-0.92, p <0.05 .
Chapter 2: PATIENTS AND METHODOLOGY
2.1. Patients
Consisting of 85 patients diagnosed with complete ACL rupture who
were assigned to ACL reconstruction with gracilis and semitendinosus
tendon at Hospital 198 - Ministry of Public Security during June 2017 to
July 2018.
2.1.1. Patient selection criteria
- Patients aged 18-50, diagnosed with a complete rupture of ACL with
or without meniscal injuries, and need high-intensity exercise and physical
activity, indicated for ACL reconstruction.
- The patient underwent double-bundle ACL reconstructed if the
gracilis and semitendinosus tendon grafts size meet the requirements (3-
strand semitendinosus tendon graft at least 80mm in length, minimum
diameter 6.0mm. Minimum length of 4-strand gracilis tendon graft is
60mm, minimum diameter is 5.0mm). If grafts does not meet the
requirements, the patient will receive single-bundle ACL reconstruction.
7
2.1.2. Patients exclusion criteria
- Patients with Hamstring tendon injury or abnormalities before surgery
(Clinical evaluation and imaging).
- ACL rupture is accompanied by damage to other ligaments such as
posterior cruciate ligament, lateral and medial collateral liagment.
- Patients with ACL injuries with severe articular cartilage damage or
with a previous knee fracture.
- Patients with open physes, severe bone bruising or medical conditions
contraindicated surgery.
- Patient did not agree to participate in the study.
2.2. Research method
The longitudinal observational methodology
RESEARCH CHART
85 patients with ACL rupture have surgical indications ACL
reconstruction with the gracilis and semitendinosus tendon
autograft
Collect information on anthropometric
Measure the length and CSA of the gracilis and semitendinosus
tendons on CT and MRI image Aim 1
Graft harvest
Evaluation of length and diameter of tendon after harvest
Requirements:
- Gracilis graft (4-strand) ≥ 60mm long, ≥ 5mm diameter
- Semitendinosus graft (3-strand) ≥ 80mm, diameter ≥ 6mm
42 patients were performed double-bundle
ACL reconstruction
Evaluate the results postoperatively
Aim 2
8
2.3. Research content
2.3.1. Research equipment and devices
- 16 slice CT scanner and 1.5T MRI and Syngovia-Vascular modeling
and measurement software
- Medical scales, vernier calipers, protractors, protruding gauges
- Scalpels, surgical scissors, surgical clamps, tendon removal tools ...
2.3.2. Diagnosis and assessment of patients before surgery
Diagnosis and assessment of patients before surgery based on clinical
examination methods such as Lachman, anterior drawer test and Pivot-
shift...Assessment anterior–posterior translation by KT1000. Evaluation of
ACL rupture on MRI.
2.3.3. Study the size of the gracilis and semitendinosus tendons
* Record some characteristics of the research team before surgery:
Age, gender. Measure the parameters on the patient: height, weight, BMI,
thigh length, thigh circumference according to the guidance of the
National Institute of Nutrition.
* Investigate the length of gracilis and semitendinosus tendons on 16
slice CT scanner before surgery: Investigate the length of gracilis and
semitendinosus tendons on the CT by the method of Yasumoto, M. (2006).
Measure the length of the gracilis and semitendinosus tendons based on
the determination of density of tendons on 3 axial planes, coronal, coronal,
sagittal associated with 3D images.
.
Figure 2.6. 3D-CT image rendering and tendon length measurement before surgery
* Investigation CSA of gracilis and semitendinosus tendons on 1.5
Tesla MRI machine before surgery: Investigate the section of gracilis and
semitendinosus tendons on the Axial layers under the method of Bickel
B.A.(2008) 3cm above the medial knee joint.
9
Figure 2.7. Measure the CSA of gracilis and semitendinosus tendons on MRI
* Graft harvesting, measure the actual length and diameter
- Measure the length of the the section of gracilis and semitendinosus
tendons: Use scissors to trim the auxiliary strips and the thin tail of the
tendon, keeping the tendon thick enough to be used as grafts.
- Measure the length and diameter of the graft: We use 4-strand gracilis
and 3-strand semitendinosus. Particularly the technique of 3-strand
semitendinosus requires the veins to be reversed through the Endobutton
ring at least 20mm.
