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Rece ved / Gel ş: 03.07.2020 · Accepted / Kabul: 30.09.2020 · Publ shed / Yayın Tar h : 14.12.2020

Correspondence / Yazışma: Şer fe Şeyma Torgutalp · Gaz ler F z k Tedav ve Rehab l tasyon Eğ t m ve Araştırma Hastanes Spor Hek ml ğ Bölümü, Ankara Turkey · seymatorgutalp@gma l.com

Research Art cle / Araştırma Makales

Inc dence rates of njur es assoc ated w th anter or cruc ate l gament tear d agnosed by magnet c resonance mag ng: A retrospect ve cohort study

Manyet k rezonans görüntüleme le tanı konulmuş ön çapraz bağ yırtığı le l şk l yaralanmaların görülme sıklığı: Retrospekt f kohort çalışması

Şer fe Şeyma Torgutalp¹ , Gürhan Dönmez² , Feza Korkusuz²

1Sports Med c ne Sect on, Gaz ler Phys cal Therapy and Rehab l tat on, Tra n ng and Research Hosp tal, Ankara, Turkey 2Department of Sports Med c ne, Faculty of Med c ne, Hacettepe Un vers ty, Ankara, Turkey

ABSTRACT

Object ve: Preceding studies to date have assessed the relationship between anterior cruciate ligament (ACL) tears and other related injuries without evaluating the ACL tear as partial or complete. In this study, we aimed to investigate the relationship between the type of an ACL tear assessed with magnetic resonance imaging and demographic factors, injury characteristics, and concomitant injuries.

Mater al and Methods: A retrospective cohort study was performed on patients admitted to the Sports Medicine Outpatient Clinic. The diagnosis of ACL tear was based on magnetic resonance imaging. Of the 310 patients with an acute ACL injury, 90 patients diagnosed with ACL tear by magnetic resonance imaging were divided into two groups according to the tear type; partial (n=26) and complete tear (n=64). Demographic factors, injury cha‐

racteristics and meniscal, articular cartilage, collateral ligament, and posterior cruciate ligament lesions conﬁrmed by magnetic resonance imaging were recorded.

Results: The mean age of the participants was 27.2 ± 7.9 years. Most of the patients (74.4%) were recreational athletes and football was the most common sports discipline (65.6%) among the patients. The most common accompanying injury was meniscal tear (61.1%), followed by articular carti‐

lage damage (45.6%). There were no signiﬁcant differences between partial tear and complete tear groups regarding incidence rates of injuries ac‐

companying the ACL tear (p > 0.05 for all).

Conclus on: We found similar incidence rates of menisci, articular cartilage, collateral ligaments, and posterior cruciate ligament injuries associated with ACL tear among the partial ACL tear and the complete ACL tear groups.

Keywords: Knee, anterior cruciate ligament injury, meniscus, cartilage ÖZ

Amaç: Bugüne kadar yapılan çalışmalarda, ön çapraz bağ (ÖÇB) yırtığı ile buna eşlik eden diğer yaralanmalar arasındaki ilişki, ÖÇB yırtığı kısmi veya tam kat olarak ayrılmaksızın incelenmiştir. Bu çalışmada, manyetik rezonans görüntüleme aracılığıyla değerlendirilen ÖÇB yırtığının tipi ile demograﬁk faktörler, yaralanma özellikleri ve eşlik eden yaralanmalar arasındaki ilişkinin incelenmesi amaçlanmıştır.

Gereç ve Yöntem: Spor Hekimliği Polikliniğine başvuran hastalar retrospektif kohort yöntemiyle değerlendirildi. ÖÇB yırtığı tanısı manyetik rezonans gö‐

rüntüleme ile konuldu. Akut ÖÇB yaralanması geçiren 310 hastadan manyetik rezonans görüntülemesi ile ÖÇB yırtığı tanısı alan 90 hasta yırtık tipine göre kısmi (n=26) ve tam kat yırtık (n=64) olarak iki gruba ayrıldı. Demograﬁk faktörler, yaralanma özellikleri ve manyetik rezonans görüntüleme ile teyit edilmiş menisküs, eklem kıkırdağı, kollateral ligamentler ve arka çapraz bağ lezyonları kaydedildi.

