Download PDF
J Knee Surg 2021; 34(07): 712-716
DOI: 10.1055/s-0039-1700810
Original Article

The Reliability of Classifying the Morphology of Anterior Cruciate Ligament Remnants during Surgery

Barak Haviv
1   Arthroscopy and Sports Injuries Unit, Hasharon Hospital, Rabin Medical Center, Petch-Tikva, Israel
2   Department of Orthopedics, Sackler Faculty of Medicine, Tel-Aviv University, Israel
3   Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, Petch-Tikva, Israel
,
Shai Shemesh 
4   Department of Orthopedics, Beilinson Hospital, Rabin Medical Center, Petch-Tikva, Israel
,
Mohamed Kittani
1   Arthroscopy and Sports Injuries Unit, Hasharon Hospital, Rabin Medical Center, Petch-Tikva, Israel
3   Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, Petch-Tikva, Israel
4   Department of Orthopedics, Beilinson Hospital, Rabin Medical Center, Petch-Tikva, Israel
,
Mustafa Yassin
2   Department of Orthopedics, Sackler Faculty of Medicine, Tel-Aviv University, Israel
3   Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, Petch-Tikva, Israel
,
Lee Yaari
1   Arthroscopy and Sports Injuries Unit, Hasharon Hospital, Rabin Medical Center, Petch-Tikva, Israel
3   Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, Petch-Tikva, Israel
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Arthroscopic classification of the torn anterior cruciate ligament (ACL) morphology is fundamental for clinical studies on emerging techniques such as repair and preservation. At present, the most acknowledged classification is Crain description of four morphological patterns. The purpose of the study was to analyze the intra- and interobserver reliability of Crain classification in patients undergoing ACL reconstruction surgeries. The study included 101 patients who had ACL reconstruction surgery between the years 2014 and 2017. The morphological pattern of ACL remnant scar formation during surgery was observed and classified according to Crain by three orthopaedic surgeons. Inter- and intraobserver reliabilities were measured using kappa statistics. Intraobserver reliability for the Crain classification ranged from 0.63 to 0.83 (substantial to almost perfect agreement). Interobserver reliability was 0.51 (moderate agreement). In almost a third of the cases, observers reported on additional morphological pattern of scar formation that was not well defined by Crain. A modified classification of four patterns was suggested: (A) without scar tissue, (B) with adhesion to the femoral notch (wall or roof), (C) with adhesion to the notch and posterior cruciate ligament (PCL), and (D) with adhesion to the PCL. Reanalysis of these four morphological configurations resulted in interobserver reliability of 0.82 (almost perfect agreement). In conclusion, the Crain classification of torn ACL remnant morphology has moderate interobserver reliability; however, a suggested classification with modified and additional configurations has almost perfect reliability and may be useful for studies on ACL repair and preservation.