Figure 2.8. Measure the length and diameter of the graft
* Subgroup patients and study the relationship
- Group A: Gracilis tendon graft (4-strand) with a length ≥ 60mm,
diameter ≥ 5.0mm; Semitendinosus (3-strand) has a length of ≥ 80mm, a
diameter ≥ 6.0mm. Patients with eligible graft dimensions will receive
double-bundle ACL reconstruction and evaluate results for goal 2.
- Group B: Gracilis and semitendinosus tendon graft are not enough
size according to the above standard. This group of patients underwent
conventional ACL reconstruction surgery and the results of treatment will
not be assessed in goal 2 of the study.
2.3.4. Clinical research: 42 patients of group A (with the size of the
gracilis and semitendinosus tendon graft eligible) were undergoing
double-bundle ACL reconstruction.
* Surgical method: We used double-bundle ACL reconstruction
technique of Christel P. (2008) combined with the all-inside technique of
Lubowitz J.H. (2011).
* Rehabilitation of knee joints after surgery: Patients are rehabilitated
according to the Guidelines of Wright R.W. (2015) and Malempati C.
(2015).
* Method of evaluating results
10
- Evaluate clinical results:
+ General condition and at the incision
+ Pain level after surgery: VAS scale
+ Knee joint movement amplitude based on protractor.
+ Anterior drawer test, Lachman test, Pivot-shift.
+ Measure the anterior slip of the tibial plateau with KT1000.
- Evaluation of subclinical results:
+ X-ray of knee after surgery: Assessing the position of the tendon
hanging button. Evaluate the location of the femur tunnel along the
Blumensaat’s line, evaluate the location of the femoral tunnel along the
Amis Jacob’s line.
+ Postoperative MRI scan: Assessing over 10 patients who had
standard MRI knee at 1 year postoperative.
- Assessing complications and complications of surgery: complications
in surgery, the rate of complications, ACL revision frequency...
- Evaluation criteria
+ Evaluation of knee joint function on the Lyshlom scale.
+ Evaluating the level of sports activities on Cincinnati scale.
+ Evaluating functional of knee joints based on IKDC category.
2.3.5. Data processing methods
The collected information was coded, processed and analyzed on SPSS
16.0 and STATA 14.0 software. Apply statistical algorithms, analyze and
understand the implications.
2.4. Research ethics
The study was approved by the Medical Ethics Council of Hanoi
Medical University and the Medical Ethics Council of the 198 Ministry of
Public Security Hospital.
Chapter 3: RESEARCH RESULTS
3.1. Research results on the size of gracilis and semitendinosus
tendons
3.1.1. General characteristics
* Age and gender: The patients in the study group were all men with
average age of 27.3 ± 5.1 years, the lowest was 19 years old, the highest
was 42 years old.
* Height: The patients had an average height of 171.4 ± 4.2cm, the
lowest was 164cm, the highest was 181cm.
* Weight: Patients with an average weight of 69.9 ± 7.0kg, the lowest
was 50kg, the highest was 88kg.
11
* BMI: The patients had an average BMI of 23.8 ± 2.14, the lowest
was 18.59; the highest was 29.4.
* Leg length: Patients with average foot length of 86.4 ± 3.4cm, the
lowest was 78cm, the highest was 95cm
* Thigh length: Patients with average thigh length 49.4 ± 2.07cm, the
lowest was 44cm, the highest was 55cm.
* Thigh circumference on the surgical side: The patients in the study
group had the average thigh circumference on the surgical side: 45.5 ±
3.5cm, the lowest was 37cm, the highest was 52.7cm.
* Thigh circumference on the non-surgical side: The patients had
average thigh circumference of 46.3 ± 3.5cm, the lowest was 38cm, the
highest was 54cm.
3.1.2. The size of the gracilis and semitendinosus tendons on CT,
MRI imaging
Measured on 3DCT, the gracilis tendon had an average length of 238.6
± 22.8mm, the shortest was 152.5mm, the longest was 283.4mm. The
semitendinosus tendon had an average length of 273.5 ± 22.7mm, the
shortest was 214.2mm, the longest was 316.9mm.