Bulgular: Katılımcıların yaş ortalaması 27.2±7.9 yıl idi. Hastaların çoğu (%74.4) rekreasyonel sporcular olup, en yaygın spor disiplini futboldu (%65.6).

En sık eşlik eden yaralanmalar menisküs yırtığı (%61.1) ve eklem kıkırdağı hasarı (%45.6) olarak bulundu. ÖÇB yırtığına eşlik eden yaralanmaların görül‐

me sıklığı açısından kısmi yırtık ve tam kat yırtık grupları arasında istatistiksel anlamlı fark gözlemlenmedi (tümü için p>0.05).

Sonuç: Kısmi ÖÇB yırtığı ve tam kat ÖÇB yırtığı grupları arasında ÖÇB yırtılması ile ilişkili menisküs, eklem kıkırdağı, kollateral ligamentler ve arka çap‐

raz bağ yaralanmaları açısından benzer görülme sıklığı bulundu.

Anahtar Sözcükler: Diz, ön çapraz bağ yaralanması, meniskü, kıkırdak

INTRODUCTION

The anter or cruc ate l gament (ACL) s accountable for re- s st ng translat onal and rotat onal load at the knee, espec - ally dur ng the p vot ng movement, as t g ves h gh rotat - onal stress on the knee (1). An solated ACL tear s rare and

occurs n less than ten percent of cases (2). Consequently, further evaluat on s necessary for the presence of ACL-assoc ated njur es (2).

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The most common njur es related to ACL tear are men scal, art cular cart lage, med al collateral l gament (MCL) and lateral collateral l gament (LCL) njur es ow ng to the anato- m cal and funct onal relat ons of these structures w th ACL (2). The nc dence of accompany ng men scal njury s abo- ut 60% (3,4), art cular cart lage njury s between 16 - 46%

(5), and MCL and LCL njury s between 5 - 24% (6,7).

The d srupt on of ACL eventually causes changes n knee k nemat cs due to nstab l ty n the jo nt (8,9). Pat ents w th part al ACL tears o en su er s m lar to a complete tear, ho- wever, mechan cal nstab l ty of the knee s rather small n a part al tear than a complete tear (9). Demograph c and other confound ng var ables such as sports d sc pl ne, sk ll level, and mechan sm of njury, wh ch const tute a r sk fac- tor for accompany ng njur es n pat ents w th ACL rupture, have been prev ously stud ed (4,10,11). Prev ous stud es have evaluated the relat onsh p between ACL tears and other related njur es w thout cons der ng the ACL tear as par- t al or complete (4,10,11). As ment oned above, n part al tear, mechan cal nstab l ty of the knee s rather small when compared to complete tear. Therefore, the nc dence of njur es accompany ng part al and complete ACL tears m ght vary. To our best of knowledge, no stud es have been reported on the relat onsh p between the type of an ACL tear, as part al or complete, and demograph c factors, n- jury character st cs, and concom tant njur es.

The a ms of our study were; to evaluate the ep dem ology of njur es accompany ng ACL tear, and to assess whether there was a d erence n the nc dence of concom tant njur es between part al ACL tear and complete ACL tear.

MATERIAL and METHODS Study Design

A retrospect ve cohort study was performed on pat ents ad- m tted to the Sports Med c ne Outpat ent Cl n c to nvest ga- te the assoc at on between the type of an ACL tear and demograph c factors, njury character st cs, knee magnet c resonance (MR) mag ng f nd ngs. The Local Research Et- h cs Comm ttee approved the study w th GO/17/681-38 Dec - s on Number.

Study Population

Inclus on cr ter a for th s study were; to have an acute ACL njury accord ng to the h story and phys cal exam nat on, to have an MR mage at the same nst tut on, and to have a part al or total ACL rupture accord ng to MR mag ng at the n t al presentat on. S nce mult planar MR mag ng of ACL prov des mproved accuracy and conf dence regard ng the d agnos s of ACL tears, all MR exam nat ons were performed n the ax al, coronal, and sag ttal plane (12). Recurrent ACL njury, a h story of prev ous surgery nvolv ng knee, l -

gamentous les ons or osteoarthr t s, and the absence of an MR mage n the same nst tut on were exclus on cr ter a.

