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1 INTRODUCTION 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 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: Investigating the size of gracilis and semitendinosus tendon by diagnostic imaging techniques Evaluating the results of Double Bundle Anterior Cruciate Ligament Reconstruction 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 not recover their normal knee function and often complain of persistent knee instability after surgery Many patients 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 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 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 The structure of the thesis The thesis has 136 pages, including: Background (02 pages), Chapter – Overview (34 pages), Chapter 2- Objectives and Methodology (30 pages), Chapter - Research Results (31 pages), Chapter – 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 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 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 anteriormedial 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 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 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 onebundle 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 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
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