Measured on MRI, the gracilis tendon had an average section of 8.34 ±
1.64mm2, the smallest was 5.3mm2, the largest was 14.2mm2. The
semitendinosus tendon had an average section of 15.64 ± 2.93mm, the
smallest is 8.4mm2, the largest is 26.1mm2.
3.1.3. Characteristics of gracilis and semitendinosus tendons in
surgery
The patients in the study group had an average gracilis tendon length of
238.4 ± 17.4mm, the shortest was 180mm, the longest was 280mm. The
semitendinosus tendon length was 279.7 ± 20.6mm, the shortest was
230mm, the longest was 330mm.
The patients in the study group had an average 4-strand gracilis tendon
graft diameter was 5.05 ± 0.73mm, the smallest was 4.0mm, the largest
was 6.5mm. The average diameter of 3-strand semitendinosus tendon graft
was 6.69 ± 0.49mm, the smallest was 5.5mm, the largest was 7.5mm.
12
3.1.4. Analyze the correlation of the size of the Gracilis tendon graft
Table 3.2. Correlation in Gracilis tendon graft size (n = 85)
Correlation r, p GT Length GT Diameter
Parameter r p r p
Age 0,0815 0,4584 -0,0279 0,8001
Height 0,4111 <0,001 0,3451 0,0012
Weight 0,3781 <0,001 0,3838 0,0003
BMI 0,1935 0,0761 0,2372 0,0289
Leg length 0,5311 <0,001 0,3051 0,0045
Thigh length 0,4729 <0,001 0,3140 0,0034
Thigh circumference
0,1051 0,3356 0,1139 0,2995
(ipsilateral)
Thigh circumference
0,0147 0,8931 0,0799 0,4673
(contralateral)
GT Length (3DCT) 0,8537 <0,001 0,5041 <0,001
GT CSA (MRI) 0,4153 <0,001 0,7442 <0,001
3.1.5. Analyze the correlation of the size of the semitendinosus tendon
Table 3.3. Correlation of the size of the semitendinosus tendon (ST) (n=85)
Correlation r, p ST Length ST Diameter
Parameter r p r p
Age -0,1258 0,2512 -0,0594 0,5891
Height 0,5063 <0,001 0,3524 <0,001
Weight 0,2769 0,0100 0,4510 <0,001
BMI 0,0246 0,8235 0,3095 0,0039
Leg length 0,6229 <0,001 0,3414 0,0014
Thigh length 0,5530 <0,001 0,3349 0,0017
Thigh circumference
-0,0389 0,7236 0,0286 0,7950
(ipsilateral)
Thigh circumference
-0,1119 0,3081 -0,0291 0,7913
(contralateral)
ST Length (3DCT) 0,8743 <0,001 0,4599 <0,001
ST CSA (MRI) 0,2598 0,0164 0,7887 <0,001
13
3.1.6. Predictive size of grascilis tendon graft in double-bundle ACL
reconstruction.
Table 3.4. Predictive results of Gracilis tendon length (n = 85)
Positive Probability of
Cut off predicti Sensitivity Specificity accurate
ve value diagnosis
Height 171,0cm 0,7838 0,5088 0,7143 0,5765
Leg length 85,9cm 0,8000 0,7018 0,6429 0,6824
Thigh length 49,0cm 0,8182 0,7895 0,6429 0,7412
GT Length 232,3mm 0,9231 0,8421 0,8571 0,8471
(3DCT)
Table 3.5. Predictive results of Gracilis tendon graft diameter (n = 85)
Positive Probability of
Sensitivit
Cut off predictive Specificity accurate
y
value diagnosis
Height 171cm 0,6757 0.5208 0.5208 0,5882
Weight 70,0 kg 0,6667 0,6250 0,6250 0,6118
BMI 23,7 0,6047 0,5417 0,5417 0,5412
GT CSA 0,8043
8,3mm2 0,7708 0,7708 0,7647
(MRI)
3.1.7. Predictive size of Semitendinosus tendon graft in double-
bundle ACL reconstruction.
