MRI Assessment of Tendon Graft: Letter to the Editor

Dear Editor:

We are writing in response to the article recently published by Cordier et al, ¹ titled “MRI Assessment of Tendon Graft After Lateral Ankle Ligament Reconstruction: Does Ligamentization Exist?” We appreciate the authors’ effort to shed light on the important concept of ligamentization in tendon grafts after lateral ankle ligament reconstruction (LALR). However, we would like to point out that the concept of LALR ligamentization has been previously described, contrary to what was mentioned in the title, abstract, and discussion section of their article.

Our study, titled “Adaptation of the Signal Noise Quotient MRI Classification for Graft Ligamentization Analysis Following ATFL and CFL Anatomical Reconstruction: Validation of the SNQA,” ² has already explored the early postoperative assessment of LALR ligamentization, employing the Signal/Noise Quotient for Ankle (SNQA) protocol on magnetic resonance imaging (MRI) in a cohort of 20 patients. In this work, we aimed at comparing the signal intensity of the calcaneofibular ligament and the anterior talofibular ligament to that of the fibular tendon as a control. Our results offered a methodological basis for the early detection of ligamentization, which was tested and validated through a high interclass correlation coefficient, highlighting the reproducibility and effectiveness of the SNQA technique in detecting early graft MRI changes at 3 months postoperatively.

However, we wish to acknowledge the significant contributions made by Cordier et al’s ¹ study to the field. Their longitudinal analysis over 6, 12, and 24 months after surgery provides an in-depth view of the ligamentization process, extending beyond the early postoperative period covered in our study. The correlation of MRI signal changes with clinical outcomes, as measured by the Karlsson score, offers valuable insights into the functional implications of graft maturation over time. This approach not only complements our findings on the early detection of ligamentization using the SNQA technique but also expands the narrative by illustrating the dynamic nature of graft healing and its impact on patient recovery.

The complementary nature of our studies underscores the multifaceted approach required to fully understand the ligamentization process. Our findings provide a crucial baseline that is further examined and expanded upon by Cordier et al, ¹ offering a comprehensive view of graft maturation and its clinical ramifications.

We thank The American Journal of Sports Medicine for the opportunity to highlight these points and commend Cordier et al ¹ for their valuable contribution to the field.

Alexandre Hardy, MD, MSc Arnaud de Rousiers, MD Grégoire Rougereau, MD Benoit Rousselin, MD Tristan Langlais, MD Marie-Eva Rollet, MD Manon Bachy, MD, MSc Mohamad K. Moussa, MD, MSc Thomas Bauer, MD, PhDParis, France