For th s purpose, a total of 14.078 pat ents appl ed to our nst tut on for any compla nts between 01.01.2015 - 31.08.2017 were rev ewed retrospect vely from med cal re- cords (F gure 1). The d agnos s for ACL njury was based on h story and/or phys cal exam nat on, whereas the d agno- s s of ACL tear was based on MR mag ng. Accord ngly, there were 310 pat ents w th an acute ACL njury, and 108 of them had an MR mage at our nst tut on. F nally, 90 pat - ents d agnosed w th ACL tear by MR mag ng were d v ded nto two groups accord ng to the type of the tear: part al tear (n = 26) and complete tear (n = 64).

Figure 1. Flow chart of the study population. ACL: anterior cruciate ligament, MRI: magnetic resonance imaging

Data Collection

The cl n cal notes were rev ewed to gather data regard ng pat ents’ age, gender, level of sports act v ty, sports d sc pl - ne, njury s de, and njury type.

In all pat ents, men scal, art cular cart lage, MCL, LCL, and poster or cruc ate l gament (PCL) les ons were conf rmed by MR mag ng. Men scal tears were class f ed accord ng to the Internat onal Soc ety of Arthroscopy, Knee Surgery and Ort- hopaed c Sports Med c ne (ISAKOS) class f cat on (13). Me- n scal tears were further class f ed accord ng to the r presence n the med al and/or lateral men scus, and n the anter or horn, the body, and/or the poster or horn.

Statistical Analysis

Stat st cal analyses were performed us ng the Stat st cal Package for the Soc al Sc ences (SPSS) vers on 21 so ware (IBM SPSS Stat st cs for W ndows, Vers on 21.0., Armonk, New York, USA). The var ables were nvest gated us ng v su- al (h stograms and probab l ty plots) and analyt cal met‑

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hods (Kolmogorov-Sm rnov test and Shap ro-W lk test) to determ ne normal or non-normal d str but ons. Descr pt ve analyses were presented us ng means and standard dev at - ons, med ans and range, or frequenc es and percentages, where appropr ate. The Mann-Wh tney U test was used to compare age between groups. The Ch -square test or F s- her’s exact test was used to compare the gender, level of sports act v ty, sports d sc pl ne, ACL njury s de, ACL n- jury type, and the knee MR mag ng f nd ngs between groups. The correlat on between the type of an ACL tear and other var ables was nvest gated us ng the Spearman test because the ord nal var ables were present. A 5% type-I er- ror level was used to nfer stat st cal s gn f cance.

RESULTS

Demograph c character st cs, level of sports act v ty, and sports d sc pl ne of the pat ents are g ven n Table 1. The mean age of the part c pants was 27.2 ± 7.9 years. Most of the pat ents (74.4%) were recreat onal athletes. Football was the most common sports d sc pl ne (65.6%) among the pat ents, followed by basketball (10 %) and volleyball (5.6%).

Table 1. Demographic characteristics of the patients Total

(n = 90)

Male (n = 80)

Female (n = 10) Age, years

Mean ± SD 27.2 ± 7.9 27.9 ± 7.6 20.9 ± 7.9

Level of sports activity

Recreational, n (%) 67 (74.4) 64 (80) 3 (30) Professional, n (%) 23 (25.6) 16 (16) 7 (70) Sports discipline

Football, n (%) 59 (65.6) 59 (73.8) -

Basketball, n (%) 9 (10) 6 (7.5) 3 (30)

Volleyball, n (%) 5 (5.6) 2 (2.5) 3 (30)

Kickboxing, n (%) 3 (3.3) 2 (2.5) 1 (10)

Ski, n (%) 2 (2.2) 1 (1.3) 1 (10)

Athletics, n (%) 2 (2.2) 1 (1.3) 1 (10)

American football, n (%) 2 (2.2) 2 (2.5) -

Others*, n (%) 8 (8.9) 7 (8.6) 1 (10)

*Other sports disciplines: badminton, bicycle, gymnastics, handball, rugby, ulti- mate frisbee, wrestling.

Compar sons between the part al tear and complete tear groups accord ng to age, sex, level of sports act v ty, sports d sc pl ne, and s de of njury are g ven n Table 2. There were no s gn f cant d erences between the groups n terms of the aforement oned parameters (p > 0.05 for all).