Table 3.6. Predictive results of Semitendinosus tendon length (n = 85)
Positive Probability
Cut off predictive Sensitivity Specificity of accurate
value diagnosis
Height 171cm 0,9123 0,4521 0,6667 0,6941
Leg length 49,0cm 0,9273 0,6986 0,6667 0,6941
Thigh length 85,5cm 0,9245 0,6712 0,6667 0,6706
ST Length 256,9mm 0,9846 0,8767 0,9167 0,8824
(3DCT)
Table 3.7. Predictive results of Semitendinosus tendon graft diameter (n = 85)
Positive Probability of
Sensitivit
Cut off predictiv Specificity accurate
y
e value diagnosis
Height 171cm 0,9729 0.4390 0,6667 0,4470
Weight 70,0 kg 0,9778 0,5366 0,6667 0,5412
BMI 23,7 0,9756 0,4878 0,6667 0,4941
ST CSA (MRI) 14,7mm2 0,9831 0,7073 0,6667 0,7059
14
3.2. Clinical application of the results
3.2.1. Condition after surgery
* Symptoms of pain after surgery
Pain is the most common complaint of patients on the first day, then
decreases and almost gone after 02 weeks with an average of 0.4 points.
* General condition and at the incision
The patients after surgery are stable body condition, all healed at the
first stage.
* Knee joint movement amplitude
All patients after surgery have amplitude normal stretching (0
degrees). Before the patients were discharged, the knee flexion was ≥ 90
degree. The amplitude of the knee folds increases during rehab.
3.2.2. Evaluate knee joint function after surgery
* Stability Assessment by KT1000 arthrometer
Table 3.18. Assessment anterior–posterior translation by KT1000 (n=42)
Preoperative 6 months 9 months 12 months
KT1000
n % n % n % n %
≤ 2 mm 0 0 22 52,4 25 59,5 30 71,4
3-5 mm 20 47,7 16 38,1 14 33,4 10 23,8
6-10 mm 19 45,2 4 9,5 3 7,1 2 4,8
>10 mm 3 7,1 0 0 0 0 0 0
Average±S
6,4±2,5 mm 2,6±2,3 mm 2,3±2,2 mm 1,6±1,9 mm
D
* Stability Assessment by Pivot-Shift test
Table 3.19. Assessment by Pivot-Shift test (n=42)
Preoperative 6 months 9 months 12 months
Mức độ
n % n % n % n %
Độ 0 0 0 27 64,3 31 73,8 35 83,3
Độ I 0 0 13 30,9 9 21.4 6 14,3
Độ II 25 59,5 2 4,8 2 4,8 1 2,4
Độ III 17 40,5 0 0 0 0 0 0
* Functional Evaluation by Lysholm score
Table 3.20. Evaluation by Lysholm score (n=42)
Preoperative 6 months 9 months 12 months
Lysholm n % n % n % n %
Excellent 0 0 18 42,9 24 57,1 26 61,9
Good 0 0 20 47,6 16 38,1 14 33,3
Fair 10 23,8 4 9,5 2 4,8 2 4,8
Poor 32 76,2 0 0 0 0 0 0
15
Average±SD 54,7±9,1 89,5±5,4 92,3±5,8 93,6±5,7
* Functional Evaluation by IKDC category
Table 3.21. Evaluation by IKDC category (n=42)
Preoperative 6 months 9 months 12 months
IKDC
n % n % n % n %
A 0 0 22 52,4 25 59,6 27 64,3
B 0 0 16 38,1 14 33,3 12 28,6
C 8 19,1 4 9,5 3 7,1 3 7,1
D 34 80,9 0 0 0 0 0 0
A+ B 0 90,5% 92,9% 92,9%
* Sports activity according to the Cincinnati scale score
Table 3.22. Sports activity according to the Cincinnati scale score (n=42)
Sports Preoperative 6 months 9 months 12 months
activity n % n % n % n %
Level I 0 0 12 28,6 20 47,6 26 61,9
Level II 0 0 19 45,2 16 38,1 10 23,8
Level III 24 57,1 8 19,1 6 14,3 6 14,3
Level IV 18 42,9 3 7,1 0 0 0 0
Average
47,2±3,8 74,5±15 82,0±10 84,5±10,6
±SD
3.2.3. Accidents and complications
- Surgery complications: not recorded any patients having
complications in surgery such as vascular lesions, nerves, broken bone
tunnel or defect after transplantation fixed.