Keywords

anterior cruciate ligament - ACL - tear - remnant - morphology - Crain


Publication History

Received: 19 February 2019

Accepted: 18 September 2019

Article published online:
04 November 2019

© 2019. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Ahmad SS, Schreiner AJ, Hirschmann MT. et al. Dynamic intraligamentary stabilization for ACL repair: a systematic review. Knee Surg Sports Traumatol Arthrosc 2019; 27 (01) 13-20
    CrossrefPubMedGoogle Scholar
  • 2 Daniels SP, van der List JP, Kazam JJ, DiFelice GS. Arthroscopic primary repair of the anterior cruciate ligament: what the radiologist needs to know. Skeletal Radiol 2018; 47 (05) 619-629
    CrossrefPubMedGoogle Scholar
  • 3 Taylor SA, Khair MM, Roberts TR, DiFelice GS. Primary repair of the anterior cruciate ligament: a systematic review. Arthroscopy 2015; 31 (11) 2233-2247
    CrossrefPubMedGoogle Scholar
  • 4 Haviv B, Kittani M, Yaari L. et al. The detached stump of the torn anterior cruciate ligament adheres to the femoral notch wall and then to the posterior cruciate ligament within 6 months from injury. Knee Surg Sports Traumatol Arthrosc 2019; 27 (08) 2653-2658
    CrossrefPubMedGoogle Scholar
  • 5 Kirizuki S, Matsumoto T, Ueha T. et al. The influence of ruptured scar pattern on the healing potential of anterior cruciate ligament remnant cells. Am J Sports Med 2018; 46 (06) 1382-1388
    CrossrefPubMedGoogle Scholar
  • 6 Yanagisawa S, Kimura M, Hagiwara K. et al. The relationship between the clinical results and the remnant type following anterior cruciate ligament reconstruction using a hamstring tendon. J Orthop Surg (Hong Kong) 2019; 27 (02) 2309499019837653
    Google Scholar
  • 7 Maeda S, Ishibashi Y, Tsuda E, Yamamoto Y, Toh S. Intraoperative navigation evaluation of tibial translation after resection of anterior cruciate ligament remnants. Arthroscopy 2011; 27 (09) 1203-1210
    CrossrefPubMedGoogle Scholar
  • 8 Crain EH, Fithian DC, Paxton EW, Luetzow WF. Variation in anterior cruciate ligament scar pattern: does the scar pattern affect anterior laxity in anterior cruciate ligament-deficient knees?. Arthroscopy 2005; 21 (01) 19-24
    CrossrefPubMedGoogle Scholar
  • 9 Adachi N, Ochi M, Takazawa K. et al. Morphologic evaluation of remnant anterior cruciate ligament bundles after injury with three-dimensional computed tomography. Knee Surg Sports Traumatol Arthrosc 2016; 24 (01) 148-153
    CrossrefPubMedGoogle Scholar
  • 10 Guo L, Chen H, Luo JM, Yang L, Gu LC, Fu DJ. An arthroscopic second-look study on the effect of remnant preservation on synovialization of bone-patellar tendon-bone allograft in anterior cruciate ligament reconstruction. Arthroscopy 2016; 32 (05) 868-877
    CrossrefPubMedGoogle Scholar
  • 11 Nagai K, Araki D, Matsushita T. et al. Biomechanical function of anterior cruciate ligament remnants: quantitative measurement with a 3-dimensional electromagnetic measurement system. Arthroscopy 2016; 32 (07) 1359-1366
    CrossrefPubMedGoogle Scholar
  • 12 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (01) 159-174
    CrossrefPubMedGoogle Scholar
  • 13 Fowler PJ, Regan WD. The patient with symptomatic chronic anterior cruciate ligament insufficiency. Results of minimal arthroscopic surgery and rehabilitation. Am J Sports Med 1987; 15 (04) 321-325
    CrossrefPubMedGoogle Scholar
  • 14 Gao F, Zhou J, He C. et al. A morphologic and quantitative study of mechanoreceptors in the remnant stump of the human anterior cruciate ligament. Arthroscopy 2016; 32 (02) 273-280
    CrossrefPubMedGoogle Scholar
  • 15 Vahey TN, Broome DR, Kayes KJ, Shelbourne KD. Acute and chronic tears of the anterior cruciate ligament: differential features at MR imaging. Radiology 1991; 181 (01) 251-253
    CrossrefPubMedGoogle Scholar
  • 16 Lo IK, de Maat GH, Valk JW, Frank CB. The gross morphology of torn human anterior cruciate ligaments in unstable knees. Arthroscopy 1999; 15 (03) 301-306
    CrossrefPubMedGoogle Scholar
  • 17 Gachter A. The various faces of anterior cruciate ligament tears during arthroscopic examination. In: Jakob RP, Staubli HU. eds. The Knee and the Cruciate Ligaments. Berlin: Springer-Verlag; 1992: 190-192
    CrossrefGoogle Scholar
  • 18 Ma T, Zeng C, Pan J, Zhao C, Fang H, Cai D. Remnant preservation in anterior cruciate ligament reconstruction versus standard techniques: a meta-analysis of randomized controlled trials. J Sports Med Phys Fitness 2017; 57 (7-8): 1014-1022
    PubMedGoogle Scholar
  • 19 Muneta T, Koga H. Anterior cruciate ligament remnant and its values for preservation. Asia Pac J Sports Med Arthrosc Rehabil Technol 2016; 7: 1-9
    PubMedGoogle Scholar
  • 20 Masuda T, Kondo E, Onodera J. et al. Effects of remnant tissue preservation on tunnel enlargement after anatomic double-bundle anterior cruciate ligament reconstruction using the hamstring tendon. Orthop J Sports Med 2018; 6 (12) 2325967118811293
    Google Scholar
  • 21 Siebold R, Fu FH. Assessment and augmentation of symptomatic anteromedial or posterolateral bundle tears of the anterior cruciate ligament. Arthroscopy 2008; 24 (11) 1289-1298
    CrossrefPubMedGoogle Scholar
  • 22 Kiapour AM, Murray MM. Basic science of anterior cruciate ligament injury and repair. Bone Joint Res 2014; 3 (02) 20-31
    CrossrefPubMedGoogle Scholar
  • 23 Colombet P, Dejour D, Panisset JC, Siebold R. French Arthroscopy Society. Current concept of partial anterior cruciate ligament ruptures. Orthop Traumatol Surg Res 2010; 96 (8, Suppl): S109-S118
    CrossrefPubMedGoogle Scholar
  • 24 Dejour D, Ntagiopoulos PG, Saggin PR, Panisset JC. The diagnostic value of clinical tests, magnetic resonance imaging, and instrumented laxity in the differentiation of complete versus partial anterior cruciate ligament tears. Arthroscopy 2013; 29 (03) 491-499
    CrossrefPubMedGoogle Scholar
  • 25 da Silveira Franciozi CE, Ingham SJ, Gracitelli GC, Luzo MV, Fu FH, Abdalla RJ. Updates in biological therapies for knee injuries: anterior cruciate ligament. Curr Rev Musculoskelet Med 2014; 7 (03) 228-238
    CrossrefPubMedGoogle Scholar