D str but on of men scal, art cular cart lage, MCL, LCL, and PCL les ons accompany ng ACL tear s presented n Table 3.

The most common accompany ng njury was men scal tear (total: n = 55, 61.1%; part al tear: n = 13, 50%; and complete tear: n = 42, 65.6%), followed by art cular cart lage damage (total: n = 41, 45.6%, part al tear: n = 10, 38.5%, and complete tear: n = 31, 48.4%).

Of 90 pat ents; 39 had an solated med al men scus tear (43.4%), 6 had an solated lateral men scus tear (6.7%), 10

had tears of both men sc (11.1%), and 35 pat ents had no men scal tear (38.9%). The men scus tear was most commonly seen n the med al men scus (n = 49, 54.4%), and the most common tear locat on of the med al men scus was the poster or horn, followed by the body. Also, there were no d erences between part al tear and complete tear groups regard ng men scal, art cular cart lage, MCL, LCL, and PCL les ons n MR mag ng (p > 0.05 for all). There were no s g- n f cant correlat ons between the type of an ACL tear and other les ons accompany ng ACL tear (p > 0.05 for all).

Table 2. Comparison of the groups according to the type of anteri- or cruciate ligament (ACL) tear by magnetic resonance (MR) imaging

Total (n = 90)

Partial tear (n = 26)

Complete tear (n = 64) P Age

0.25 Mean ± SD 27.2 ± 7.9 28.9 ± 8.2 26.5 ± 7.8 Median (min-max) 27.5 (15 - 54) 29 (15 – 54) 25 (16 – 54)

Sex 0.47

Male, n (%) 80 (88.9) 22 (84.6) 58 (90.6) Female, n (%) 10 (11.1) 4 (15.4) 6 (9.4) Level of sports activity

0.05 Recreational, n (%) 67 (74.4) 23 (88.5) 44 (68.8) Professional, n (%) 23 (25.6) 3 (11.5) 20 (31.3) Sports discipline

0.61 Football, n (%) 59 (65.6) 16 (61.5) 43 (67.2) Others, n (%) 31 (34.4) 10 (38.5) 21 (32.8) Injury side

0.79 Right, n (%) 50 (55.6) 15 (57.7) 35 (54.7) Left, n (%) 40 (44.4) 11 (42.3) 29 (45.3)

DISCUSSION

Stud es have shown that solated ACL tears are scarce and ACL tears mostly seen w th accompany ng men sc , art cular cart lage, and collateral l gament njur es (4,10,11). In th s study, we a med to assess the relat onsh p between the type of an ACL tear and demograph c factors, njury character st cs, and concom tant njur - es. Preced ng stud es to date have assessed the relat onsh p between ACL tears and other related njur es w thout evaluat ng the ACL tear as part al or complete. Therefore, accord ng to our cur- rent knowledge, the lack of stud es assess ng the relat onsh p between the type of an ACL tear, as part al or complete, and demograph c factors, njury character st cs, and concom tant njur es make our f nd ngs s gn f cant. Add t onally, the fact that the rele- vant results were obta ned from pat ents who appl ed to the outpat ent cl n c for 2.5 years was another mportant po nt of our study. Our f nd ngs regard ng the overall nc dence of njur es accompany ng ACL rupture were n l ne w th the rates n the l terature (3-7).

Football was the most common sports d sc pl ne not only n total (65.6%) but also n part al tear (61.5%) and complete tear (67.2%) groups. S m larly, n a study evaluat ng the pat ent demograph cs and njury patterns at the t me of ACL reconstruct on by act v t es that lead to ACL njur es, Granan et al. found football as the lead ng sport wh ch was assoc ated w th ACL njur es (14). The pos - t on of the player n football as on o ense or defense, the act on of the player as head ng, pass ng, rece v ng the ball or tackl ng have an mpact on the r sk of ACL njury (15). The fact that there are many defens ve and tackl ng maneuvers n football m ght expla n

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Table 3. Knee MR imaging ﬁndings of the patients diagnosed with anterior cruciate ligament (ACL) tear Total

(n = 90)

Partial tear (n = 26)

Complete tear

(n = 64) p

Meniscal tear 55 (61.1) 13 (50) 42 (65.6) 0.17

Medial Meniscus (n = 49)