- Symptoms:
+ Inflammation of fistula with tendon removal: 02 patients (4.8%)
+ Knee joint effusion after surgery: 01 patient (2.4%)
- The graft was ruptured: No patient was re-repture after 12 months of
follow-up.
3.2.4. Several factors affect the outcome of the 2-bundle surgical
group treatment
* Several factors affect Lyslom scores and IKDC classification
Age factors, diameter of the AM and PL bundles, the time from injury
to surgery and meniscus injury were not statistically significant to the
Lyslom score and IKDC classification 12 months after surgery
* Several factors affect the level of sports activity
Age factors, diameter of AM and PL bundles were not significantly
related to the results of rehabilitation of sports activity level 12 months
after surgery.
The results of restoration of sports activities in the group of patients
with no meniscus injury had better recovery results than the group of
patients with damaged meniscus. Results of rehabilitation of sports
16
activities in patients who arrive late after 12 weeks are worse than those in
patients who arrive early before 12 weeks.
Chapter 4: DISCUSSION
4.1. Study the size of the gracilis and semitendinosus tendons
4.1.1. Characteristics of the gracilis and semitendinosus tendons in
the study
Gracilis tendon graft with an average length of 238.4 ± 17.4mm; made
4- strand with an average length of 59.6 ± 0.6mm (45.0-70.0mm); Average
diameter of 5.05 ± 0.73mm (4.0-6.5mm).
Semitendinosus tendon has an average length of 279.7 ± 20.6mm;
made 3-strand with an average length of 86.6 ± 0.6mm (70.0-103.3mm);
Average diameter 6.69 ± 0.49mm (5.5-7.5mm).
Nguyen Quoc Dung (2017): The 2-strand semitendinosus tendon graft
with an average length of 13.58cm (11-16cm), an average diameter of
5.89mm (5.0-6.5mm); The 2-strand gracilis tendon graft has an average
length of 11.96cm (10.5-14cm) and an average diameter of 4.33mm (3.5-
5.5mm). Xie G. (2012): gracilis tendon graft with an average length of
251.5 ± 20.8mm; made 4-strand with an average diameter of 5.9 ± 0.6mm.
Semitendinosus tendon has an average length of 279.9 ± 20.8mm; made 4-
strand with an average diameter of 7.4 ± 0.7mm
4.1.2. The relationship between the size of the gracilis,
semitendinosus tendons and the anthropometric indicators
* Age and gender (n = 85)
We found no correlation between age and size of gracilis and
semitendinosus tendons graft. This is also consistent with studies of other
authors in the world, the size of the gracilis and semitendinosus tendons is
not correlated with the age of the patient.
* Height, weight (n = 85)
The height of patients was positively correlated, the same direction
with the length of gracilis and semitendinosus tendons at average level
with correlation coefficient r = 0.41-0.51. The patient's weight is
positively correlated with the tendon diameter of gracilis and
semitendinosus tendons at an average level with a correlation coefficient r
= 0.38-0.45
Similar to our study, author Reboonlap N. et al (2012), Xie G. (2012),
Schwartzberg R.S. (2014), Le Manh Son (2015) also reported the height
and weight correlated with the average level with the size of the gracilis
and semitendinosus tendons.
17
* Body mass index (BMI) (n = 85)
The correlation study results showed that BMI had a positive
correlation, low to moderate level with gracilis tendon diameter (r = 0.24;
p <0.03) and semitendinosus tendon diameter (r = 0.31; p <0.004).
Similar to our study, author Xie G. (2012), Schwartzberg R.S. (2014)
also found a correlation of the gracilis tendon diameter with BMI.
Some other authors like Pepeira R.N. (2016), Celiktas M. (2013) did
not find a correlation between BMI and diameter of gracilis and
semitendinosus tendons. However, these are studies using double-stranded
ligament grafts for the one-bundle ACL reconstruction technique.
* Leg length, thigh length (n = 85).
The correlation coefficient of leg length with the length of gracilis and
semitendinosus tendons is r = 0.53-0.62, respectively. The correlation
coefficient of thigh length with gracilis and semitendinosus tendon length
is r = 0.47-0.55.
Similarly to our study, Reboonlap N. (2012), Schwartzberg, R S.
(2008) reported that the length of legs and thigh length of patients were
positively correlated with the length of the gracilis and semitendinosus
tendons.
* Thigh circumference on the surgical side and the non-surgical side
As well as the studies of many other authors in the world, we found
that the size of the gracilis and semitendinosus tendons was not
significantly correlated with thigh circumference of the patient.
4.1.3. Study the size of the gracilis and semitendinosus tendons on
imaging diagnostics
* Length of gracilis and semitendinosus tendons on CT
Measured on 3-D CT, the semitendinosus tendon had an average length
of 273.5 ± 22.7mm, the shortest was 214.2mm, the longest was 316.9mm;
Gracilis tendon had an average length of 238.6 ± 22.8mm, the shortest was
152.5mm, the longest was 283.4mm.
The results of the correlation study, the length of gracilis and
semitendinosus tendons on the 3D-CT and in surgery have a close
correlation with each other. The correlation coefficients are respectively
with gracilis and semitendinosus tendons r = 0.85-0.87, which is
statistically significant with p = 0.001.
Yasumoto M. (2006) measured on a 3-D CT semitendinosus tendon
with an average length of 248.0 ± 17.1mm (from 220.3-285.4mm). Actual
measurement in surgery, gracilis tendon has a length of 257.2 ± 16.5mm
18
(from 230.0-290.0mm). The results of the correlation study, the length of
the semitendinosus tendon on 3D-CT and in surgery have a close
correlation with each other. The correlation coefficient r = 0.63,
statistically significant with p = 0.002
* The CSA of the gracilis and semitendinosus tendons on the MRI
Measured on MRI, the CSA of gracilis tendon had an average area of
8.34 ± 1.46mm2, the smallest was 5.3mm2, the largest was 14.2mm2, the
CSA of semitendinosus tendon had an average area of 15.64 ± 2.93mm2 ,
the smallest was 8.4mm2, the largest was 26.1mm2.
The CSA of gracilis and semitendinosus tendons on MRI and the
diameter of the graft of the gracilis and semitendinosus tendons during
surgery have a strong correlation with each other. Correlation coefficients
were respectively with gracilis and semitendinosus tendons r = 0.74-0.79;
is statistically significant with p = 0,000.
Galanis, N (2016) measured the section of gracilis tendon on MRI with
an average of 10.18 ± 2.16; The semitendinosus tendon had an average
CSA of 13.22 ± 2.46 The CSA of tendons on the MRI correlates positively
and in the same direction with the actual diameter of the graft in surgery.
The correlation coefficients were respectively with gracilis and
semitendinosus tendons r = 0.563-0,807, with statistical significance with
p <0.05.
Vardiabasis N. et al (2019) measured the diameter of tendons on MRI
located at 3cm above the knee joint. Diameter of gracilis tendon on MRI
was 3.50 ± 0.47mm; The semitendinosus tendon diameter measured on
MRI was 4.53 ± 0.63mm. The tendons diameter on MRI correlated
positively and in the same direction with the actual diameter of the graft in
surgery with r = 0.62-0.71, which is statistically significant with p
<0.0001.
4.1.4. Application of tendon size research results based on imaging
diagnostics
* Results of the research the size of the gracilis and semitendinosus
tendons on CT, MRI
In order to predict gracilis and semitendinosus tendons that are eligible
for length to performed double-bundle ACL reconstruction, we choose
gracilis tendon measured on CT with a length greater than or equal to
232.3mm, semitendinosus tendon measured on CT greater than or equal to
256.9mm (probability of accurate prediction of CT from 84.7% - 88.2%)
In order to predict the gracilis and semitendinosus tendons eligible for
diameter to double-bundle ACL reconstruction, we selected CSA of
19
gracilis tendon measured on MRI greater than or equal to 8,3mm 2, the
CSA of semitendinosus tendon measured on MRI greater than or equal to
14,7mm2 (probability of accurate prediction of MRI from 70.7% - 76.5%)
Wernecke et al. (2011) selected the minimum CSA of gracilis tendon at
least 10mm2 and the minimum CSA of semitendinosus tendon was 17mm2
to predict the possibility of gracilis and semitendinosus tendons graft
suitable for double-bundle ACL reconstruction. Due to the use of the 2-
stranded tendons, the author has selected the CSA of gracilis and
semitendinosus tendons on the MRI at higher level than ours.