Posterior horn tear 38 (42.2) 8 (30.8) 30 (46.9) 0.16

Anterior horn tear 6 (6.7) - 6 (9.4) 0.18

Body tear 10 (11.1) 2 (7.7) 8 (12.5) 0.72

Lateral Meniscus (n = 16)

Posterior horn tear 13 (14.4) 2 (7.7) 11 (17.2) 0.33

Anterior horn tear 5 (5.6) - 5 (7.8) 0.32

Body tear 2 (2.2) 2 (7.7) - 0.08

Articular cartilage damage 41 (45.6) 10 (38.5) 31 (48.4) 0.39

MCL sprain 11 (12.2) 2 (7.7) 9 (14.1) 0.5

LCL sprain 1 (1.1) - 1 (1.6) > 0.99

PCL sprain 1 (1.1) 1 (3.8) - 0.29

Data were presented as number (%). LCL: lateral collateral ligament, MCL: medial collateral ligament, MR: magnetic resonance, PCL: posterior cruciate ligament

why football was the most common sport d sc pl ne n pat ents w th ACL tears (15).

When we exam ned the nc dence of men scus njury, we found that more than half of the pat ents (54.5%) had a med al men scal tear, and the most common tear locat on of both the med al and lateral men sc was the poster or horn. These f nd ngs were con- s stent w th the l terature (4). The med al men scus thought to be a secondary stab l zer of the knee a er ACL aga nst the anter or d splacement of the t b a, therefore, t s subjected to anter or-poster or shear forces (4). H gh nc dence of med al men scus njury s most l kely assoc ated w th ACL njury due to th s feature.

We d d not f nd a s gn f cant d erence n terms of the nc dence of men sc , art cular cart lage, MCL, LCL, and PCL njur es assoc - ated w th ACL tear between the part al tear and the complete tear groups. D srupt on of ACL m ght eventually cause assoc ated nju- r es, lead ng to changes n knee k nemat cs due to nstab l ty n the jo nt (8,9). Mechan cal nstab l ty n the knee of pat ents w th a part al tear s thought to be rather small than a complete tear (9).

In a study, Fayard et al. assessed the r sk factors for a part al ACL tear progress ng to a complete tear (16). The authors ncluded 41 pat ents, who were act ve n sport and d agnosed w th a part al ACL tear, w th no concom tant men scal or chondral les ons on MR mag ng. They found that a part al ACL njury progressed to a complete ACL tear n 39% of pat ents, w th half of the complete tears present ng w th a concom tant men scal les on at the t me of reconstruct on. In l ght of the f nd ngs of our study and Fayard et al. (16), the mpa rment of knee b omechan cs n ACL tear seems to lead the accompany ng njur es n the chron c per od rather than acute. Therefore, the s m lar nc dence rates of ACL-related njur es among study groups m ght be expla ned by the nclus on of only pat ents w th an acute ACL njury n our study.

Our study has some l m tat ons. F rst, we d d not have data on the lower extrem ty b omechan cs of the part c pants, so we were not able to nclude these var ables n the analys s. It s known that va- r ous mechan sms, such as lower l mb al gnment and load d str - but on m ght a ect the frequency of men scal tears n part cular (4,17). Hence, conduct ng ep dem olog cal stud es nvolv ng b - omechan cal analys s w ll deepen our understand ng of th s sub- ject. Secondly, although all pat ents were act ve n sports, the r ac- t v ty levels were not recorded. Further prospect ve stud es nclu- d ng the aforement oned var ables m ght prov de a better understand ng of the relat onsh p between grade of ACL tear and the related njur es.

CONCLUSION

We found football as the lead ng sport d sc pl ne assoc ated w th ACL njur es. The most common accompany ng njury was the me- n scal tear, followed by art cular cart lage damage. The men scal tear was most commonly seen n the med al men scus, and the most common tear locat on was the poster or horn. We found s - m lar nc dence rates of men sc , art cular cart lage, MCL, LCL, and PCL njur es assoc ated w th ACL tear among the part al ACL tear and the complete ACL tear groups.

Conﬂict of Interest / Çıkar Çatışması

The authors declared no con cts of nterest w th respect to authorsh p and/or publ cat on of the art cle.

Financial Disclosure / Finansal Destek

The authors rece ved no f nanc al support for the research and/or publ - cat on of th s art cle.

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