* Factors affecting the predicted results
Objective factors: the quality of the scanner (CT, MRI) such as the
number of slices of the CT, the power output of the MRI machine, the
quality of the image processing software.
Subjective factors: technician, techniques; who built images and
measures results; surgeon skills, tendon harved technique, suture
technique, tendon stretching technique before measurement, technical
errors in measurement
4.2. Results of double-bundle ACL reconstruction
4.2.1. Reasons for choosing 4 tunnels technique for double-bundle
ACL reconstruction
Many large-scale system studies in the world show that double-bundle
ACL reconstruction results in better recovery of knee stability than single-
bundle ACL reconstruction, especially to improve rotation. The rate of re-
rupture ACL in the group of double-bundle surgery technicians is also
lower than that of the single-bundle reconstruction group.
Mascarenhas, R. (2015) conducted meta-analysis studies comparing the
results of single-bundle and double-bundle technique using 9 meta-
analysis studies. The results show that with the highest level of evidence,
double-bundle ACL reconstruction results in improved knee joint stable on
the KT machine and the Pivot Shift method is better than single-bundle
ACL reconstruction.
Svantesson E (2017) reported the results of 22,460 patients undergoing
ACL recontruction arthroscopic with gracilis and semitendinosus tendons.
Results showed that patients who had double-bundle surgery techniques
had a lower risk of re-rupture of ACL than patients who had single-bundle
surgery technique, the difference in the rate of re-rupture of ACL between
the 2 groups was statistically significant. p = 0.019.
4.2.2. Indications for double-bundle ACL reconstruction
20
We designate double-bundle ACL reconstruction in patients diagnosed
with complete rupture of ACL, from 18-50 years old, in need of regular
high intensity physical exercise and exercise.
Authors Muller, B. (2013) indicated double-bundle ACL reconstruction
for patients diagnosed with rupture of both AM and PL bundles. Le Manh
Son (2015) indicated double-bundle ACL reconstruction on young patients
with strong daily activity levels.
4.2.3. Double-bundle ACL reconstruction technique
We use Acufex device to support drilling 2 tunnels for AM and PL
bundles by the technique of Christel P. (2008). This device is designed to
guide the AM and PL tunnels to the right position, keeping the bone
bridge between the two tunnels about 2-3mm, the angle between the two
tunnels enough to make sure the two tunnels are not broken. Le Manh Son
(2015), Tran Hoang Tung (2018) when performing double -bundle ACL
reconstruction also use Acufex device to increase accuracy and reduce
surgical complications.
Our tunnel drilling and PL bundle fixing technique is based on the all-
inside ACL reconstruction technique described by Lubowitz J.H. (2011).
The all-inside ACL reconstruction technique is also applied by many
domestic authors such as Tang Ha Nam Anh (2013), Nguyen Manh Khanh
(2015), Tran Quoc Lam (2018), the results are very positive.
4.2.4. Characteristics of double-bundle ACL reconstruction group.
* Graft size
4-strand gracilis tendon graft (minimum length 60mm, minimum
diameter 5.0mm) and 3-strand semitendinosus tendon graft (minimum
length 80mm, minimum diameter 6.0mm)
The size of our 4-strand gracilis tendon graft is similar to Sim J.A.
(2015), Nguyen Manh Khanh (2015). The size of our 3-strand
semitendinosus tendon graft is similar Sim J.A. (2015) and Krishna, L.
(2018).
* Operation duration
The mean operative time in our study was 85.95 ± 9.12 minutes, the
fastest was 65 minutes and the longest was 100 minutes. The operative
time in our study is longer than the authors who performed 1-bundle ACL
reconstruction such as Tran Trung Dung (2011), Tran Quoc Lam (2018),
equivalent to some other authors who also do 2-bundle ACL
reconstruction technique as Le Manh Son (2015).
* Location of the femur and tibia tunnels
The femoral tunnel of the AM bundle compared to the Blumensaat’s
line was 25.9 ± 1.8%, the position of the femoral tunnel of the PL bundle
compared to the Blumensaat’s line was 31.3 ± 1.9%. The position of the